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Prone positioning is contraindicated in patients who have increased intracranial pressure, hemodynamic instability, spinal cord injuries, maxillofacial injuries, or rib fractures, and in those who have had recent abdominal surgery.
Don appropriate personal protective equipment (PPE) based on the patient’s signs and symptoms and indications for isolation precautions.
Pronation therapy, or prone positioning, is a short-term therapeutic modality used to improve oxygenation in patients with acute respiratory distress syndrome (ARDS). It involves turning the patient onto the abdomen in the face-down position.
ARDS is not a diffuse, homogenous disease that affects all areas of the lungs equally; instead, the dependent lung areas are more heavily damaged than the nondependent lung areas. Pronation therapy improves perfusion to less damaged areas of the lungs and improves ventilation-perfusion matching.3
Pronation therapy is indicated in patients with ARDS who have a partial pressure of arterial oxygen/fraction of inspired oxygen (PaO2/FIO2 or P/F) ratio less than or equal to 150 mm Hg.5 This therapy can be used to facilitate the mobilization of secretions and provide pressure relief, and it improves oxygenation6 and mortality in patients with ARDS.4
No standard has been established for the length of time a patient should remain in the prone position. For maximum benefit, the prone position may be used up to 20 hours a day.1 The therapy is considered successful if the patient has an improvement in PaO2 of greater than 10 mm Hg or an increase in the P/F ratio of 20 mm Hg within 30 minutes of being placed in the prone position.1 The positioning schedule (length of time in the prone position and frequency of turning) is usually based on the patient's tolerance of the procedure, the success of the procedure in improving the patient's PaO2, and the patient's ability to sustain improvements in PaO2 when turned back to the supine position.
The most significant limitation to prone positioning is the actual mechanics of turning the patient. A number of methods are discussed in the literature, including manually turning the patient with the use of a single sheet, a turning system, or a turning frame and turning the patient with the use of the RotoProne® Therapy System.
Complications of the procedure include dislodgment or obstruction of tubes and drains, cardiac arrhythmias, hemodynamic instability, massive facial edema, pressure injuries, aspiration, and corneal ulcerations.
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Rationale: These maneuvers prevent disconnection of the ventilator tubing or kinking of the ET tube during the turning procedure.
Rationale: All IV tubing and invasive lines are adjusted to prevent kinking, disconnection, or contact with the body during the turn and while the patient remains in the prone position.
Rationale: Keeping the shoulder in neutral position and the elbow at 90 degrees prevents hyperextension of the shoulder.
Rationale: Reverse Trendelenburg position is recommended to keep the head of the bed up to decrease edema and prevent complications associated with enteral feeding and aspiration.
Rationale: All IV tubing and invasive lines are adjusted to prevent kinking, disconnection, or contact with the body during the turn and while the patient remains in the supine position.
Use pillows if gel pads are not available.
Do not place the pad below the iliac crest as femoral nerve compression can occur.
Rationale: Three health care team members are required for the turn; two perform the actual lifting and turning, while the third is positioned at the head of the bed.
8 Those health care team members stationed on either side of the bed maintain body contact with the bed at all times, serving as side rails to ensure a safe environment. Additional health care team members may be required based on the size of the patient.
Rationale: The chest piece is the only immovable part and serves as the marker for proper placement of the device.
Rationale: This position prevents direct pressure over bony prominences and provides sufficient distance between the chest and pelvis to allow the abdomen to be free of restriction and prevent bowing of the back.
If the patient has a limited neck range of motion or a short neck, the face-down position is optimal.
Because readjusting the head to relieve pressure points is difficult, move both headpieces to the top of the frame. Only the head cushion supports the forehead, and the chin is suspended to reduce the risk of skin breakdown from pressure.
Rationale: If the device is not secured tightly before the turn, the patient may develop shear or friction injuries on the chest and pelvic area during the turn.
When secured correctly, the device appears uncomfortable and possibly painful, but it creates a feeling of pressure as well as a sense of security for the patient during the turning process.
Ensure that the health care team member at the head of the bed supports the head and the artificial airway during the turn, while ensuring that all tubes and lines are secure.
A pillow under the ankles allows correct body alignment and prevents tension on the tendons in the foot and ankle region. If the patient is tall enough, dangling the feet over the edge of the mattress may be a sufficient alternative to supporting the ankles and feet in correct alignment.
Add extension tubing, as necessary, to lines that are too short to be placed at the head or end of the bed.
Rationale: If the side packs are not secured tightly before the turn, the patient may develop shear or friction injuries during the turn. All packs need to be positioned to prevent undue pressure on the patient's body surfaces and avoid malposition of joints (hyperextension of knees and hips in the prone position).
Rationale: Positioning the pads prevents direct pressure over bony prominences and provides sufficient distance between the chest and pelvis to allow the abdomen to be free of restriction and prevent bowing of the back.
Tighten chest pads last because constriction of the chest may restrict the patient's ventilatory effort and increase peak airway pressure.
During the procedure, have another health care team member monitor invasive lines and ventilator tubing to ensure that they are positioned correctly. In the absence of another health care team member, use the hand control unit at the head of the bed to turn the patient so that all invasive lines and tubes are visible during turning.
Rationale: The patient must be rotated before being turned prone.
The face pack is the only piece without a safety sensor.
Release the button if the need arises to stop the turning procedure because of kinking or pulling on tubes.
Rationale: All back hatches can be opened to allow full chest expansion. The foot hatch should be opened and propped open to prevent undue pressure on the heels.
If the need arises to return the patient to the supine position quickly, use the "CPR" button on the touch screen or below the screen at the foot of the bed.
Placement of the lower leg packs and either the chest or pelvic packs is required for supine rotation.
Rational: Keeping the shoulder in neutral position and the elbow at 90 degrees prevents hyperextension of the shoulder.
Rationale: The response time varies among patients. Some patients immediately respond; others may take several hours to show maximal response to the position change.
Reportable conditions: Decreasing peripheral oxygen saturation, hemodynamic instability
Rationale: The face and ears have minimal structural padding to reduce the risk of skin breakdown. Patients with short necks or limited neck range of motion have difficulty assuming a head side-lying position. These patients are more likely to develop facial skin breakdown.
Reportable condition: Skin breakdown
Rationale: Patients requiring prone positioning are at risk for skin breakdown, particularly to facial areas and bony prominences. Frequent, patient specific assessment is needed to prevent pressure injury.
Reportable conditions: Nonblanchable redness, shearing and friction injuries
Rationale: The prone position promotes postural drainage. Drainage from the nares may be a sign of an undetected sinus infection.
Reportable conditions: Drainage from the nares, change in the amount or character of secretions
Rationale: Tube feedings should continue even during pronation therapy.
Reportable condition: Evidence of tube-feeding material when suctioning
Reportable condition: Decreases in oxygenation saturation
Rationale: One vertebral level below the line crossing both the inferior angles of the scapula corresponds to the largest cross-sectional area of the left ventricle.
Rationale: Pressure can be applied to both direct compression on the middle thoracic spine and bilateral compression methods if the spine is unstable.
Berry, K. (2015). Pronation therapy case report: Nurse's perspective and lessons learned. Dimensions of Critical Care Nursing, 34(6), 321-328. doi:10.1097/DCC.0000000000000142
Mölnlycke Health Care. (2017). How to prone with Mölnlycke® Tortoise™ turning and positioning [video]. Retrieved March 31, 2020 from https://www.youtube.com/watch?v=WjzTue4McE0
*In these skills, a “classic” reference is a widely cited, standard work of established excellence that significantly affects current practice and may also represent the foundational research for practice.
Adapted from Wiegand, D.L. (Ed.). (2017). AACN procedure manual for high acuity, progressive, and critical care (7th ed.). St. Louis: Elsevier.
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