The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [240]
To optimize patient comfort. E
To maintain joint and soft tissue range (ACPIN 1998, C; E; Barnes 2001, R4; Edwards 1998, E).
To maintain soft tissue and joint range (Edwards 1998, E; Shumway-Cook and Woollacott 2001, E).
5b Consider and apply possible modifications as specified below for side-lying (see Action Figure 5a1(b).
Place pillow under head and in front of trunk.
Place pillow in front of trunk.
Place patient’s affected arm on pillow. Apply resting splint for hand/forearm if required.
To support the patient’s affected shoulder and upper limb due to a risk of trauma, pain, muscle and soft tissue shortening (Ada et al. 2005, R2b, E; Dean et al. 2000, R2b).
To reduce the influence of primitive developmental reflexes and asymmetrical posturing of head and trunk in patients with high or low tone. E
May be effective in maintaining opposing trunk muscles. E
To maintain soft tissue and joint range (Barnes 2001, R4; Edwards 1998, E; Shumway-Cook and Woollacott 2001, E).
Postprocedure
The general principles of care mentioned earlier in the chapter are all relevant to this section.
For patients requiring use of an external splint to maintain joint position and range, skin condition must be closely monitored. To monitor skin integrity and pressure care. E
Action Figure 5a1 Positioning the patient with neurological weakness. (a) Supine: affected arm supported on pillow. (b) Side-lying: affected arm supported on pillow.
Action Figure 5a2 (a) Ankle foot orthosis. (b) Ankle foot orthosis in situ.
Problem-solving table 7.4 Prevention and resolution (Procedure guideline 7.10)
Postprocedural considerations
The general principles of care 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.
Ongoing care
Where the patient requires use of an external splint to maintain joint position and joint range, skin integrity must be closely monitored (see Chapter 9), including skin/pressure care, and any adverse effects treated accordingly following assessment.
Documentation
The general principles of care mentioned earlier in the chapter are all relevant to this section. However, in addition, instructions regarding the appropriate use of splints should be clearly documented in the patient’s care plan including application, removal and timing of wear.
Education of patient and relevant others
The patient and carer(s) should be given written information regarding use of any splints or orthotics including application, removal and timing of wear according to the therapist’s advice. Environmental and clinical management strategies should be explained to the patient and carers for effective holistic management.
Positioning and management of an amputee
Definition
Amputation refers to the loss of a part or whole of a limb normally as a result of trauma or vascular disease (Figure 7.18).
Figure 7.18 Levels of amputation in the upper and lower limb.
Reproduced from Engstrom and van de Ven (1999).
Related theory
The level of the amputation and the surgical technique can affect both the cosmetic appearance as well as the potential functional ability for the individual.
There are certain levels of amputation that provide a residual limb suitable for a prosthetic fitting, function and cosmesis. Cosmetic appearance will depend to some extent on the level of the amputation and what prosthetic options this leaves. It is essential that one of these levels is selected rather than the boundary of the dead or diseased tissue with the viable tissue. (Engstrom and van de Ven 1999)
Evidence-based approaches
Rationale
Indications
Positioning and moving patients both before and after amputation are indicated for all patients undergoing upper or lower limb amputation whatever the level.
This is in order to:
prevent problems arising as a consequence of reduced mobility
maintain range of movement and muscle strength in order to rehabilitate the patient early postoperatively