POSITION CHANGE AS A POSITION CHANGE AS A NURSING MANEUVERNURSING MANEUVER

Body positioning is one of the general kinds of Body positioning is one of the general kinds of nursing actions during care of patients.nursing actions during care of patients.

Critically ill patients positioning maximizes Critically ill patients positioning maximizes ventilation to improve oxygenation which in ventilation to improve oxygenation which in turn would affect the individual’s ability to turn would affect the individual’s ability to maintain an internal environment that allows maintain an internal environment that allows normal cellular function normal cellular function

The critical care nurse plays a crucial role in the The critical care nurse plays a crucial role in the assessment, diagnosis, and management of assessment, diagnosis, and management of

patients with respiratory problems who develop patients with respiratory problems who develop hypoxemia. hypoxemia.

Studies related to the adequate duration in each Studies related to the adequate duration in each position and the frequency of turning patients position and the frequency of turning patients for maimizing ventilation to improve systemic for maimizing ventilation to improve systemic

oxygenation has not been attemptedoxygenation has not been attempted

The importance of The importance of the effect of body the effect of body position on position on ventilatory ventilatory function and gas function and gas exchange has been exchange has been appreciatedappreciated

Less information is Less information is available available concerning the concerning the effect of position effect of position change on gas change on gas exchange in human exchange in human body body

To determine the effect of To determine the effect of position change on position change on oxygenation and respiratory oxygenation and respiratory mechanics in mechanically mechanics in mechanically ventilated patientsventilated patients

MATERIALMATERIAL

SettingSetting

Critical care Critical care units of the Main units of the Main University University Hospital in Hospital in Alexandria.Alexandria.

SubjectsSubjects

Adult patients with Adult patients with respiratory problems respiratory problems receiving mechanical receiving mechanical ventilatory support ventilatory support were studied. They were studied. They were aged from 16 to were aged from 16 to 70 years.70 years.

Intern nurses were Intern nurses were trained to help the trained to help the researcher in researcher in turning patients, turning patients, four at a timefour at a time

30304848

Patients were classified Patients were classified to four groupsto four groups

Normal

lungs

Bilateral lung

diseaseRight lung Right lung

diseasedisease

left lung

disease

Patients excluded from the study

Low Low hemoglobinhemoglobin

ArrhythmiArrhythmiaa

Facial Facial

surgerysurgery

Skeletal Skeletal deformitydeformity

Head or Head or spine injuryspine injury

obesityobesity

AbdominalAbdominal distensiondistension

Carbon monoxide poisoning,Carbon monoxide poisoning, pulmonary hemorrhage,pulmonary hemorrhage,

pulmonary abscess. pulmonary abscess.

hyperthermiahyperthermia

METHODSMETHODS

*HD, ABG, RM were evaluated immediately before and every half-hour after turning patient for a total of 6 hours for each patient

*Patients were turned to left, prone, right, supine position respectively

*Researcher trained nurses to help in patient turning

* Instructions were given about how to turn the ventilated patients in the proper way

Nurses’ instructionsPatients positioning

##General characteristics General characteristics of the study sampleof the study sample

##Effects of turning onEffects of turning on

Results Results werewere

Oxygenation Respiratory Respiratory

mechanicsmechanics

Distribution of patients by ageDistribution of patients by age

10%

23%

30%

37%

20-40

40-60

>60

<20

63%

37%

malefemale

Distribution of patients by Distribution of patients by sexsex

Position change and hemodynamicPosition change and hemodynamic

0

10

20

30

40

50

60

70

80

90

100

110

120

B.L.P 0.5 L.L.P 1 L.L.P 1.5 L.L.P 0.5 P.P 1 P.P 1.5 P.P 0.5 R.L.P 1 R.L.P 1.5 R.L.P 0.5 S.P 1 S.P 1.5 S.P

HRSBPDBPMAP

B.L.P=Base line position L.L.P=Left lateral position

P.P= Prone position R.L.P=Right lateral position

S.P= Supine position

Position change and respiratory Position change and respiratory mechanicsmechanics

0

5

10

15

20

25

30

35

40

45

B.L.P 0.5 L.L.P 1 L.L.P 1.5 L.L.P 0.5 P.P 1 P.P 1.5 P.P 0.5 R.L.P 1 R.L.P 1.5 R.L.P 0.5 S.P 1 S.P 1.5 S.P

PIPPpLCstatCdynR

B.L.P=Base line position L..L.P= Left lateral position

P.P= Prone position R.L.P= Right lateral position

S.P= Supine position

Position change and arterial blood gasesPosition change and arterial blood gases

0

20

40

60

80

100

120

140

160

180

200

220

240

260

280

300

320

340

B.L.P 0.5L.L.P 1L.L.P 1.5L.L.P 0.5P.P 1 P.P 1.5 P.P 0.5R.L.P 1R.L.P 1.5R.L.P 0.5 S.P 1 S.P 1.5 S.P

Paco2Sao2pHHco3Pao2/Fio2Pao2

B.L.P=base line position L.L.P=Left lateral position

P.P=Prone position R.L.P=Right lateral position

S.P=Supine position

position changes had a significant effect on

oxygenation in mechanically ventilated patients

The improvement in arterial blood gases depends The improvement in arterial blood gases depends on site and extent of lung pathologyon site and extent of lung pathology

NormalNormal

lungslungs

BilateralBilateral

diseasedisease

UnilateralUnilateral

diseasedisease

ABG are improved in all positions ABG are improved in all positions

The best position is prone The best position is prone

The subsequent are right and then leftThe subsequent are right and then left

The same improvement in duration andThe same improvement in duration and

frequency but less than in normal lungfrequency but less than in normal lung

Are improved with the good lung down Are improved with the good lung down

Are worsened with the affected lung downAre worsened with the affected lung down

In bothIn both

Healthy

lungs

Diseased lungs

Prone and side lying positions enhance

the efficiency of O2 transport

and thereby minimize or avoid use of high

concentration of supplemental oxygen

and positive end expiratory pressure.

body positioning isbody positioning is

a 24-hours concerna 24-hours concern

For any For any critically ill critically ill

patientpatient

Patients with normal Patients with normal lungs and patients with lungs and patients with bilateral lung diseasebilateral lung disease

Turn

Left

1.5 hr

Prone

1.5 hrRight

1.5 hr Supine

1.5 hr

Patients with right lung Patients with right lung diseasedisease

Turn

Left

1.5 hr

Prone

1.5 hr Right

0.5hr

Supine

1.5 hr

patients with left lung patients with left lung diseasedisease

Turn

Prone

1.5 hr Right

1.5 hr Supine

1.5 hr

No left

Position change is aPosition change is a simple simple way to reduce shunting and way to reduce shunting and improve oxygenation improve oxygenation

It allows reduction in FIOIt allows reduction in FIO2 2

and PEEP and reducing their and PEEP and reducing their complicationscomplications

*do your patients

a good turn

*Try the position

changes early in

the course of

illness

*do your patients

a good turn

*Try the position

changes early in

the course of

illness Turning a critically ill Turning a critically ill patients is not difficult. It patients is not difficult. It requires four trained nursesrequires four trained nurses

More studies are neededto evaluate

Using

larger

sample

Frequent Frequent

cyclescycles

using

different

duration

Steep position

Other range Other range of positionsof positions

Hospital

administration

Schools of

nursing

CriticalCritical

care unitscare units

*pre-service*pre-service training training programs (for newly critical programs (for newly critical

care nurses)care nurses)*in-service*in-service training programs training programs

(for already critical care (for already critical care nurses) nurses)

Books and scientific Books and scientific magazinesmagazines

The care of critically ill The care of critically ill patients in their programspatients in their programs

TurnTurn TurnTurn

TurnTurn TurnTurn