Positioning in the supine position is often used to create comfort for the client, to relieve pressure and prevent pain. Positioning is also used to optimize work health and safety for the caregivers, by helping hold the client or patient still. However, that positioning has a positive effect on respiration is often overlooked.
Secretion is Accumulated in the Lungs
Normal practice is often to have patients with respiratory difficulties lie down with the head end of the bed elevated at approximately 30-degrees. When the client is halfway lying and halfway sitting in this position, gravity will push the secretion from the lungs down to the bottom of the lung tissue allowing the client to breathe more easily because he/she is only using the top half of the lungs.
However, sitting or partially lying down in this position also harms the patients’ lungs ability to function. This is particularly true for the lower half of the lungs as secretion accumulates and fills the alveolar sacs. In time, this can limit the expansion of the lungs making it harder for the patient to breathe.
Ventilation of the Lungs
In pulmonary physiotherapy, using the lateral recumbent or side-lying position can be a great way of ventilating the lungs.
If the client lies in the right lateral recumbent position, the secretion found in the left lung will be more easily extruded as the lung is ventilated. This also helps the alveolar sacs maintain their elasticity and improves overall lung health.
It is important for the lung tissue to be ventilated in this manner, therefore, making sure to position clients or patients with respiratory difficulties in the lateral recumbent position, and turning them from one side to the other, is very important for respiratory health.
Many clients with pulmonary issues will typically not find it comfortable to lie in the lateral position, because it becomes harder for them to breathe. Therefore, the patient might become anxious and fear falling over into the prone position where their respiration will be even more challenged.
Therefore, it is important to make the lateral position as comfortable as possible for the patient by using positioning products designed to provide stability. This way it is possible to support and optimize the treatment of respiratory disorders.
Treatment Method
Practical experience suggests that lung diseases can be prevented by continuously and actively working with positioning. In this video, we present four different ways of positioning patients or clients, to help with respiratory difficulties.
The methods can be used for all clients with respiratory challenges such as Cystic Fibrosis, COPD, pneumonia and more.
In obstructive lung disease, such as COPD, asthma or bronchiectasis it takes longer to empty your lungs. The airflow is slower because the disease makes the airways narrower or the lungs less elastic.
Because breathing out is slower, the person may need to breathe in again before they have emptied their lungs. This is called hyperinflation or gas-trapping and makes breathing uncomfortable.
Try our suggestions to reduce breathlessness in obstructive lung conditions
Stand leaning forward
Stand leaning forward (figure 1) lean from the hips, with your forearms resting on something at the right height, such as a chair or kitchen work surface.
When you’re out and about, you could lean on a walking stick or a frame with wheels. If you’re shopping, use your supermarket trolley.
Sit leaning forward
Sit leaning forward (figure 2): lean resting your elbows on your knees
Sit leaning forward at a table
Sit leaning forward at a table (figure 3): rest your head and arms on pillows on a table when you’re really short of breath.
Side lying with leg on the floor bent at knee
Lie on your side with pillows under your head (figure 4). Make sure the top pillow supports your neck. Slightly bend the knee of the leg you are lying on, with your top leg straight. Having your legs apart may also help. This position can help when you’re breathless when you’re resting, such as when your symptoms flare up.
Download our breathlessness information (PDF, 582KB)
Download our breathlessness information (PDF, 582KB)
Patient positioning is vital to a safe and effective surgical procedure. Fowler’s position is the most common position for patients resting comfortably, whether in-patient or in the emergency department. Also known as sitting position, Fowler’s patient positioning is typically used for neurosurgery and shoulder surgeries. Variations of the Standard Fowler’s Position include Low Fowler’s Position, Semi Fowler’s Position, and High/Full Fowler’s Position.
With numerous applications, Fowler’s position is used for patients who have difficulty breathing because, in this position, gravity pulls the diaphragm downward allowing greater chest and lung expansion.2 Learn more about Fowler’s position use cases in common medical procedures, and the differences between the positions.
What is Standard Fowler’s Position
Standard Fowler's position, also known as sitting position, is typically used for neurosurgery and shoulder surgeries. The bed angle is between 45 degrees and 60 degrees. The legs of the patient may be straight or slightly bent. This position is often used for head, chest, and shoulder surgeries.
Standard Fowler’s position is the preferred position to combat respiratory distress syndrome. Due to the positioning of the bed, Standard Fowler's position allows for better chest expansion, improving breathing by facilitating oxygenation.3 Other advantages include an increase in blood and cerebral spinal fluid drainage and improved hemostasis.
Low Fowler’s, like Supine Position, is when a patient’s head is included at a 15–30-degree angle. This position can be used post-procedure, to reduce lower back pain, administer drugs and prevent aspiration during tube feeding. Low Fowler’s position is considered the best position for patients to rest.
What is Semi Fowler’s Position
In Semi Fowler’s Position, the patient is usually on their back. The bed angle is between 30 degrees and 45 degrees. The legs of the patient may be straight or bent.
Semi Fowler’s Position can be used when the patient faces difficulty breathing or is undergoing breathing treatments and when drainage occurs after an abdominoplasty. Due to the positioning Semi Fowler’s position is the preferred position during childbirth to improve the comfort of the mother.4 Also, patients experience less nausea in this position compared to patients lying down.
What is High/Full Fowler’s Position
In High Fowler’s position, the patient is usually seated upright with their spine straight. The upper body is between 60 degrees and 90 degrees. The legs of the patient may be straight or bent. This Position is commonly used when the patient is defecating, eating, swallowing, taking X-Rays, or to help with breathing.
High Fowler’s position is usually prescribed to elderly patients as it is scientifically proven to aid in the digestion process and help the patient overcome breathing problems.3 Resting in a High Fowler’s position for an extended period can cause discomfort and increase the development of pressure ulcers.
Contradictions of Fowler’s Position
Positioning of the patient is primarily for reasons of anatomical exposure for the surgical procedure. In instances where the patient does not tolerate the sitting position well, adjustments can be made to accommodate any intolerances of the patient. For Example, patients with pressure ulcers in the lower back or buttocks may not be able to tolerate the sitting position.
Additional measures to reduce pressure and contact of the injured area with hard surfaces may be needed. These can include extra padding, changing angles, employing tilt to remove pressure where the injury is lateral. Additionally, patients with previous spine surgery may have range of motion limitations that make this position contraindicated. Patients should be assessed for their ability to tolerate this position and for any intrinsic patient factors that may pose any additional risk to the patient.
Patient Positioning Considerations for Fowler’s Position
Fowler’s position can be achieved in many different ways using either the native sections of a general surgical table or through the addition of surgical table accessories and positioning aids. Common surgical table accessories & positioning aids used when employing Fowler’s position include Beach Chair positioners or foam body positioners.
Beach Chair Positioners are most often used for High Fowler’s positioning in orthopedic shoulder procedures (total shoulder replacement, shoulder arthroscopy, rotator cuff, etc.). Beach Chairs often have removable left & right back sections that provide surgical site access to the patient’s shoulder. It is also common for Beach Chairs to have a lateral support that is employed to keep the patient positioned upright and restricts lateral torso movement during the rigors of upper extremity procedures.
Limb Positioners are commonly used in collaboration with Beach Chairs when employing High Fowler’s positioning in orthopedic shoulder procedures. Basic limb positioners can include arm and elbow positioners for neutral positioning of the patient’s operative arm for surgical site access or the non-operative arm(s) to get them out the surgeon’s way. More advanced limb positioners allow the surgical team to position the patient arms in unique, spatial positions that enable surgical site access to the shoulder across a spectrum of shoulder joint procedures. OR staff can also employ advanced limb positioners for positions other than Fowlers; for instance, in lateral patient position to enable suspended arm positioning for orthopedic shoulder procedures.
Multi-position armboards are similar to basic limb positioners in that they facilitate neutral positioning of the patient’s operative arm for surgical site access or the non-operative arm(s) to get them out the surgeon's way to access the target anatomy.
Neurosurgical headrests and head positioners are commonly used in Semi-Fowler’s and High Fowler’s positioning to attain surgical site access to the patient’s skull, facial and neck anatomy. The general table is often positioned using native table sections (no Beach Chair used) to achieve the desired Fowler’s position. The native head section of the surgical table is often removed, and the desired anterior or posterior positioning accessories are attached to facilitate immobilization of the head and surgical site access.
Gel and foam positioners are often used across all Fowler's positioning variations. Common positioning aids that support the patient across Fowler's positions include headrest donuts, face masks (for Beach Chairs), arm cradles, wedge positioners (for the legs or feet), heel & ankle cradles, and egg-crate foam sheets to protect or bolster key anatomical areas. Pre-operative patient assessments are always advised to assess the patient’s skin, body morphology, bony prominences, and any special anatomical areas that need unique consideration during surgery. See STERIS's Healthcare Knowledge Center article on Pressure Management to learn more.
Conclusion
One of the most common patient positions, the Fowler’s position provides better surgical exposure and improved breathing. Surgical staff should consider risks and complications associated with the Fowler’s position such as:
- a decrease in the return of blood to the heart
- venous embolism
- air or gas inside the skull
- an increased potential for airway loss
- an increased risk for nerve damage and facial edema
Variations to the Fowler’s position include the Standard Fowler’s, Low-Fowler’s, Semi-Fowler’s, and High-Fowler’s position.
Regardless of what position is being used for a patient during a procedure, it’s important to follow best practices for positioning.1 Surgical Staff should always refer to their facility's positioning policies, procedures, and training when positioning a patient.
- Have an adequate number of personnel, devices, and equipment available during positioning activities helps to ensure patient and personnel safety.
- Respect the patient’s dignity and privacy during positioning: only necessary personnel in the room when the patient is exposed.
- Maintain the patient in a natural neutral alignment. Keep the patient’s head and neck in a neutral position without extreme lateral rotation and avoid hyperextending.
- Verify the patient's complete body is in physiologic alignment and that the hands, fingers, feet, and toes are protected from surgical table articulations.
- Operating Room staff should always use safe body mechanics during transfers and positioning.
- Ensure that the patient is not in contact with any metal portions of the surgical table or positioning devices.
- Never exceed the weight limits for the table or the accessories used and always follow the manufacture’s guidelines and recommendations when using the surgical table and accessories.
- Inspect all equipment, pads, and accessories before use and replace them as needed.
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References
1Guideline for positioning the patient. (2017). AORN Journal, 105(4), P8-P10. doi:10.1016/s0001-2092(17)30237-5
2 //nurseslabs.com/patient-positioning/#fowlers_position
3 //www.topregisterednurse.com/fowlers-position/
4 //nurse.plus/nclex-terminology/terms-abbreviations/semi-fowlers-position/