Page 135 - ACCCN's Critical Care Nursing

112 P R I N C I P L E S A N D P R A C T I C E O F C R I T I C A L C A R E

Changing Body Position to fully consider the individual needs of patients: they
Mobility is defined as the ability to change and control may have a history of back or neck problems, and the
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body position. The complications of immobilisation in selective use of soft or firm pillows and mattresses may
critically ill patients are well documented, and include be relevant. Pillows can optimise the patient’s position so
decubitus ulcer, venous thromboembolism and pulmo- that the shoulders and chest are squared, and may reduce
nary dysfunction such as atelectasis, retained secretions, the work of breathing for patients with chronic airways
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pneumonia, dysoxia and aspiration. The routine stan- disease. Some pressure-relieving mattresses have an
dard for immobilised patients in ICU is 2-hourly body adjustable pressure control, which can be changed accord-
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repositioning, although this does not always happen, ing to pressure relief assessment and patient comfort.
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and the optimal interval for turning critically ill patients When patients are positioned lying on one side, consid-
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is unknown. In addition to providing pressure relief, it eration should be given to their feeling of security; for
is recommended that the patient’s position be changed example, ensuring that they are well supported by pillows
often to ensure comfort, relaxation and rest, to inflate and the bed rails are raised. Provided cerebral perfusion
both lungs, improve oxygenation and help mobilise pressure is maintained above 50 mmHg, even severely
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airway secretions, to orient the patient to the surround- head-injured patients can be moved safely, however it
ings and for a change of view, and to improve circulation is important to maintain the neck in alignment to
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to limbs through movement. The frequency of body promote venous drainage (see Chapter 17), and for those
repositioning should be determined according to the with spinal injuries, log-rolling may be required (see
patient’s pressure ulcer risk (preferably using one of the Chapter 17).
assessment tools described below), clinical stability and
comfort. Pressure Area Care
The prevalence of pressure ulcers in an ICU ranges from
Good body alignment helps prevent pressure points, con- 5% to 18% and the risk of developing a pressure sore
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tractures and unnecessary pain or discomfort for the is cumulative: 5% risk after 5 days; 30% risk after 10 days;
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patient. The nurse caring for the immobile critically ill and 50% risk after 20 days in the ICU. Pressure area risk
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patient is most often responsible for determining patient for critically ill patients can be attributed to their immo-
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positioning. Here, careful consideration should be given bility, lack of sensory protective mechanisms, suboptimal
to factors (outlined in Table 6.6) such as haemodynamic tissue perfusion and environmental factors that cause
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and cardiopulmonary responses of the patient, the pressure and friction. The commonest locations for
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timing and method of positioning patients, and whether pressure ulcers are the sacrum, the heels and the head.
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there are any restrictions on movement. It is important
Significant risk factors include the age of the patient, the
number of days since admission, malnutrition, 42,49 and
delays in the use of pressure-relieving mattresses. 72,73
Pressure risk assessment tools can help nurses identify
at-risk patients. However, it is unusual for a patient in
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TABLE 6.6 Factors to consider when positioning critical care to be assessed as low-risk. There are several
patients pressure area risk assessment tools available such as
Braden score and the revised Jackson/Cubbin pressure
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Factors Comments risk calculator (Table 6.7) that was designed specifically
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Haemodynamic ● Placing patients in the left lateral for use in ICU and provides an awareness of the many
and position can cause a (usually harmless)
cardiopulmonary fall in oxygenation for a few minutes
responses
Timing ● Position the patient to avoid clashes
with treatment/investigations such as
chest physiotherapy or chest X-ray TABLE 6.7 Components of the revised Jackson/Cubbin
● Consider the need for the patient to pressure area risk calculator 74
rest
Method ● The need to use lifting devices Risk assessment
● The availability of staff to perform a categories Scoring
safe manoeuvre
● The placement of pillows to support ● Age ● Score range = 12–48.
limbs; to facilitate both comfort and ● Weight/tissue viability ● One point is deducted for each of
respiratory efficiency ● Past medical history the following:
● Use of bed adjustments to create ‘chair’ affecting condition ● The patient has spent time in
positions to prepare patients to sit out ● General skin condition surgery/scan in the past 48
of bed ● Mental status hours.
● Mobility ● The patient has received blood
Restrictions on ● The need for spinal alignment ● Haemodynamics products.
positioning ● Cerebral injury ● Respiration ● The patient is hypothermic.
● Haemodynamic instability ● Oxygen requirements ● A lower score indicates higher
● Respiratory compromise ● Nutrition risk.
● Access to devices for therapies ● Incontinence ● A score of <29 indicates high risk.
● Body size ● Hygiene