patient positioning: more than just “turn every 2h” p

16 BARROW QUARTERLY • Vol. 22, No. 3 • 2006

O R I G I N A L A R T I C L E

Patient Positioning: More ThanJust “Turn Every 2h”

Positioning patients with neurologicinjury may seem like a routine nurs-

ing task. However, neuroscience nursesmust consider many factors when theyposition patients. Nurses must optimizethe neurologic function of patients witha brain injury while protecting them fromthe hazards associated with immobility.Patient positioning is not just a matter of“turn every 2h” or “head of bed 30 de-grees at all times.” Delicate balances inthe circulation of blood, CSF, and cellu-lar fluid as well as the dynamics of cerebralelastance and anatomical shift must beconsidered when patients with differenttypes of brain injury are positioned. Im-portant factors related to positioning alsoaffect cognition, peripheral nerve func-tion, joint mobility, pulmonary function,and general recovery from brain injury.

Position of Head of BedOnce a cervical injury has been ruled

out, several factors determine how thehead of bed is positioned in patients withbrain injuries. Research by physicians andnurses offers conflicting findings regard-ing the best position for the head of thebed for patients with neurologic injury.Positioning the head of the bed at 30 de-grees is associated with lower ICP com-pared to a flat or lower elevation (Fig. 1).6

Others advocate individualizing this de-cision for patients with large hemispher-ic strokes.11 Elevating the head of the bedto 30 degrees decreases ICP, but it also de-creases systolic arterial blood pressure.The effects of position change on othervariables, including measures of cerebralperfusion pressure, jugular venous oxy-gen saturation, and velocity of cerebralblood flow, have also been studied.6 Most

For patients with neurological conditions, the routine nursing task of turning andrepositioning requires special attention. Neuroscience nurses must select theoptimal adjustments for the head of the bed and the best equipment and meansof mobilization when caring for this complicated patient population. This articledescribes the careful balance of intervention and vigilance, hallmarks of neuro-science nursing care, in terms of patient positioning.

Key Words: nursing, positioning

Abbreviations Used: CSF, cerebrospinal fluid; EEG, electroencephalog-raphy; ICP, intracranial pressure

Division of Nursing, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center,Phoenix, Arizona

Terry Bachman, RN

Copyright © 2006, Barrow Neurological Institute

researchers advocate raising the head ofthe bed to 30 degrees for patients with el-evated ICP.6 Researchers also advocateelevating the head of the bed to augmentvenous jugular return, arguing that thebenefits outweigh the effects of loweredsystolic arterial blood pressure.8

The position of the head of the bedmay be individualized for patients witha subdural hematoma. Patients withchronic subdural hematomas tend to befrom an older population and thereforehave diminished cerebral elastance andsome degree of brain atrophy. At our in-stitution, such patients are managed withthe head of bed flat after the subdural he-matoma has been evacuated. This posi-tion prevents gravity from pulling thebrain away from the dura. Theoretically,the flat position allows the CSF to floatthe brain in a more neutral position.Once the cerebral tissue has had a chanceto expand to fill the void of the evacuat-

ed area, the head of the bed is elevated astolerated (as determined by the physi-cian’s evaluation of a patient’s routinecomputed tomography scans).

Patients with subarachnoid hemor-rhages, cerebral contusions, epidural he-matomas, and cerebral infarcts need thehead of the bed positioned at 30 degrees.The head itself is positioned neutrallywith the nose, chin, and sternum inalignment (Fig. 2). This position opti-mizes jugular venous drainage and de-creases the chance of aspiration relatedto craniopharyngeal weakness. Thehead-up and neutral positions are main-tained while the patient is alternatedthrough the supine, right, and left side-lying positions. Pillows and rolled tow-els are placed strategically to preventgravity or hyperactivity from placing par-alyzed or overly active limbs, respective-ly, in a position that decreases venous re-turn (Fig. 3).

For patients who have undergonetranssphenoidal resection of a pituitarytumor, the head of bed is maintained atmore than a 45-degree elevation to pro-mote venous drainage of the head andbrain. The drainage afforded by this po-sition helps decrease swelling of the softtissues of the face and helps to decreasefluid pressure on the surgical site. Thiselevation is instituted during the earlypostanesthesia phase while nurses teamtogether to lift and position the patient inbed. It is maintained when the patient isalert and moving independently.

Determining the best position for pa-tients with a CSF leak is another chal-lenge. At our institution, the neuro-science nurses reason through the bestmanagement for each patient in collabo-ration with the physicians. In general, thehead of the bed is elevated at all times forpatients with rhinorrhea and otorrhea.Patients with leakage from spinal incisionsare initially maintained with the head ofthe bed flat. If the patient has a lumbardrain inserted to manage the leak, stipu-lations for positioning may include grad-ually increased activity with titration ofthe height of the drainage chamber toachieve a desired volume of drainage.10

Activity may be increased to include sit-ting in a chair, assisted ambulation, orboth.

While the patient is standing andwalking, the nurse closes the drain. Whenthe patient is seated and comfortably sta-tionary, the nurse levels and reopens thedrain. During all repositioning, the nursemaintains the integrity of the drainage sys-tem. Pulling or tugging the drainage tubeis avoided. The tube is observed careful-ly to avoid over- or underdrainage.

Severe IntracranialHypertension

Patients with severe intracranial hy-pertension requiring treatment with apentobarbital coma must be maintainedin a neutral head position (Fig. 2) to op-timize pulmonary function. Pentobar-bital induces a comatose state, createstotal flaccidity of the muscles, and in-terrupts basic reflexes. The patient’s nat-ural defenses against aspiration, atelec-

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Bachman: Patient Positioning: More Than Just “Turn Every 2h”

BARROW QUARTERLY • Vol. 22, No. 3 • 2006

Figure 1. (A) The head of the bed is positioned at a 30-degree angle compared to a (B) horizontal or flat position.

B

A

tasis, and immobility are thereby para-lyzed. Patients in this induced comatosestate may experience profound increas-es in ICP merely from the stimulationassociated with repositioning.

A solution to the complications asso-ciated with patient immobility has beenthe use of rotational beds. These bedsuse a motorized mechanism to turn pa-tients from supine to side-lying positionsat frequent intervals while eliminatingthe stimulation that can increase ICP.The head and limbs are maintained incontrolled neutral positions via bolsters

adjusted by the nurse according to thecontour of an individual patient’s habi-tus. The specialized beds provide the ro-tation necessary to mobilize pulmonarysecretions and to promote pulmonarycirculation.

Several types of rotational beds areavailable, and each has its own advantagesand disadvantages. At our institutionRoto Rest® beds (Kinetic Concepts Inc.,San Antonio, TX) are preferred (Fig. 4).The firm bolsters on this bed achieve neu-tral alignment and continue to maintainthe patient’s position after hours of rota-

tion. With this bed, the patient requiresless frequent repositioning by the nurse.

The air pillow-styles of other rota-tional beds provide support and rotationbut do not seem to adequately maintainneutrality of the axis formed by the head,chin, shoulder, and sternum, which op-timizes jugular venous return. Air-stylebeds, however, relieve pressure and pro-vide maximum degrees of rotation.Consequently, attention to skin integri-ty, especially over the bony prominencesduring activities of daily living, must bevigilant. Prolonged supine positioning

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Figure 2. (A) Patient shown in optimal neutral alignment. (B) Misalignment can compromise a patient’s jugular venous drainage andshould be avoided.

Figure 3. (A) Pillows positioned to elevate the arms in a supine position at the level of the heart to improve venous return and to minimizethe risk of injury to the ulnar nerve. (B) Hyperflexed arms, which can impede venous return and decrease mobility, should be avoided.

A

A

B

B

can cause a decubitus ulcer to form onthe occiput. To maintain skin integrity,waffle air products can be used to cush-ion the occiput.

Even with the use of the best rota-tional bed, further intervention via man-ual positioning is sometimes needed tomanage high ICP. Attention to subtledifferences in a patient’s physiologic re-sponses to turning may show that a pa-tient’s ICP is higher when rotated to oneside compared to the other. Patients maybe intolerant to rotation as indicated byICP sustained higher than 20 torr.

The issue of turning rests on the judg-ment of the critical care nurse who mustbalance the effects of various ICP inter-ventions with the effects of rotation.Sometimes actions to facilitate pul-monary function alleviate factors that in-crease ICP. Close monitoring and ad-justment of rotational bed settings so thata patient rotates to two possible direc-tions, from supine to the side of best ICP,can allow continued mobilization of thepatient in the presence of precarious in-tracranial hypertension.

Avoidance of PeripheralNerve Injury

Patients with various degrees of braininjury may or may not be able to sense orrespond to the numbness, tingling, or painassociated with the onset of a peripheralnerve injury. Much of the research on ia-trogenic peripheral nerve injuries is basedon monitoring of postoperative compli-cations. The most common peripheralnerve injury is ulnar neuropathy, which isassociated with positioning for surgery.As a preventive measure at our institu-tion, neurosurgical patients undergomonitoring during surgery to identifyslowing of nerve conduction that can sig-nal the possible onset of neuropathy.When indicated by the EEG technician,patients are repositioned during surgery toprevent potential injury.

In other inpatient care settings wherepatients are not monitored by EEG, thepreventive measures advocated by theAssociation of Operating Room Nurs-es and The American Society of Anes-thesiologists can still be considered.1

These measures include avoiding ex-tended pressure on the ulnar (Fig. 5) andperoneal nerves (Fig. 6). Patients arepositioned with the extremities sup-ported on pillows while the extremes offlexion and extension are avoided. Toprevent irritation of the ulnar nerve,pressure is avoided in the area of theelbow and ulnar groove. To prevent ir-ritation of the peroneal nerve, pressureon the head of the fibula must be avoid-ed. Therefore, pillows are placed toavoid pressure behind the knee. Thevariability of peripheral nerve anatomyamong patients requires nurses to devel-op individualized positioning changesfor each patient. The nurse can adjustpositioning by recognizing subtle move-ments of a semicomatose patient suchas the tendency to move an extremityfrequently or to grimace when a limb isrepositioned. Simply alternating theposition of an upper extremity fromsemiprone to supine can alleviate pres-sure on a susceptible ulnar nerve.3

Cardiovascular Function,Joint Mobility, and MotorFunction

The comatose condition of patientsrecovering from serious brain injury canlead to weakened cardiovascular func-tion, joint immobility, and decreasedmotor function. Neurologic injury canlead to spasticity and abnormal muscletone, and these symptoms can be exac-erbated by immobility. Bedrest in healthysubjects is associated with an increasedheart rate and decreased cardiac vagaltone. In a study of five young healthymales subjected to 21 days of bedrest, anincrease in their maximal heart rate wasassociated with a reduction in their max-imal uptake of oxygen. The authors re-lated the findings to decreased stroke vol-ume and cardiac output.4 Periods ofimmobility can lead to stiffness; to short-ening of tendons and musculature sur-rounding the joints, especially in thescapula, hip, and lower back;2 and to boneloss that can be slow to reverse with ther-

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Figure 4. Photograph of the RotoRest® bed used at our institution. The bed is shownrotated about 45 degrees to the left.

apy. Loss of joint mobility can impair re-habilitation. Patients with joint immo-bility must struggle to overcome both theimmobility and paresis.

For these reasons, position changeshave an important role in maintainingmobility for patients who will eventu-ally regain motor function. Intermit-tently raising the head of the patient’sbed to 45 to 90 degrees for short peri-ods as soon as tolerated can help pro-mote orthostatic responsiveness andcombat some of the cardiovascularchanges related to the supine position.Recognizing muscle hypertonicity andflaccidity before repositioning can helpoptimize intervention. Patients withhypertonic resistance to passive range ofmotion benefit from positioning thatgently encourages relaxation of hyper-tonic muscles and increased range ofmotion of the affected joints. Somehemiplegic patients respond to posi-tioning on the affected side so that theaffected scapula is splinted in a positionthat decreases pain, allowing the sur-rounding muscles to relax. Positioningthe upper extremities so that gravity cangradually open an affected elbow jointcan enable a gentle increase in mobilityof the upper extremity. Wrapping thinpillows to serve as splints around theelbow can help decrease hypertonicityand open the joint (Fig. 7).

Simple measures in turning brain-injured patients can prevent injury tojoints and ensure smooth action of themuscles. When a patient is turned, firstmoving the patient’s nose and chin intothe direction of the turn often elicits acooperative effort from the patient toreach into the turn (Fig. 8). By careful-ly placing a hand with fingers spread sup-portively behind the patient’s scapula, thenurse can move the patient further intothe sidelying position without injuringthe scapula or shoulder joint.

Other measures are considered whena brain-injured patient is being reposi-tioned. Periodically, patients slip down inbed and must be repositioned (Fig. 9).Incapacitated patients should be placedin a sitting position in bed or in a sup-portive chair at least twice a day. Consis-tently placing support under the affected

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Figure 5. Illustration showing the course of the ulnar nerve and the site susceptible to pres-sure injury (arrow).

Figure 6. Illustration showing the course of the peroneal nerve in the lower leg and thesite susceptible to pressure injury (arrow).

Figure 7. Patient with pillow splint around left elbow.

limb and behind both the affected andunaffected scapula can be enough to helpthe seated patient to maintain an alignedupright posture (Fig. 10). This positionpromotes chest expansion and decreasesthe likelihood of shoulder subluxation.

Early bilateral range of motion is an-other significant intervention provided bynurses and therapists. Range of motionperformed bilaterally with the patient ina neutral supine position with the upperextremities moved in tandem may con-tribute to positive redevelopment ofmovement pathways (Fig. 11). Linkingthe reaching and rotating movements ofthe upper extremity during position

changes strengthens core muscles andcontributes to the balanced developmentof laterally weakened trunk muscles. Thistherapeutic maneuver can rehabilitate sit-ting balance and eventually can aid pos-ture while standing. Proponents of thistype of assisted activity stress the impor-tance of avoiding overstimulation of com-pensatory unilateral hypertonic move-ments. Further increase in this kind ofmobility is achieved by stimulation ofnormal body movements during activitiesof daily living and with activities that fa-cilitate normal balance and muscle tone.Great patience and effort are needed tosupport patients in performing their own

simple movements such as reaching to-ward a side rail or moving higher in bed.

Pulmonary FunctionManaging patient position to opti-

mize pulmonary function is a commonchallenge for neuroscience nurses, andcurrent research supports the nurses’ ef-forts in this area. Studies have shown thatmaintaining the head of the bed at a min-imum of 30 degrees is independently as-sociated with fewer occurrences of ven-tilator-acquired pneumonia.9,12 Studiesalso support intermittently positioningpatients in the prone position to promote

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Figure 8. (A) Appropriate technique for turning incapacitated patients. The patient’s head is first positioned in the direction of the turn(inset). (B) Inappropriate turning technique can lead to shoulder subluxation. When the head lags behind, the patient is more likely toresist the turn.

A B

Figure 9. (A) When patient is positioned in bed appropriately, the hips are flexed to encourage normal expansion of the chest and ab-domen. (B) When the patient’s body slips toward the foot of the bed, flexion occurs higher than the hip and breathing is inhibited.

A B

recovery from severe respiratory compli-cations.5 The nurse must balance thepositive effect of positioning against thepatient’s ability to tolerate the position.As stated earlier, small changes in posi-tion can have large effects on ICP. An-ticipating how rotation will affect the po-sition of invasive lines such as the

endotracheal tube, ventilator tubing,feeding tube, and central line is impor-tant. Overstimulation of a cough or gagreflex by movement of the lines can causeprecarious increases in lung pressure.

Adding a semiprone position to aturning regimen may be beneficial forpatients unable to tolerate a fully prone

position. The semi-prone position issimilar to the side-lying position but in-cludes more rotation (Fig. 12). The pa-tient’s elevated shoulder, arm, hip, andlower limb are rotated beyond midlineand supported on pillows. This positionis thought to help increase circulationwithin the lung fields and to allow some

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Figure 10. (A) Appropriate positioning of a right hemiplegic patient. The right side of the head, both scapulae, and both arms are sup-ported to maintain an aligned upright position. (B) When the patient is positioned inappropriately and the head and limb are unsup-ported, the patient lists to the right.

A

Figure 11. Sequence of range-of-motion exercises. The nurse moves the patient’s upper extremities in tandem.

B

A B

movement of static secretions, which, inturn, may open collapsed alveoli. Al-though the patient is not fully prone inthis position, the patient’s airway is stillless visible to the nurse. Consequently, itis crucial to check the airway to makesure that it remains patent.

CognitionPositioning procedures can have pos-

itive effects on the cognition of patientswho are lethargic or even semico-matose. Such patients may have theireyes open only for brief periods. Whenreclined to 30 degrees or less, as is typi-cal, their view is mostly of the ceilingand upper parts of walls (Fig. 13A).Caregivers are predominantly seen lean-ing over side rails straining to placethemselves in the patient’s line of vision.If the patient’s response to positionchanges (i.e., ICP, cerebral perfusionpressure, systolic arterial blood pressure)begins to stabilize, repositioning the pa-tient to an upright 45- to 90-degreeangle provides a relatively normal view(Fig. 13B). Caregivers in the patient’sline of vision no longer need to strainto see the patient. They can stand or sitcomfortably and see the patient “eye toeye.” This perspective may help patientsto comprehend their environment, tosee their family in ordinary stance, andthereby to improve their interactionwith their caregivers.7

ConclusionNeuroscience nurses must balance

the basic standards of nursing practicewith evidence-based and aesthetic as-pects of caregiving. The benefits of reg-ular changes in a patient’s position mustbe weighed against the risk of fluctua-tions in cerebral blood flow, cerebralperfusion pressure, ICP, and systolic ar-terial blood pressure and the myriad is-sues associated with immobility. Whenthese complex issues are artfully bal-anced by neuroscience nurses, signifi-cant complications can be avoided andlifetime outcomes for patients can beimproved.

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Figure 12. Appropriate placement of patient in the semi-prone position. Because the pa-tient’s airway is partially obscured, the nurse must be vigilant to ensure adequate respi-ration.

Figure 13. (A) Typical view from patient’s perspective when the head of the bed is posi-tioned at 30 degrees. (B) View from patient’s perspective when positioned at a 90-degreeangle.

A

B

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Force on Prevention of Perioperative PeripheralNeuropathies: Practice advisory for the preven-tion of perioperative peripheral neuropathies.Anesthesiology 92:1168-1182, 2000

2. Bloomfield SA: Changes in musculoskeletalstructure and function with prolonged bed rest.Med Sci Sports Exerc 29:197-206, 1997

3. Chuman MA: Risk factors associated with ulnarnerve compression in bedridden patients. JNeurosurg Nurs 17:338-342, 1985

4. Convertino VA: Cardiovascular consequences ofbed rest: Effect on maximal oxygen uptake. MedSci Sports Exerc 29:191-196, 1997

5. Curley MA: Prone positioning of patients withacute respiratory distress syndrome: A system-atic review. Am J Crit Care 8:397-405, 1999

6. Fan JY: Effect of backrest position on intracrani-al pressure and cerebral perfusion pressure inindividuals with brain injury: A systematic review.J Neurosci Nurs 36:278-288, 2004

7. Inouye SK, Bogardus ST, Jr., Baker DI, et al: TheHospital Elder Life Program: A model of care toprevent cognitive and functional decline in olderhospitalized patients. J Am Geriatr Soc 48:1697-1706, 2000

8. Jandial R, Aryan HE, Nakaji P: Neurosurgical Es-sentials. St. Louis: Quality Medical Publishing,2004

9. Kollef MH: Ventilator-associated pneumonia. Amultivariate analysis. JAMA 270:1965-1970,1993

10. Lemole GM, Jr., Henn JS, Zabramski JM, et al:The management of cranial and spinal CSFleaks. BNI Quarterly 17(4):4-13, 2001

11. Schwarz S, Georgiadis D, Aschoff A, et al: Effectsof body position on intracranial pressure and ce-rebral perfusion in patients with large hemi-spheric stroke. Stroke 33:497-501, 2002

12. Torres A, Serra-Batlles J, Ros E, et al: Pulmonaryaspiration of gastric contents in patients receiv-ing mechanical ventilation: The effect of body po-sition. Ann Intern Med 116:540-543, 1992

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patient positioning: more than just “turn every 2h” p

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