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3 Ensure that the bed is at the optimum height for handlers. If two handlers are required try to match handlers’ heights as far as possible. To minimize the risk of injury to the practitioner (Smith 2005, C).

Procedure

4 Auscultate the chest. To determine most affected area and therefore area to be treated. E

5 Position patient with segment to be drained uppermost. Use gravity to facilitate drainage of secretions. Bronchopulmonary segment needs to be perpendicular to gravity. E

6 Leave to drain for 10 minutes if tolerated. Suggested optimal duration (Fink 2002, R).

7 Physiotherapy techniques such as breathing/manual techniques may be carried out whilst in position. To further assist the removal of secretions. E

Problem-solving table 7.3 Prevention and resolution (Procedure guideline 7.9)

Moving and positioning the patient with neurological impairment

The general principles of positioning discussed earlier can be applied for this group of patients. However, the complexity of these patients highlights the difficulty of a uniform approach to overall management. Therefore, this section will look at some of the variations in presentation of this patient group and suggest some principles to be considered when positioning these patients.

This will cover recommendations for assisting patients presenting with physical neurological symptoms affecting their central nervous systems (CNS) and peripheral nervous systems (PNS) as a consequence of their disease or treatment itself. These may include:

hemiparesis or monoparesis*

hemi-aesthesia*

peripheral motor/sensory neuropathies*

spinal cord compression/injury.

Definitions

Neurological insult through disease or illness can cause damage to patients’ central, peripheral and autonomic nervous systems, affecting the relay of messages to and from nerves to enable normal motor and sensory function. Sequelae associated with neurological deficit include altered tone, abnormal movement patterns, sensory, cognitive, perceptual* and speech and language problems.

Anatomy and physiology

The nervous system is a complex organ which allows us to automatically and volitionally adjust to internal and external environments. This maintains equilibrium of body systems and enables effective, efficient motor and cognitive function. It can be considered in three main areas: central nervous system, peripheral nervous system and autonomic nervous system (ANS). The CNS consists of two parts: the brain and spinal cord. The brain consists of four lobes (frontal, temporal, parietal and occipital), the midbrain, pons, medulla oblongata and cerebellum. Each has individual and joint roles, and interconnects with the others via a complex system of pathways producing automatic and volitional movement and cognitive function. These connect with every part of the body via the PNS, consisting of cranial and spinal nerves which carry motor and sensory (afferent) fibres. The ANS, made up of sympathetic and parasympathetic components, regulates structures not under conscious control, for example arterial blood pressure, gastrointestinal motility and secretion, urinary bladder emptying, sweating, body temperature, activated mainly by centres in the brainstem, spinal cord and hypothalamus. Illness, disease and/or side-effects of treatment can affect any or all of these systems which will have implications for clinical practice and patient management.

Related theory

Disease or damage to the central or peripheral nervous system can lead to temporary or permanent complex physical, cognitive, psychological and psychosocial problems (Brada 1995, Ellison and Love 1997, Guerrero 1998, Kirshblum et al. 2001, Lindsay et al. 2004, Tookman et al. 2004). These may include:

weakness: unilateral, bilateral or global

altered tone

sensory changes

balance problems

perceptual problems

visual problems

cognitive problems

dysphagia*

dysphasia*

behavioural changes

autonomic dysfunction

dysarthria*.

If a person with a neurological presentation is unable to move, they are deprived of