637 Body Positioning

What are the key concepts of gravity?

• Affects O2 transport

• Essential to normal cardiovascular and pulmonary function

• Physiological position - “upright and moving” with normal O2 transport

• O2 transport can be improved, maintained, worsened by body position changes

• Consider compression forces in upright and sidelying positions

• Frequent body position changes and avoiding prolonged period in same position is optimal

• Length of time a body position is maintained in response dependent and NOT time dependent

  • Patient preference, age, body mass, condition/pathology

In the upright position, where are ventilation & perfusion more distributed? What is increased more toward the lower zone? What is decreased more toward the lower zone?

• Ventilation and perfusion are both more distributed toward the lower zone (base) due to gravity

• Perfusion increases more dramatically than ventilation toward the base

• V/Q is lower at the base than at the apex (means that blood flow is greater, can achieve more efficient gas exchange)

Where is V/Q highest in the upright position?

Mid-lung

What is the accepted standard of care for patient positioning? What does body positioning affect physiologically? What could be potential explanations for the positive effects?

• Accepted standard of care = adjusting/turning client every 2 hours

• Body position has “potent and direct” effects on steps of the O2 transport pathway (and movement of mucus)

• Improved mucociliary transport OR positioning the better lung downward to improve gas exchange

What is the equation for functional residual capacity?

FRC = ERV + RV

What is the optimal bed position for patients with pulmonary conditions?

• 60 degrees or more in sitting or for exercise

• ~45 degrees is what COPD pts prefer

What is the significance of upright positioning on mucus?

• Positioning impacts how mucus settles

• Layers of mucus → consolidates → hard to mobilize b/c thickening

• Upright is better for mobilizing mucus

• FREQUENCY matters

How does the upright position impact kidney function?

• Promotion of urinary drainage from the renal pelvi to the bladder when in the upright position, as a result of the reduced area for urinary stasis when in upright vs supine position

• Optimal renal function is essential to preserving normal hemodynamic status

What are the approximations of upright position in supine?

Supine → recumbent → propped up (typical goal) → sitting/standing (ideal)

What specific structure does the supine position affect during respiration? Why? What lung capacities reduce in supine? Why?

• Diaphragm

  • Due to increased pressure from abdominal viscera that keeps diaphragm from moving caudally

  • Increase in intrathoracic blood volume

• TLC, VC, and FVC all reduce in supine

  • Less inspired air with greater diaphragmatic movement

What pts would benefit from sidelying the good lung down? When is the sidelying position often preferred to the supine position? What are the effects of prolonged sidelying? What does sidelying increase?

• ABGs improve in pts with unilateral lung disease when positioned with good lung down

• Sidelying >supine preferred by pts who are hospitalized

• Decreased dynamic lung compliance in lateral and prone positions than supine in intubated pts

• Prolonged sidelying can mobilize lung water in pts with pulmonary edema and pulmonary inflammation

• Sidelying increases EDV pressure on dependent side

What kind of patients would benefit from GOOD LUNG DOWN?

Tumor, areas of atelectasis, cystic fibrosis

How does the prone position affect the heart? Blood vessels? Weight of heart and abdominal organs? Posterior lung surface area? Fluid concentration? Secretions? Overall benefits? Risks?

• Increased volume to right side of heart

• Constriction of blood vessels to lungs decreases

• Weight of heart and abdominal organs is on chest instead of lungs

• Greater posterior lung surface area

• Fluid concentrated to anterior

• Secretions can leave mouth and nose easier as head is down

• Benefits: requires less support from ventilator, can improve heart function and better distribution of gas exchange in lungs

• Risks: potential increased incidence of pressure injuries

What position is best to organize pleural fluid?

Upright position

What is the issue with acute cardiopulmonary conditions with meeting body demands? What are causes of poor return to PLOF? What does the ICU consist of? What are issues of psychological stress?

• Pts oxygen transport pathway cannot meet needs of body

• Causes of poor return to PLOF: acute inflammation, severity of illness, exposure to corticosteroids, neuromuscular blocks, sedation, bedrest, and marginal baseline function

• ICU: continuous central line monitoring, vasoactive medication, sedation, circulatory assist devices, mechanical ventilation, and artificial airways

• Psychological stress: fear, unknown length of stay, powerlessness, anxiety, isolation, spiritual distress

*What are the systemic effects of immobilization? (CV, resp, MSK, CNS, met)

(Table 19.1)

• Cardiovascular system

  • Increased basal heart rate

  • Decreased maximal heart rate

  • Decreased maximal oxygen uptake

  • Orthostatic hypotension

  • increased venous thrombosis risk

  • Decreased total blood volume

  • Decreased hemoglobin concentration

• Respiratory system

  • Decreased vital capacity

  • Decreased residual volume

  • Decreased PaO2

  • Impaired ability to clear secretions

  • Increased ventilation-perfusion mismatch

• Musculoskeletal system

  • Decreased strength

  • Decreased girth

  • Decreased efficiency of contraction

  • Joint contractures

  • Decubitus ulcers

• Central nervous system

  • Emotional and behavioral disturbances

  • Cognitive deficits

  • Altered sensation

  • Decreased balance

• Metabolic system

  • Hypercalcemia

  • Osteoporosis

Patients in acute care setting with cardiopulmonary conditions may have what?

• Poor cough mechanics

• Difficulty performing airway clearance

• Difficulty achieving enough inspiratory effort

• Poor oxygenation status

• Poor hemodynamic status

• Decreased endurance, activity tolerance, and functional mobility (Table 19.2)

What are conditions associated with acute cardiopulmonary dysfunction and associated preferred practice patterns? Where will you commonly find an S3 heart sound? CO2 retention/respiratory acidosis?

(Table 19.2)

What are airway clearance techniques? Indications? Important factors in airway clearance plan? What precautions to follow?*

• Manual or mechanical procedures to mobilize secretions from the airways

• Postural drainage positions may be used to leverage gravity in the mobilization of secretions in addition to manual techniques such as percussion and vibration as well as cough and breathing techniques and airway suctioning

• Indications: impaired mucociliary transport, excessive pulmonary secretions, ineffective or absent cough

• Important factors in airway clearance plan: stability of medical status, pathophysiology and symptoms, pt’s adherence to techniques

• Maintaining droplet, airborne, and contact safety precautions are imperative as pathology may be contagious

What are some 8 condition that require airway clearance?

1. Cystic fibrosis

2. Bronchiectasis

3. Atelectasis

4. Respiratory muscle weakness

5. Mechanical ventilation

6. Neonatal respiratory distress syndrome

7. Asthma

8. ALSO: CHF

True or false: the higher a score on the BORG rating of perceived exertion, the better it is

False, a score of 10 means “maximal, just like my hardest race” and a score of 0 means “rest”

True or false: there are usually multiple areas of consolidation, not just one

True

What do you prioritize with postural drainage? What equipment do you need to have ready? How long do you maintain each position and how many positions on average? What should the patient do? What are signs of intolerance?

• Treat most affected lung segments first

  • Positions can be modified due to a precaution or relative contraindication

  • Equipment for positioning: adjustable bed, pillows, bolsters, blanket rolls, enough personnel

• Have secretion materials ready BEFORE starting: tissues, secretion cup, airway suctioning equipment, and body substance barriers

• Each position should be maintained for 5-10 minutes as long as the pt is stable; 2-3 positions on average

  • Pt should be encouraged to take deep breaths and cough (or be suctioned) between each position change

  • Can be used in coordination with other services, bathing, turning for skin protection, linen change

• Signs of intolerance: anxiety, SOB, HTN, nausea, dizziness, bronchospasm

*What are precautions and relative contraindications for postural drainage?

• Precautions

  • Pulmonary edema

  • Hemoptysis

  • Massive obesity

  • Large pleural effusion

  • Massive ascites

• Relative contraindications

  • Increased intracranial pressure

  • Hemodynamically unstable

  • Recent esophageal anastomosis

  • Recent spinal fusion or injury

  • Recent head trauma

  • Diaphragmatic hernia

  • Recent eye surgery

What is percussion? Technique? Speed and duration? What to avoid?

• Airway clearance technique used to mobilize secretions either manually or with a device

• Should be specific to affected lung segment

• Technique:

  • Cupped hands to trap air (can use percussor cups)

  • Alternating to produce hollow, thumping sound (should not sound like a slap)

  • Wrists and elbows stay relaxed as hands are clapped over thorax

  • Speed 100-480 bpm for 3-5 min

  • Avoid bony prominences, surgical incisions, medical appliances

What is vibration? Who would benefit from it? Technique? Speed and duration?

• Palmar aspect of pt’s hand in full contact with chest wall

• Hands may be overlapping

• Pt is cued to take a deep breath

• On exhale, PT applies pressure and gently oscillates until full exhale

• Speed = 12-20 hz (12-20 cycles/sec)

• 5-8 breaths

*What are precautions and relative contraindications for percussion and vibration?

• Precautions

  • Uncontrolled bronchospasm

  • Osteoporosis

  • Rib fractures

  • Metastatic cancer to ribs

  • Tumor obstruction of airway

  • Anxiety

  • Coagulopathy

  • Convulsive or seizure disorder

  • Recent pacemaker placement

• Relative contraindications

  • Hemoptysis

  • Untreated tension pneumothorax

  • Platelet count below 20.000 per mm³

  • Unstable hemodynamic status

  • Open wounds, burns in the thoracic area

  • Pulmonary embolism

  • Subcutaneous emphysema

  • Recent skin grafts or flaps on thorax

Which is the less aggressive method: vibration or percussion?

Vibration