The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [225]
Oedema/swelling
Where possible, swollen limbs should not be left dependent but be supported on pillows/footstool as elevation will help to maximize venous return and minimize further swelling. Oedema may result in pain, fragile skin or loss of joint movement.
Pain
Ensure the patient has optimal pain relief before moving. Patients who are pain free at rest may need additional analgesic cover before movement. It is important to allow adequate time for any medication to take effect. See also Chapter 9.
Weakness
Consider the patient’s ability to maintain the position. Additional support may be required in the form of pillows or towels to maintain the desired posture.
Limitations of joint and soft tissue range (contractures)
Soft tissue changes and contractures occur through disuse in normal muscle (Jones and Moffatt 2002). As a result, restrictions in joint range may mean that positions need to be modified or become inappropriate.
If there is the potential for any joint or soft tissue restrictions then liaise with the PT or OT regarding any specific exercises or positions necessary for the patient to avoid contractures. This may affect position choice or may involve incorporating appropriate splinting to maintain muscle length.
Communication and involvement with the multidisciplinary team will aid interventions such as physiotherapy as treatment could occur at the same time as positional changes. This potentially allows for more physical assistance in moving the patient without involving other staff, allows collaborative working such as changing sheets, repositioning and assessment of pressure areas, and will minimize unnecessary disturbance of the patient (Hough 2001).
Fracture or suspected fracture
Patients with unstable fractures or suspected fractures should not be moved and the area should be well supported. A change of position could result in pain, fracture displacement and associated complications. Patients with osteoporosis* or metastatic bony disease with unexplained bony pain should be treated as having a suspected fracture. Risk factors for osteoporosis increase with age and include being female, Caucasian and postmenopausal, having a low BMI, a positive family history, a sedentary lifestyle and smoking. Before an osteoporotic lesion becomes apparent radiologically, at least 50% of bone mass must be lost so that pain may precede radiological changes (McGarvey 1990).
Altered tone
Tone can be altered by positioning with either positive or negative consequences. For further information on patients with neurological impairment and the unconscious patient, see below.
Spinal stability
It is important to establish spinal stability before positioning or moving the patient. The specifics of moving and positioning a patient with spinal cord compression are discussed later in this chapter.
Medical devices associated with treatment
Care should be taken to avoid pulling on lines or causing occlusion if the patient has a catheter, intravenous infusion, venous access device or drain. Pulling on devices may cause pain/injury to the patient and be detrimental to care. Prior to procedure ensure that electrical pumps have been disconnected and sets are untangled and flowing freely. Ensure these are reconnected once the patient is repositioned.
Medical status/cardiovascular instability
The defining parameter for mobilization is that the patient’s oxygen transport system is capable of increasing the oxygen supply to meet metabolic demand (Pryor and Prasad 2008). Patients who are medically unstable may become more unstable during movement. Therefore, patients who are acutely unwell should be monitored carefully during any change of position.
Fatigue
Fatigue can be a distressing symptom, so advice and help should be given to the patient to pace their everyday activities. Barsevick et al. 2002 describe energy conservation as ‘the deliberate planned management