Skill List > Breathless Patient – Positioning
Clinical Alert
Elsevier Clinical Skills covers the principles of this procedure. You must follow local policies and procedures regarding technique, equipment used and documentation.
Authors:
Based on Nicol: Essential Nursing Skills 4E
Adapted by: Moya Paton BSc MAEd PGCE RNT RN(Adult) RN(Children); Sue Faulds BSc(Hons) MA(Ed) DipHE RN
Updated by: Sue Faulds BSc(Hons) MA(Ed) DipHE RN
Last updated: May 2017
Positioning to alleviate breathlessness. (From Esmond G 2001 Respiratory Nursing. Baillière Tindall, Edinburgh.)
Learning Objective
After reading the skill overview, watching the video, following up some of the references/web sites and completing the self-test quiz you should be ready to be assessed in practice in the skill of positioning a breathless patient.

Introduction


The term ‘breathless’ is a lay term used to describe feeling ‘short of breath’, and synonyms commonly used by nurses include dyspnoea and respiratory distress (Simon et al. 2013). It may be caused by disease processes such as asthma and chronic obstructive pulmonary disease (COPD), and by non-pathological causes such as exercise and anxiety (Janssen et al. 2015). Breathlessness may be a temporary symptom (e.g. in acute asthma) or it may be chronic (e.g. in chronic obstructive pulmonary disease). Breathlessness is also a commonly occurring symptom in life-limiting, palliative and end of life care and can be very distressing for the patient, and it is important for the nurse to recognise that the patient’s family or caregiver may find the breathlessness equally distressing to witness.  Understanding the impact on both the patient and the family is an important part of supporting the person with breathlessness.

The most widely accepted definition is proposed by the American Thoracic Society (ATS 2012), defining breathlessness as 'a subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity. The experience is derived from interaction among multiple physiologic, psychological,  social, and environmental factors and may induce secondary physiological and behavioural responses'.

As well as producing objective measurable changes such as increased respiratory rate, fatigue, colour change, and changes in blood gases, breathlessness also has an important subjective element. This makes it imperative that the nurse communicate carefully with the patient to find out which nursing intervention most effectively provides comfort. Dyspnoea can make it difficult for the patient to communicate effectively, however, due to fatigue or neurological changes as a result of inadequate gas exchange. Use of communication techniques such as closed questions can be useful (Herigstad et al. 2016).

Among medical and nursing interventions to relieve dyspnoea, patient positioning is frequently used by patients and nurses. According to Barnes (2010) there is a lack of robust evidence to support the use of one particular position over another, though anecdotally, a position whereby the patient is leaning forwards appears to be most naturally adopted by the breathless patient. This action enhances the ability to use the abdominal muscles for breathing, decreases diaphragmatic pressure, and creates more ‘space’ in the thoracic cavity for the lungs to expand (Bott 2013).

Ambulant patients may find relief from standing with their back to a wall or from leaning over the back of a chair. Patients who prefer or are required to lie down may need supporting with their chest and head up, or for some, lying on their side with their abdomen unsupported but this is dependent upon the patient.

To facilitate the ability to use abdomen muscles and decrease diagrammatic pressure, patients in a chair or in bed may gain most relief from sitting upright supported by pillows or by elevation of the head of the bed. They may also prefer to lean forwards, for example, onto a bed table supported by pillows, or simply onto a stack of pillows. This position is referred to as the ‘orthopnoeic’ position. Some patients may prefer to sleep or rest on their side and they can be supported in a semi-upright position by careful placing of pillows (Figure 1). Patients who are experiencing shortness of breath will often recruit the muscles in their neck (sternocleidomastoid and upper trapezius), also known as the accessory muscles.  These are not designed to support breathing and therefore the patient may experience tension and pain in these muscles.  Supporting the patient to relax these muscles using techniques such as focused breathing or guided breathing may help (Bott 2013).  It is important that the position allows the shoulders and upper chest to relax and lets the diaphragm and abdomen expand. 

If using pillows, it is important to have a sufficient number to support the patient but not so many that the patient sinks into them, as this may increase distress by creating a feeling of suffocation, and also decreases the expansion capacity of the rib cage.

Most modern hospital beds have an electronic raising mechanism allowing the patient to be easily repositioned. Additionally, the end of the bed may be elevated slightly to prevent the patient slipping down. The use of built-in bed backrests is not always advisable, as there may be a risk of the patient becoming entrapped in a similar way to the dangers created by bedrails (NPSA 2007). In community settings, use of pillows and a portable backrest may be required.

In summary, patients, especially those with chronic breathlessness, may have a preferred position and this individual preference should be facilitated where possible.

Preparation and safety

  • Ask the patient what has worked for them in the past and their preferences.
  • Explain the procedure to gain the patient’s consent and cooperation. The patient may be anxious due to their breathlessness.
  • Allow time to communicate effectively with the patient, using closed questions if necessary.
  • Adequate time should be allowed for the procedure to allow for the patient becoming easily fatigued.
  • Ensure any prescribed oxygen therapy is being administered correctly.
  • Two nurses may be needed if the patient requires assistance to move.
  • Additional moving and handling equipment such as sliding sheets or a hoist may be needed if indicated by risk assessment.
  • Carry out hand hygiene.
  • Put on an apron. Additional protective clothing may be necessary if indicated by the patient’s condition.

Procedure

  1. Explain to the patient exactly what is planned so that movement is reduced to a minimum.
    Rationale – The breathless patient may become exhausted very quickly
  2. Arrange the pillows to maximise respiratory functioning while reducing physical effort.
    Rationale – Well-placed pillows offer support and comfort for the patient.
  3. Raise the head of the bed or adjust the backrest.
    Rationale – Provides support for the patient and helps them to maintain their position
  4. The patient should feel comfortable, with pillows supporting the small of the back so that the patient does not sink into them.
    Rationale – Sinking into the pillows may restrict chest movement and increase patient distress.
  5. If desired, the patient may get relief by leaning forward, with the forearms resting on a pillow on a bed table.
    Rationale – This orthopnoeic position maximises chest expansion.
  6. If able to get out of bed, the breathless patient may be more comfortable sitting in an armchair, and may prefer to sleep in this position.
    Rationale – The patient should be assisted into the position that they find offers maximum benefit.

Ongoing care, monitoring and support

  • Ensure that the patient is comfortable and that the position is facilitating their breathing.
  • Ensure the nurse call system is to hand.
  • Ensure the patient has their requirements within easy reach (e.g., drink, glasses, book).
  • Ensure any prescribed oxygen therapy is running correctly and has not become dislodged during positioning.
  • Review the patient as their condition dictates, or if there are any changes, and offer assistance to reposition as needed Observe for changes in respiratory pattern, cough, colour, and any increase in dyspnoea or fatigue.
  • Allow the patient time to rest before any further nursing or medical intervention.
  • If the patient is immobile for long periods, a pressure-relieving device may be needed to prevent pressure ulcers as per individual risk assessment.
  • Consider additional supportive measures such as fan therapy (Booth et al. 2016).

Documentation and reporting

  • Document the care given and update the patient’s care plan if necessary.
  • Report any changes in respiratory pattern, cough, colour, and any increase in dyspnoea or fatigue.
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