Learn — Patient safety, positioning & mobility

5 notes · 26 questions on the topic

Patient positioning

Positioning is the deliberate placing of a patient's body to achieve a physiological or procedural aim: to improve ventilation, to lower intracranial pressure, to give access for a procedure, to protect an airway or to keep pressure off skin and joints. It matters because the right position is often a treatment in its own right, given free and instantly, while the wrong one can obstruct an airway, raise intracranial pressure or drop the blood pressure of a pregnant woman within a minute.

The Fowler family is defined by the angle of the backrest: low Fowler 15 to 30 degrees, semi-Fowler 30 to 45 degrees, Fowler 45 to 60 degrees and high Fowler 60 to 90 degrees, with the knees slightly flexed to stop the patient sliding down and shearing the sacral skin.
Semi-Fowler at 30 to 45 degrees is the position for nasogastric feeding and for 30 to 60 minutes afterwards, for preventing ventilator-associated pneumonia, and for a patient with raised intracranial pressure, whose head is also kept midline with the neck and hips unflexed to keep the jugular veins draining.
High Fowler or the orthopnoeic position, sitting forward with the arms resting on a table, is for severe dyspnoea, acute pulmonary oedema and COPD, because it drops the diaphragm and lets the accessory muscles work.
The Sims or left lateral position with the upper knee flexed is used for an enema, a suppository and a rectal examination, because it follows the direction of the descending and sigmoid colon, and the lateral position is also the recovery position for an unconscious patient who is breathing.
Prone positioning is used in moderate to severe ARDS for long sessions, commonly 12 to 16 hours a day; it needs a trained team, protection of the eyes, face and every pressure point, and every line and tube secured and checked before and after the turn.
Trendelenburg, the whole bed tilted head-down, is no longer used to treat shock but is used for central line insertion into a neck or subclavian vein to distend the vein and prevent air embolism; reverse Trendelenburg is used for head and neck surgery and to reduce gastric reflux.
A woman more than 20 weeks pregnant is never nursed flat on her back: the left lateral position, or a wedge under the right hip, lifts the uterus off the inferior vena cava and restores venous return, and the exaggerated Sims or knee-chest position is used for a prolapsed umbilical cord.
Procedure positions to know are lithotomy for vaginal examination, delivery and perineal surgery, with both legs raised and lowered together to protect the hips and the blood pressure; the knee-chest position for sigmoidoscopy; the right lateral position for about two hours after a liver biopsy to compress the puncture site; and flat supine after a lumbar puncture or spinal anaesthetic per unit policy.
Turn at least every 2 hours, use a 30 degree lateral tilt rather than a full 90 degree side-lying so that the body weight does not sit on the greater trochanter, float the heels off the mattress on a pillow under the calves, and keep the head of the bed no higher than 30 degrees when it is not clinically needed, to limit shear.
Move a patient with a suspected spinal injury only by a log roll with a team and one person controlling the head, and never twist the spine.

Patient safety — SPEAK UP and NPSG

Patient safety is the discipline of designing care so that predictable human error does not reach the patient, using checklists, standard communication and independent verification instead of relying on individual vigilance. It matters at the bedside because the commonest serious harms in a hospital, the wrong patient, the wrong drug, a missed critical result, a fall and an infection, all fail in the same way, through a handover or an identity check that nobody completed.

Identify the patient with two identifiers, usually the full name and the hospital or registration number read from the wristband and confirmed by the patient where possible; the bed number and the diagnosis are never identifiers, because patients move beds.
Improve staff communication: a critical laboratory value is telephoned to a responsible person, is read back word for word, and is recorded with the time, the value and the name of the caller, and it is acted on immediately rather than at the next round.
SBAR structures every escalation and handover: Situation (who the patient is and what is wrong now), Background (the relevant history), Assessment (the observations and what you think is happening) and Recommendation (what you want the listener to do and by when).
Use medicines safely: label every syringe, bowl and container at the moment it is filled, including in theatre and procedure rooms, reconcile the patient's medicines at admission, transfer and discharge, and give anticoagulants under a documented protocol.
Prevent mistakes in surgery with the Universal Protocol and the WHO Surgical Safety Checklist: verification of the patient, procedure and documents, marking of the site by the person doing the procedure with the patient involved, and a team time-out immediately before the incision, with the three checkpoints being sign in before anaesthesia, time out before incision and sign out before the patient leaves.
Prevent falls with a multifactorial assessment on admission and after any change: the bed at its lowest position with the wheels locked, the call bell and belongings within reach, non-slip footwear, adequate lighting and a clear floor, planned toileting rounds, and a review of sedatives, diuretics and antihypertensives.
Alarm safety means alarms are set to limits that suit the patient, are audible where staff work, and are never silenced or disabled because they are irritating; alarm fatigue is a recognised cause of death.
SPEAK UP asks the patient to Speak up, Pay attention to the care being given, Educate himself about his illness, use an Advocate such as a trusted friend or relative, Know the medicines he takes, Use an accredited quality facility, and Participate in decisions about his care.
Report incidents and near misses factually in an incident report that describes what happened without opinion or blame, note in the patient's record only the clinical facts and the action taken, and understand that the aim is a root cause analysis of the system, not the punishment of the individual.
The Indian equivalents map onto the same list: NABH patient safety goals cover correct identification, safe surgery, hand hygiene, medication safety and the prevention of falls, and are audited in the same way.

Crutch walking — gaits

Crutch walking is assisted ambulation in which the arms take part or all of the body weight through two crutches, allowing a patient to move while a leg is not allowed to bear weight. It matters at the bedside because the measurement and the gait have to match the weight-bearing order the surgeon wrote, and because a crutch that is too long or leaned on at the armpit compresses the brachial plexus and causes crutch palsy.

Measure standing where possible: the crutch tip rests about 15 to 20 cm in front of and to the side of the foot, the axillary pad sits about two to three finger-breadths (roughly 5 cm) below the axilla, and the hand grip is set so the elbow is flexed 20 to 30 degrees with the wrist extended.
The lying measurement is the height minus about 40 cm, or from the anterior axillary fold to a point about 15 cm lateral to the heel; whichever is used, the fit is rechecked with the patient in the shoes he will actually walk in.
All the weight is taken through the hands on the grips and never through the axillae; pressure in the armpit compresses the nerves and vessels there and produces crutch palsy with weakness and numbness of the hand and wrist.
The tripod position, with the crutch tips about 15 to 20 cm in front of and to the side of each foot, is the starting and resting stance and gives the widest base of support.
Four-point gait moves right crutch, left foot, left crutch, right foot: it is the slowest and the most stable and needs the patient to bear weight on both legs.
Two-point gait moves the right crutch with the left foot and then the left crutch with the right foot: it is faster, mimics normal walking and needs partial weight bearing on both legs.
Three-point gait advances both crutches and the affected leg together and then swings the unaffected leg through: it is the gait for a patient who is non-weight-bearing or partially weight-bearing on one leg.
Swing-to and swing-through gaits advance both crutches and then swing both legs to the crutches or beyond them, and are used by a patient with paralysis of both legs wearing braces; swing-through is the fastest gait of all.
On stairs the good leg leads going up and the crutches with the affected leg go first coming down, remembered as up with the good and down with the bad; a handrail is used with both crutches held in the other hand when one is available.
To sit, the patient backs up until the chair touches the back of his legs, moves both crutches into the hand on the affected side, reaches back for the armrest with the free hand and lowers himself; standing reverses the sequence.
Prepare before the first walk: quadriceps and gluteal setting exercises, sitting push-ups and triceps and wrist strengthening, well-fitting non-slip shoes, dry floors, and rubber crutch tips inspected for wear.

Restraint — types and care

A restraint is any manual method, physical or mechanical device, material or medication that restricts a patient's freedom of movement or normal access to his own body and that he cannot remove himself. It is used only as a last resort, for the shortest possible time, when there is an immediate risk of serious harm to the patient or others, because restraint itself causes injury, delirium, pressure damage and, occasionally, death by asphyxia.

The types are physical (limb holders, a vest or jacket, mitts, a belt, and full-length side rails when they prevent the patient from getting out of bed), chemical (a drug given to control behaviour rather than to treat a diagnosed condition), and seclusion.
Restraint is used only after alternatives have been tried and recorded: treating the cause of the agitation such as pain, a full bladder, hypoxia, hypoglycaemia, sepsis or a drug, reorientation, family presence, a sitter, activity and toileting rounds, moving the patient nearer the nurses' station, and covering lines so they are not visible.
It requires an order from a licensed independent practitioner before application, or within 1 hour when it has been started in an emergency, with a face-to-face evaluation of the patient within 1 hour for violent or self-destructive behaviour; a standing order or a PRN order for restraint is never acceptable.
Orders are time-limited and renewed: commonly up to 4 hours for an adult, 2 hours for a child aged 9 to 17 years and 1 hour for a child under 9, with reassessment before each renewal and discontinuation the moment the release criteria are met.
Apply the least restrictive device that will work, over clothing or padding, with two fingers able to slide between the device and the skin, and tie it to the movable part of the bed frame and never to a side rail or a fixed part, using a quick-release knot such as a clove hitch or half-bow that one nurse can undo instantly; a square knot is never used.
Monitor continuously for a violent restraint and at least every 15 minutes otherwise, checking circulation, colour, temperature, sensation, the skin under the device, and the patient's behaviour, hydration and comfort.
Release each limb one at a time at least every 2 hours for range-of-motion exercise, repositioning, skin care, toileting, food and fluid, and never leave a restrained patient prone, alone in a closed room, or with anything covering the face.
Document the behaviour that made restraint necessary in objective terms, the alternatives tried and their outcome, the type and site of the device, the time applied and removed, the order and its renewals, every monitoring check, the care given during release, and the criteria for stopping.
Restraint is never used for staff convenience, as a punishment, or in the absence of an immediate danger, and four side rails raised on a confused patient count as a restraint as well as being a climbing and entrapment hazard.
The patient and the family are told why the restraint is needed, what will end it and how they can help, and their agreement is sought and recorded.

Pressure ulcer stages

A pressure injury is localised damage to the skin and the underlying soft tissue, usually over a bony prominence or under a medical device, caused by sustained pressure or by pressure combined with shear. It matters because it is almost entirely preventable by nursing care and because the stage recorded at the first assessment drives everything that follows, from the mattress ordered to the dressing chosen and the incident report filed.

Stage 1 is intact skin with non-blanchable erythema over a localised area; in darker skin the colour change may not be visible, so look instead for an area that feels warmer or cooler, firmer or boggier, or that the patient says is painful.
Stage 2 is partial-thickness loss of the dermis, seen as a shallow open ulcer with a red or pink wound bed, or as an intact or ruptured serum-filled blister; there is no slough, no granulation tissue and no visible fat.
Stage 3 is full-thickness skin loss in which subcutaneous fat is visible, sometimes with slough, undermining or tunnelling, but bone, tendon and muscle are not exposed; its depth varies by site, being shallow on the nose, ear, occiput and malleolus where there is no fat and deep where there is.
Stage 4 is full-thickness loss with bone, tendon, muscle, cartilage or fascia exposed or directly palpable, often with slough, eschar, undermining and tunnelling, and it carries a real risk of osteomyelitis.
Unstageable means the base is covered by slough or eschar so the depth cannot be judged; the stage is assigned only after the wound bed is exposed, but stable, dry, adherent eschar on an ischaemic heel is left intact and is not debrided.
A deep tissue pressure injury is persistent non-blanchable deep red, maroon or purple discolouration, or a blood-filled blister, over intact or non-intact skin, caused by damage in the tissue beneath; it can deteriorate to a stage 3 or 4 within days despite the surface looking almost normal.
Two further categories are named separately: a medical-device-related pressure injury, which takes the shape of the device such as oxygen tubing behind the ear, a non-invasive ventilation mask, a pulse oximeter probe, an endotracheal tie or a cervical collar, and a mucosal membrane pressure injury, which is never staged.
Pressure injuries are never reverse staged: a healing stage 4 is documented as a healing stage 4 and not as a stage 2, because the lost muscle and fat are replaced by scar and not by the original tissue.
The common sites are the sacrum and coccyx (the commonest of all), the heels, the ischial tuberosities in a seated patient, the greater trochanters when side-lying, the elbows and scapulae, and the occiput and ears in children and in the supine patient.
Risk is scored with the Braden Scale, total 6 to 23 with 18 or less taken as at risk, or the Norton Scale, total 5 to 20 with 14 or less taken as at risk, alongside the clinical risks of immobility, incontinence and moisture, poor nutrition, poor perfusion, diabetes, age and fever.
Prevention is the nursing plan: reposition at least two-hourly in bed and hourly in a chair with a pressure lift every 15 minutes, use a 30 degree lateral tilt rather than lying at 90 degrees on the trochanter, float the heels completely off the mattress on a pillow under the calves, keep the head of the bed at 30 degrees or less to limit shear unless it is clinically needed higher, lift rather than drag using a slide sheet, use a high-specification foam or alternating-pressure mattress for those at risk, inspect the skin at least daily and under every device, keep the skin clean and dry with a barrier product for incontinence, and provide protein, calories and fluid.
Use the blanch test to separate reactive hyperaemia from injury: press the red area, and if it whitens and refills it is blanchable and reversible, while if it stays red it is already a stage 1 injury.
Never massage or vigorously rub a reddened bony prominence, because it damages the fragile capillaries underneath and makes the injury worse.

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