Therapeutic mobilization as nursing care: evidence from practice

Abstracts

Estudo observacional e descritivo que teve como objetivo identificar como os parâmetros relativos à mecânica pulmonar do paciente crítico, sob ventilação mecânica, se comportam, após o procedimento técnico de mudança de decúbito realizado pela equipe de enfermagem. A população acessível, inserida por amostragem não-probabilística, foram 9 pacientes críticos, sob ventilação mecânica, e seus respectivos parâmetros referentes à mecânica pulmonar. Foram observadas alterações positivas e negativas na mecânica pulmonar em todos os pacientes, em diferentes posições, possivelmente associada à mudança de decúbito. Conclui-se que a avaliação clínica é fundamental para a prescrição de enfermagem relativa à mudança de decúbito, pois a mecânica pulmonar pode se modificar de acordo com a posição do paciente no leito, trazendo, inclusive, resultados negativos.

Cuidados de enfermagem; Respiração artificial; Mecânica respiratória; Posicionamento do paciente; Modalidades de posição

ARTIGO ORIGINAL

Therapeutic mobilization as nursing care: evidence from practice^*

Movilización terapéutica como cuidado de enfermería: evidencia surgida de la práctica

Renata Flavia Abreu da Silva^I; Maria Aparecida de Luca Nascimento^II

^IMaster in Nursing. Head Risk Management Nurse, Instituto Nacional de Cardiologia Brasileiro. Rio de Janeiro, RJ, Brazil. [e-mail]

^IIRN. Ph.D. in Nursing. Academic Counselor of the Graduate Program in Nursing, Federal University of the State of Rio de Janeiro. Rio de Janeiro, RJ, Brazil. [e-mail]

Correspondence addressed

ABSTRACT

The objective of this observational and descriptive study was to identify the behavior of relative parameters related to pulmonary mechanics of critical patients undergoing mechanic ventilation, after the nursing staff performed the technical procedure of decubitus position change. The accessible population, by non-probabilistic sampling, consisted of nine critical patients undergoing mechanical ventilation and their respective parameters related to pulmonary mechanics. Positive and negative alterations in pulmonary mechanics in all patients were identified, correlating with different positions, possibly associated with the change in decubitus position. In conclusion, clinical assessment is essential in nursing care regarding decubitus position change, because pulmonary mechanics may change according to the patient's position in bed, and may result in negative consequences.

Descriptors: Nursing care; Respiration, artificial Respiratory mechanics; Patient positioning; Modalities, position

RESUMEN

Estudio observacional y descriptivo que tuvo como objetivo: identificar el modo en que los parámetros relativos a la mecánica pulmonar del paciente crítico, bajo ventilación mecánica, se comportan luego del procedimiento técnico de cambio de decúbito realizado por el equipo de enfermería. La población con acceso, inserta por muestra no probabilística, fue de nueve pacientes críticos, bajo ventilación mecánica, y sus respectivos parámetros referentes a la mecánica pulmonar. Fueron observadas alteraciones positivas y negativas en la mecánica pulmonar en todos los pacientes, en diferentes posiciones, posiblemente asociada al cambio de decúbito. Se concluyó en que la evaluación clínica es fundamental para la prescripción de enfermería relativa al cambio de decúbito, pues la mecánica pulmonar puede modificarse de acuerdo con la posición del paciente en el lecho, trayendo, inclusive, resultados negativos.

Descriptores: Atención de enfermería; Respiración artificial, Mecánica respiratoria; Posicionamiento del paciente; Modalidades de posición

INTRODUCTION

Intensive Care Units (ICUs) accommodate patients who, momentarily, need more complex care, due to their clinical condition of critical nature, highly complex care and strict control⁽¹⁾. It is verified then that nursing is involved in this process providing care with specific characteristics, since the knowledge acquired at the ICU stands out, especially, due to the progressive and fast advance of the new knowledge in the area, as well as the technological apparatuses present in these units⁽¹⁾.

The ICUs constitute a set of elements functionally grouped that require not only equipment, but also continuous and specialized medical and nursing care. Therefore, the care based on the clinical knowledge and judgment, implemented by the nurse, aims at establishing interventions that may comprise the bio-psycho-social needs of patients⁽¹⁾.

Some interventions of the nursing staff have specific objectives, for instance, the decubitus position change, which is normally referred as a prevention strategy for pressure ulcers⁽²⁾.

One of the main causes of pressure ulcers is the patients' immobility in bed, without the possibility of moving on their own, depending on passive mobilization^(2-5).

Besides the patients' immobility in bed, other factors also contribute to the development of pressure ulcers, for instance, the use of vasoactive drugs, vasculopathy, weight extremes, hyperthermia and hypothermia, circulatory changes, incontinence, immunological deficit, humidity, age extremes and changes in the turgor^(3-4).

Aimed at preventing the problem previously mentioned, systematized strategies started to be used such as the stratification of risk factors, protection of the skin against shear strength and, finally, the change in decubitus position, which has the purpose of reducing the pressure in more vulnerable points in a standardized and routinely way⁽²⁾. However, even with several causes contributing to the development of a pressure ulcer, the change in decubitus position is emphasized, as an essential function of the nursing staff and cannot, under any circumstances, be neglected⁽⁵⁾.

Among the strategies adopted to systematize the positioning of the patient in bed, it is worth highlighting a method, commonly used, based on the functioning of a "clock". In this method, every two hours, the decubitus position is changed to dorsal, to the right side and to the left side to relieve the pressure on the tissue. This technique was broadly disseminated, and it is now used in countless centers of treatment for patients in bed without active mobility⁽²⁾.

By associating the technical procedure in focus to the purpose to which it is normally directed, it is verified that its benefits include not only the prevention of pressure ulcers, but also the prevention of the muscular disuse syndrome^(6-8), comfort⁽⁹⁾, and the interference in the respiratory pattern with the optimization of the relation ventilation/perfusion^(10-14) of the patient.

Patients in bed may present several complications, among them, the muscular disuse syndrome⁽⁷⁾, and the change in decubitus position is one of the interventions to be used, aimed at preventing this syndrome and its systemic consequences^(6-7). Among the systemic consequences there are pressure ulcers, constipation, stasis of pulmonary secretions, thrombosis, infection of the urinary tract, urinary retention, reduced strength or resistance, orthostatic hypotension, disorientation, bodily image disturbance and the feeling of impotence^(6-7). Muscular disuse may also contribute to the extension of the hospitalization time of patients, also increasing their exposure to possible aggravating factors^(6-7). It is important to point out that in the Brazilian reality, the systematic interventions performed for the prevention of muscular disuse syndrome are attributions commonly executed by a physiotherapist. However, the authors of this study consider that, the professionals of the nursing staff, by promoting the change in decubitus position of the patients under their care, interfere in their position in bed, contributing to the prevention of the referred syndrome⁽⁶⁾.

Considering that the present study is focused on patients in critical condition and hospitalized in ICUs, it is observed that these patients commonly undergo mechanical ventilation. Therefore, their mobilization is extremely important because it helps the drainage of secretions from the lower airways, facilitating tracheal aspiration^(8,15). Moreover, the appropriate mobilization helps the process of discontinuation of mechanical ventilation, providing an improvement in the relationship ventilation/perfusion (V/Q) of the pulmonary tissue, reducing the resistance to the muscular work, and contributing to reduce the dyspnea feeling^(8,14-15). The decubitus position may influence in the pulmonary mechanics, increasing the respiratory work and modifying the relationship ventilation/perfusion depending on the position in bed and on the elevation degree of the patient's back^(9-14). The knowledge regarding the decubitus position change and its effects on the oxygenation of patients constitute essential knowledge for nurses who take care of patients in critical condition⁽¹⁰⁾.

It is inferred, thus, that the decubitus position change, being relevant nursing care, involves several sciences, demonstrating that simple as it may seem, it has a certain complexity⁽⁵⁾.

In the ICU daily care practice it is possible to observe unsystematically that some positions, during the decubitus position change in patients undergoing mechanical ventilation, cause the alteration of their respiratory pattern, as evidence through the change of the parameters in the mechanical ventilator. Searching the explanation to this situation in physiology, it is verified that depending on the patients' clinical condition, the decubitus position interferes directly in the increase of oxygen consumption and more respiratory work^(9-12,16-17).

The monitoring of pulmonary mechanics during the nursing care is necessary, since the nurse who is taking care of patients undergoing mechanical ventilation must be in constant surveillance^(8,18). That includes the continuous monitoring, which is currently provided by high technology, present in machines and equipment available in the market. Therefore, the nurse needs to associate the knowledge in mechanics and respiratory practice to the knowledge in physiology^(8,18). It is emphasized that the properties of the respiratory system mechanics may be easily monitored in patients in bed. Parameters such as tidal volume, flow and pressure of the respiratory system, resistance of the airways and lung compliance, may be obtained through a graphics monitor and a flow sensor connected to the artificial airways or a pneumotachograph⁽¹⁸⁾.

The application of the concepts and studies, previously mentioned, to the daily practice of the nursing staff, provides the presupposition that the technical procedure of decubitus position change in critical patients undergoing mechanical ventilation influences directly their pulmonary mechanics, requiring, thus, the clinical judgment of the nurse to be performed.

Therefore, considering that the decubitus position change is a technology inserted in the care practice of the nursing staff, with the purpose of preventing pressure ulcers, the present study aimed at achieving the following objective:

• Identifying the behavior of relative parameters related to pulmonary mechanics of critical patients undergoing mechanic ventilation, after the nursing staff performed the technical procedure of decubitus position change

Consequently, the present study intends to bring to light elements to be considered by nurses who, basing their care on clinical judgment, will be able to determine whether the decubitus position change of critical patients undergoing mechanical ventilation at an ICU is necessary, considering that certain procedures may, if misapplied, become a complicating factor for the treatment, instead of a supporting factor.

METHOD

This is an observational descriptive study developed at an intensive care unit of a federal hospital, which is a reference in cardiology, in the municipality of Rio de Janeiro.

Inclusion criteria were: patients aged over 18 years, undergoing mechanical ventilation, in assisted-controlled ventilatory mode, Ramsay Sedation Scale between 5 and 6, decreasing flow and tidal volume (VT) programmed between 4 and 8 mL/Kg. The only exclusion criterion was the refusal of the family to authorize the assessment of the patient's parameters.

The referred study complied with the specifications of the resolution 196/96 and the Nursing Ethics Code, being submitted to the Committee of Ethics and Research of the institution in question, which approved it on October 22, 2007, under the authorization number 0167/12.09.07.

The study sample consisted of 09 critical patients undergoing mechanical ventilation and their parameters regarding pulmonary mechanics, presented in this study in five charts generated from data collection, associated to the parameters of 04 patients. The patients were inserted in the study by non-probabilistic sampling by convenience with accessible population.

Data collection and presentation

Data were collected in the moments when the patients were repositioned in the decubitus position changes: right side, left side and dorsal. The assessments took place before and after the decubitus position change, in the minutes 2, 15, 60 and 120 of the execution and the ventilation device used was the BIRD 8400ST.

The variables collected were: BMI, gender, type of prosthesis (orotracheal intubation or tracheostomy), radiological diagnosis of the thorax and direct references to the pulmonary mechanics such as tidal volume, positive end-expiratory pressure (PEEP), peek pressure, plateau pressure, peripheral oxygen saturation (SpO₂), as well as the vital signs respiratory rate (RR), heart rate (HR) and blood pressure (BP).

Regarding the data collected, three parameters were used for the assessment of the patients: VT, static compliance (Cst), calculated through the plateau pressure and PEEP, and SpO₂, as they reflect better the changes that occur in the pulmonary parenchyma⁽¹⁷⁾.

The patients were named after the letters A, B, C and D, and data were presented through descriptive statistics exemplified in charts.

RESULTS

The patients who made part of the study sample presented decompensated cardiopathy and, most of them, were male (67%), overweight (67%) and elderly (89%).

It is important to highlight that the respiratory parameters assessed did not suffer the interference of oxygen optimization, because during the entire period of data collection neither the inspired fraction of oxygen (FiO₂) nor the positive end-expiratory pressure (PEEP) were modified.

Patient A (Figure 1) was old aged, overweight, intubated, undergoing mechanical ventilation for twelve days, and did not present alteration in the thorax radiography. At the moment of data collection, patient A was placed in the lateral decubitus position with the right side up and she was repositioned to the lateral decubitus position with the left side up. The RR remained stable, as well as the HR and BP, but it was possible to observe in Figure 1 that the VT, Cst and SpO₂ improved after the decubitus position change and, remained stable until two hours later.

Patient B (Figure 2) was also old aged and overweight, she had a tracheostomy, was undergoing mechanical ventilation for nine days and had no alteration in the thorax radiography. At the moment of data collection, she was placed in the lateral decubitus position with the right side up and she was repositioned to the dorsal decubitus position elevated in approximately 30 degrees. The RR and HR remained stable and there was an improvement in the BP with a decrease in the systolic blood pressure. Figure 2 shows the VT, Cst and SpO₂ and the main relevant fact to be observed is that after two hours these parameters not only improved, but also remained stable.

Figures 3 and 4 represent patient C who initially had his lateral decubitus position changed from the left to the right side. Patient C was overweight and old aged, had a tracheostomy and was undergoing mechanical ventilation for ten days, RR and HR were normal and at the moment of data collection there were no alterations in the thorax radiography. It is observed that the VT only increased after the decubitus position change, reflecting in the Cst, and, consequently, in the SpO₂.

Patient C was placed in the lateral decubitus position with the left side up and he was repositioned to the lateral decubitus position with the right side up, and after being immobilized the VT remained stable, but there was a decrease in the Cst and in SpO₂.

Patient D was old aged, overweight and presented reincidences of pleural effusions, liquid between the visceral and parietal pleura, which led the pneumologist who was following up the case to perform pleurodesis. There was no description in the medical record regarding the type of pleurodesis performed, only the indication that the right lung was the one affected.

At the moment of the assessment, the referred patient was placed in the lateral decubitus position with the left side up and she was repositioned to the dorsal decubitus position, elevated in approximately 30 degrees. It is observed in figure 5 the great increase in VT, as well as the SpO₂ and Cst. It is worth highlighting that the patient in question presented tachypnea before the decubitus position and there was an improvement in this parameter after the mobilization.

DISCUSSION

The initial data attribute to these patients a predisposition to develop lesions such as pressure ulcers and, therefore, they need systematic changes in the decubitus position^(19-20). Nevertheless, these same patients present characteristics that are considered to be counterindications for the positioning in dorsal decubitus position in bed, such as age, cardiopulmonary disease and obesity⁽¹⁷⁾, evidencing the clinical assessment necessary prior to the prescription of change in the decubitus position.

The supply of oxygen to the organism depends on the interrelationship between the respiratory and cardiovascular systems⁽¹⁷⁾, however, the systematic hemodynamic assessment was not performed during data collection in this study.

Although the purpose of the mechanical ventilation is to improve the patient's condition, it may cause adverse events since it is not physiologic, and this must be taken into consideration when changing the position of patients in bed, as the pulmonary zones are going to be affected. Furthermore, the body position influences in the distribution of ventilation, perfusion, size of the alveoli, respiratory mechanics and blood oxygenation^{(10,16,21-22)}.

A certain study⁽²¹⁾, after assessing the hemodynamics and oxygenation of patients, due to their positioning in lateral decubitus, regarded as primordial the individual assessment of patients and their response to mobilization.

Figure 1 shows that being placed in the lateral decubitus position with the left side up was the best option to patient A, because she remained hemodynamically stable and had her ventilatory parameters unaltered. This may be explained by the property of the right lung, since it is, anatomically, bigger than the left one^(11-12), and consequently better perfused. Therefore, the lateralization, if chosen, must be based on this premise, among other assessments necessary.

Another aspect to be considered is the protocol of decubitus position change that recommends its execution every two hours^(2,7,15). However, as shown in figures 1 and 2, at the moment when the pulmonary mechanics of patients A and B, respectively, reached stability, they are supposed to be mobilized again according to the routine. Is this decubitus position change to be executed beneficial for them under the respiratory aspect? Why mobilizing them if the respiratory pattern is stable?

As previously described, the mobilization of patients in bed influences the respiratory aspect^(11-14), which may or may not be beneficial for them. Nevertheless, considering that the technique in question is performed in the daily practice only for the prevention of pressure ulcers^(2,4), it is observed that this influence is not being pondered. This demonstrates the need to use the clinical logic as a guide to prioritize the care to patients. In other words, considering that mobilizing patients in bed has other benefits, besides the prevention of pressure ulcers, it is necessary to consider and prioritize these benefits, before the prescription of the decubitus position change.

Furthermore, there are strategies for the prevention of pressure ulcers, other than the decubitus position change^(2,5), and they may and must be considered, mainly when the mobilization involves respiratory and hemodynamic instability^(16,21) and, consequently, loss of clinical stability and possible damage to the patient.

Another aspect to be taken into consideration is the affirmation that the anatomic property that provides advantage to the right lung in the lateral mobilization could be used to explain what happened to patient C, figures 3 and 4, as he was placed in different lateral decubitus positions^(11-12).

It is also possible to observe the need to evidence the presence of a unilateral or bilateral disease in the lungs of patients who are going to be mobilized, that is, the lateral decubitus position is only therapeutic if pulmonary alterations are observed prior to the mobilization⁽²³⁾. This was evidenced in the case of patient D, who was placed in a decubitus position that would be counterindicated to her according to her clinical history, and this was evidenced after the decubitus position change, which, in this situation, was therapeutic, even if unintentionally.

In unilateral diseases, in most of the cases, the adagio prevails, healthy lung side down^(10-12); however, some authors question this reasoning, emphasizing that the individual assessment of patients is what shall determine the position to be adopted^{(13-14,21,23)}, and this fact is corroborated by the present study. It was observed in a certain study⁽¹⁶⁾ that in patients in post-operative period due to thoracic surgery, when the operated lung was placed down, there was an aggravation in the gas exchange, and when the healthy lung was repositioned side down, there was an increase in the PaO₂, not significant though.

The positioning of the patient in lateral decubitus is a type of non-invasive therapy, however, it may contribute to the deterioration of the respiratory status of the patient, in case the position is applied indiscriminately or inappropriately^(10,16,21).

Some considerations regarding the positions:

Dorsal (Supine) → decreases the anterior-posterior diameter of the thorax and provides an increase in the lateral diameter, occurring cranial displacement of the diaphragm due to the increased intra-abdominal pressure. Besides, it increases the thoracic blood volume, leading to the decrease of the functional residual capacity (FRC), decrease of the pulmonary compliance and increase of the respiratory work, and greater demand of oxygen; being counterindicated, mainly, to smoking, overweight and older patients⁽¹⁷⁾.

Ventral (Prone) → determines favorable effects, as the diaphragm presents better excursion in the prone position because its posterior portion has a smaller radius of curvature, generating more transdiaphragmatic pressure and greater stretching of the muscle^(10,17) .

Lateral → may be either beneficial or harmful, depending on the individual assessment of the patient; in the lateral decubitus position there is greater excursion in the dependent diaphragmatic hemicupula, due to the lengthening of these fibers due to the cephalic displacement and, consequently, the anterior-posterior displacement of the abdomen decreases the expansion of the thorax through the decrease of the supporting base of the diaphragm to perform this movement⁽¹⁷⁾.

Aimed at verifying whether the mobilization is going to be therapeutic, some criteria must be adopted every time a patient is repositioned. The parameters of the mechanical ventilator that must be verified, in association to the available monitoring, may be: oximetry, capnography, ventilometry, blood pressure, electrocardiogram and blood gas analysis⁽¹³⁾.

The body position to be adopted for the patient must be elected according to the physiological and therapeutic objectives in order to relieve dyspnea, avoid trepopnea, increase oxygenation and improve ventilation. These considerations may be confirmed by the following statement⁽¹³⁾: There is no ideal position, the patient's clinical response is sovereign.

CONCLUSION

After the mobilization in bed, alterations were observed in the pulmonary mechanics of all patients submitted to it. Some were evident, others subtle, and, even with a small number of patients, it was possible to evidence fundamental aspects to be considered before performing this technical procedure.

In the care to critical patients in mechanical ventilation, nurses face the challenge of maintaining the quality of the care provided and avoiding the damages resulting from this care, which are called adverse events.

Considering that the care prioritizes, primordially, the maintenance of life with quality, the mobilization performed with therapeutic purposes interferes in one of the most intrinsic mechanisms of the individual, the respiration, which is one of the parameters that constitute the assessment of the presence of life. Would the authors be audacious to infer that the mobilization, when practiced therapeutically, intervene in the maintenance of life, since the optimized pulmonary mechanics helps in the discontinuation of the patient from mechanical ventilation and may even postpone the invasive ventilatory support?

In face of the results obtained, it is possible to state that, by influencing the pulmonary mechanics of critical patients undergoing mechanical ventilation, the decubitus position change, performed with critic and through the clinical judgment, becomes a therapeutic mobilization.

The technical procedure of decubitus position change, performed by the nursing staff under the prescription or indication of a nurse, involves more factors than simply changing the position of patients in bed. Its influence in the pulmonary mechanics, as showed by the present study, evidences that this technique must not be performed routinely. For this reason, the mobilization of patients in bed, aimed at the prevention of pressure ulcers, must consider the other aspects resulting from it.

The present study neither exhausts nor answers all the questions regarding the influence of the mobilization of patients in the pulmonary mechanics, but it already evidences that this mobilization may or may not be therapeutic. It also demonstrates that more studies regarding this theme are necessary, so as to see the nursing care under the clinical point of view, creating evidences that may base it on a critical care, individually prescribed, according to the clinical condition of patients, even in the force of protocols.

The authors conclude that, acting according to these principles, avoiding the adverse events of the mobilization of critical patients, nurses will no longer perform a simple change in decubitus position, but a therapeutic mobilization, with awareness and scientificity.

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Correspondência:

Renata Flavia Abreu da Silva

Rua Jorge Rudge, 44 - Apto 602 - Bloco B - Vila Isabel

CEP 20550-220 – Rio de Janeiro, RJ, Brasil

*

Extraído da dissertação "Mobilização terapêutica como cuidado da enfermagem: evidência surgida na prática", Centro de Ciências Biológicas e da Saúde Universidade Federal do Estado do Rio de Janeiro, 2008.

Publication Dates

• Publication in this collection
  07 May 2012
• Date of issue
  Apr 2012

History

• Received
  16 Sept 2010
• Accepted
  24 Oct 2011