The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [234]
5 Relaxed standing (see Figure 7.16e).
These positions serve to:
support the body, reducing the overall use of postural muscle and oxygen requirements
improve lung volumes
optimize the functional positions of the respiratory (thoracic and abdominal) muscles (Dean 1985).
Preprocedural considerations
The general procedural considerations mentioned earlier in the chapter are all relevant to this section. However, there are also some other general principles that need to be considered for these patients.
Pharmacological support
Administering nebulizers
If prescribed, administering nebulizers approximately 15 minutes prior to moving will help to dilate the airways, making breathing more efficient and ensuring better oxygen delivery to the blood.
Oxygen requirements
Repositioning can cause a temporary fall in oxygen saturation or a raised respiratory rate. If the fall is greater than 4% or recovery time is protracted, supplemental oxygen delivery may be required for several minutes before, during and after moving.
Non-pharmacological support
Pacing
It may be necessary to allow the patient time to rest during the process of getting into a new position to limit the exertion and therefore increased respiratory demand.
Environment
A breathless patient may be anxious about carrying out a task that could exacerbate their breathlessness. By reducing additional stressors such as noise and a cluttered environment, this can be minimized.
Positioning to maximize the drainage of secretions
Anatomy and physiology
The trachea branches into two bronchi, one to each lung (Figure 7.17). Each main bronchus then divides into lobar and then segmental bronchi (upper, middle and lower on the right, upper and lower on the left), each one branching into two or more segmental bronchi with a smaller and smaller diameter, until they reach the bronchioles and finally alveoli.
Figure 7.17 The bronchial tree.
Reproduced from Tortora and Derrickson (2009).
The walls of the airways are lined with epithelium which contains cilia. The cilia constantly beat in a co-ordinated movement, propelling the mucus layer towards the pharynx. The mucus layer traps any dust particles/foreign objects which can then be transported along the ‘mucociliary escalator’, an important part of the lungs’ defence mechanism. An increased volume of mucus is produced in response to airway irritation and in some disease states.
A reduced ability to effectively remove this mucus can lead to an increased bacterial load and therefore may compromise respiratory functioning by causing airway obstruction. Consequently leading to segmental atelectasis or lobar collapse, long term this can lead to chronic inflammation and airway destruction.
Preprocedural considerations
The general principles of care mentioned earlier in the chapter and the preprocedural considerations to minimize the work of breathing are all relevant to this section. However, there are also some other preprocedural considerations that need to be taken into account for these patients.
Non-pharmacological support
Humidification
Drainage of secretions will be optimized if the patient and therefore the mucus layer and cilia are well hydrated. This can be ensured by adequate humidification (see Chapter 10).
The problem-solving, postprocedural considerations and complications in general principles of moving and positioning patients and respiratory compromise also apply to these patients. Refer to relevant sections in this chapter.
Procedure guideline 7.9 Positioning to maximize the drainage of secretions
Equipment
Pillows/towels
Sliding sheets/manual handling equipment if indicated following risk assessment in accordance with local manual handling policy
Bed extension for tall patients
Preprocedure
Action Rationale
1 Explain and discuss the procedure with the patient. To ensure that the patient understands the procedure and gives their valid consent (NMC 2008, C).
2 Wash hands thoroughly or use an alcohol-based handrub. To reduce the risk of contamination and cross-infection