Frequency Repositioning Crtically Ill Patients in Intensive Care Unit - Literature review Example

Introduction As outlined above, the positioning of the patient in the intensive care unit is very important. There are various positions which are available for use in the intensive care unit depending on the condition of the patient. These positions can be varied depending on the patient’s condition at that time. In a manner to reiterate what Moore & Cowman (2010) states, different diseases need different positions for the best recovery of the patient. Some diseases are worsened by use of some types of positions and made better by other positions. Some positions include prone position, sitting position, supine position and lateral positions (Johnson, 2008). i) Sitting Position According to Laski (2006), the sitting position is usually where the patient to sit on the bed. As Swann, (2009), puts it, this is one of the ways of making the patient feel relaxed and more comfortable when he or she has been sleeping for a long time. In this position, the respiratory system is not compromised and the chest movements are normal and thus there is no decrease in the vital volume. In the cardiovascular system, Swann, (2009) is further of the view that there is less venous return since the heart is a higher level than the rest of the body parts. This, as Harvey (2005) puts it will result in less overload of the heart. According to Daley (2005), in patients with shock, it is not an appropriate position since the venous return will be reduced and the head will not receive enough blood. ii) Supine Position According to Hickey (2006), this is the position in which the patient lies with the face looking up. Swann, (2009) has studied and found that the effect of gravity on the patient is very minimal and thus there is no an increase or decrease in the blood flow to the brain or the other peripheral tissues. Hamper (2008) states that in spontaneous respiration, there is also minimal effect. The effects are as follows: a) Circulation Since the intravascular pressures, as Swann (2009) argues, change by two millimeters of mercury for every two point five centimeters increase in the vertical height, there is very minimal increase in the pressure increase secondary to this position. In this position, the head can be tilted upwards or downwards depending on the disease pathology. Blood flow to the brain and the rest of the vital organs is at the normal position (Price, et al, 2007). However, Moore & Cowman, (2010) argues that, when there is tilting of the head, there can be changes in the pressures in the blood in the various organs. This can be done to achieve various therapeutic purposes. For example, when a patient is in shock in the intensive care unit, he or she should be placed in a position in which the head is tilted downwards. In this way, the blood which is in the circulation will reach the heart easier than it would have been in the normal supine position. This is because in shock, the patients usually have less blood than the normal. The brain is very sensitive to ischemia and hypoxia and decreases in the amount of blood in the circulation easily affects the cerebral perfusion pressures. Decrease in blood volume directly affects the cerebral perfusion pressure and at some critical point, the decreased blood volume leads to cessation of cerebral perfusion. This can then result to hypoxic injury to the brain (Moore & Cowman, 2010). As told by Swann (2009), Moore & Cowman, (2010) confirms this view through how the duo puts it that this position is thus useful in a case where blood is decreased and thus there is low blood pressure. Tilting the head downwards leads to the increase in the flow of blood to the brain ensuring that the blood cells receive enough blood for the carrying out of the essential metabolic processes (Lynn-McHale, 2008). In effect, the head down position usually diverts blood from the organs which are not very essential to the brain where the lack of blood can cause very devastating effects (Harvey et al, 2005). As held by Moore & Cowman, (2010), the supine position, in the head high tilt is useful mostly in the cardiac diseases. This is more important in the congestive heart diseases whereby there an overload of the cardiovascular system (Foss, 2006). Tilting of the head high and the chest higher than the feet reduces the venous return to the heart and thus decrease the amount of blood reaching the heart. In the pathogenesis of the heart diseases, the increased venous return is usually the cause of failure of the heart. Thus, by tilting the head and the chest upwards, the amount of blood flowing from the peripheral tissues decreases making it receive less blood. As a result, the heart is not vulnerable to overload which can lead to heart failure (Hardwick, 2005). b) Respiration Moore & Cowman, (2010) further argues that the supine position in the normal position has very little effect on respiration. However, in the head tilt positions, there are variations in the respiration in the patient. In head down position, the abdominal viscera move upwards towards the diaphragm. Since the diaphragm is a very important muscle for respiratory effects, the compression of it and pushing it upwards reduces its ability to move up and down for respiration. The diaphragm is supposed to move down, towards the abdomen during the inspiration (Heinemann, 2006). When the patient lies in the head down position, the abdominal viscera will compress on the diaphragm and reduce the downward movement. Moore & Cowman, (2010) therefore states that this will reduce the amount of air inspired by the patient. As a result, patients who have pulmonary diseases are likely to worsen in this position. This method is not very suitable for patients who have pulmonary compromise or those who are receiving artificial respiration or respiratory support. On the other hand, Moore & Cowman, (2010) tells of how head up position pushes the abdominal viscera away from the diaphragm. This reduces the resistance to the diaphragm for downward movement. As a result of the reduction in the resistance, the diaphragm can move effectively and sufficient air is inspired (Larson et al, 2006). With this position, the patient who has some pulmonary diseases which has led to lung compromise is able to carry out sufficient respiration enough to oxygenate the tissues. In addition, the position allows easier artificial ventilation. Less pressure is needed for the ventilation since the abdominal organs do not form a barrier for the respiratory process. It is one of the preferred methods of respiration in patients who have respiratory or pulmonary compromise. It is also fit for patients who are receiving artificial ventilation. However, in shock, the position worsens the outcome (Moore & Cowman, 2010). iii) Prone Position According to Moore & Cowman, (2010), this is the face down position. In this position, the patients face is down and the patient assistant is not able to observe the patient well. It has the following effects on reparation and circulation: a) Respiration In this position, Moore & Cowman, (2010) argues that since the chest of the patient is facing downwards, this result in the compression of the chest against the mattress. As a result of this, Gilligan (2006) claims that there is a decrease in the elasticity of the chest. Chest muscles will work extra harder to bring about chest expansion. The weight of the body which is directed towards the chest usually applies some force which is against the muscles of the chest. This results in a situation whereby the chest muscles have to use extra energy to bring about the normal expansion. However, this is usually not the case in most times. What happens is that the chest muscles get fatigued because of the overload and they work less. As a result, there is less chest expansion which will reduce respiration and reduce the oxygenation of blood. It is thus not indicated in patients with pulmonary disease. In such diseases, the already poor function of the lungs is worsened by the poor position and thus may result in poor outcome of the disease process. Other views such as that held by Schallom, et al. (2005) tries to suggest that prone position also compresses the abdominal viscera. This is because the weight of the overlying organs lies directly on the abdomen. The compression of the abdominal viscera makes them move towards the chest where they can fit to escape the pressure in the abdomen. As a result, they push the diaphragm upwards making it had for it to move down during respiration. During the inspiratory process, the diaphragm moves downward to create negative intrathoracic pressure. With the pushing of diaphragm upwards, it cannot adequately contract and create enough negative pressure which will make the process of inspiration possible. As a result, there will be inspiratory insufficiency leading to poor oxygenation of blood. This can lead to hypoxia and thus leading to ischemia. Swann (2009) takes the view that patients who have respiratory diseases should be observed carefully in the prone position. The position as outlined above can easily compromise the respiratory function of the lungs and result to more harm to the patient combined with the already existing pathology in the patient. In addition, this position can result in pulmonary diseases such as pneumonia in the patients who were previously free of such diseases (Schallom, et al. 2005). This is because of the possibility of accumulation of secretions in the patient’s lungs which a very good media for the multiplication of bacteria (Wilkinson2005). As a result, a patient who was not having a pulmonary disease will end up getting a pulmonary disease which can easily complicate the illness (Swann, 2009). b) Circulation According to Schallom, et al. (2005), the circulation is also affected although minimally in the prone position. In the prone position, there is increase in the intrathoracic pressure due to the abdominal organs escaping to thorax and also the compression of the chest. This will reduce the negative intrathoracic pressure which is always in the thoracic cavity. The decrease in the negative pressure affects the venous return to the heart. The veins do not have a pumping mechanism to pump blood back to the heart. They use various mechanisms including the negative pressure of the chest cavity which makes the blood to be sucked from the veins into the heart. Schallom, et al. (2005) further states that, when the pressure decreases, there is less suction force of blood into the heart thus less flow of blood from the peripheral tissues to the heart. This causes pooling of blood into the heart and thus makes the patient to have less filling of the heart chambers (Brea, 2007). From the starling law, it happens that the more the stretching of the muscle, the higher the force of contraction. If the muscles are not stretched to an optimum length, the force of contraction will be reduced leading to decrease in pressure of blood. This can result in hypo perfusion and lead to brain damage (Schallom, et al. 2005). c) Nursing care Patients in prone positions should be monitored very well (Swann, 2009). According to Schallom, et al. (2005), there is a high risk of suffocation in the patient since the patient can easily press her or his nose against the mattress and thus causing obliteration of the airways. As a result, the patient becomes asphyxia which can lead to death. This is very important in patients who are comatose or those who have decreased central nervous system sensitivity to stimuli (Moore & Cowman, 2010). According to Azuela (2007), most of the times, patients who will be nursed in prone position are intubated to reduce the chances of interference with the respiratory process. Suzie (2007) argues that intubation ensures that the airways are always patent and they cannot easily be obliterated. Since the patient is facing downward, the patient assistant cannot know when the patient is in pain. He or she is not able to use the facial expressions which are very important in establishing pain in comatose and semi comatose patients. As Schallom, et al. (2005) states, feeding of such patients is also a problem. Those patients receiving oral nutrition may not be easily fed because of the position of the mouth. The patient needs to change his or her position to a suitable position which will allow the attendant to feed the patient with relative ease (Moore & Cowman, 2010). In addition, Moore & Cowman, (2010) are also of the opinion that the administration of drugs to the patients is also difficult, especially the oral drugs. The nurse needs to turn the patient to such a position which will be suitable for the administration of the drugs. In cases where it is not possible for the patient to occupy any other position other than the prone position, then, it becomes very difficult to administer food or drugs through the mouth. This will call for the use of parenteral nutrition and parenteral administration of drugs which may relatively be more expensive. iv) Lateral Positions According to Swann (2009), lateral positions are the most commonly used positions in the intensive care unit. Patients can either be on left lateral or right lateral position. In the lateral position, the patient lies on one side (Pilchard, 2006). For example, in the right lateral position, the patient is lying on his or her right hand with the left hand on top. These positions are usually indicated in many situations including in postoperative care of most surgical patients (Le Gall, et al, 2008). The patient should however be turned on two hourly basis to prevent pressure sores (Hagisawa & Ferguson-Pel, 2008). The position has the following effects in nursing care: a) Respiratory System The respiratory system, as said by Moore & Cowman (2010), is very free and the expansion of chest is not compromised in anyway. Further, Bolter (2006) argues that, the patient ventilates normally without any difficulties, and thus makes it possible to oxygenate blood. The patient does not have restriction of the movement of diaphragm thus no respiratory compromise. In fact, the position is very good for the drainage of respiratory secretions. This prevents the growth of bacteria in the respiratory system since the secretions are removed and do not accumulate. In addition, in case the patient vomits, he or she does not get aspiration pneumonia due to aspiration of vomits. b) Cardiovascular System Moore & Cowman, (2010) holds the view that the cardiovascular system is less affected except for that there is more venous drainage from the peripheral tissues because the effect of gravity of venous drainage has been counteracted. References Azuela E, Chevret S, Leleu G (2007). Some ICU patients experience inadequate attention with physicians. Crucial Care Med 8: 3044-3049 . Bolter. N. C. (2006). Families are not visitors in the critical care unit. Dimensions of Critical Care Nursing 1994; 13: 2-3 Brea C, Dracut K. (2007). Helping the Critically ill patients. International ICU Journal; 78: 50-53. Daley L. (2005).The perceived immediate needs of family with relatives in the intensive care setting. Heart Lung; 13: 231-237. 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