Prone Positionin Guidelines
Prone Positionin Guidelines
Prone Positionin Guidelines
Introduction
Many ICU patients have acute respiratory distress syndrome (ARDS) requiring advanced
therapies to improve oxygenation. Most interventions and therapies do not improve
mortality or better long-term patient outcomes. Prone positioning of ARDS patients leads to
improved oxygenation and has recently been found to decrease mortality. This document
serves to inform clinicians about prone positioning of critically ill ARDS patients.
Contraindications:
● Spinal instability
● Facial or pelvic fractures
● Open chest or unstable chest wall
● Uncontrolled intracranial pressure
● Relative contraindications: Severe hemodynamic instability
Equipment:
● Minimum of 5 staff members to safely position the patient
● At least 5-10 foam dressings for padding
● 3 Waffle cushions: 2 for upper extremities and 1 for head
● 2 flat sheets
● EKG stickers
● Ambu with mask and HEPA filter
● Gel Donuts
Link to Video:
Assessment
3. Assess size and weight to determine the ability to turn within the bed frame. Ensure
whether a 180-degree turn may be safely accomplished within the confines of the
stretcher.
Preparation
1. The patient must be deeply sedated; strongly consider neuromuscular blockade.
The healthcare team should effectively manage agitation to provide a safe proning
environment.
2. Endotracheal tube must be firmly secured with a commercial device. Note the
position of the tube (cm at teeth).
3. Ensure orogastric tube in place to protect from drainage of oral secretions. Sump
stomach prior to turn to reduces the risk of aspiration.
5. Keep 5 leads on anterior chest wall and remove remaining V2-V6 leads.
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7. Secure tubes and catheters. Disconnect nonessential tubing. Foley should be at the
end of the stretcher with slack.
8. Apply 3M Cavilon moisture barrier to patient’s face. Frequently assess commercial
endotracheal securement device during prone positioning because of the possibility
of skin breakdown and potential of adhesive breakdown due to salivary drainage.
9. Place foam dressing to upper chest/clavicles, shoulders, pelvis, elbows, knees,
forehead, and tops of feet. The foam dressing will reduce the risk of friction and
shear (Refer to appendix A).
10. Disconnect arterial line from the pressure bag. Cap the arterial line at the t-piece.
1. Start with a flat sheet under the patient. Have all 5 staff members at bedside.
2. Position the staff at the sides of the bed, 2 on each side, and the respiratory
therapist at the head of the stretcher. The RT at the head of the bed is responsible
for securing the ETT, ventilator tubing. The person on the side of the bed closest to
the patient maintains body contact with the bed at all times to serve as a side rail.
3. Pull patient using the underlying flat sheet while in the supine position to the side of
the bed away from the ventilator, ultimately to turn the patient in the direction of
the ventilator.
4. Cross the patient’s outer leg over the inner leg at the ankle. Chest and/or pelvic
support can be done by placing a pillow at the abdomen before completing the turn.
6. Tuck a new flat sheet, and the arm closest to the ventilator with palm facing up,
underneath the patient to the side you are turning. The new flat sheet will pull
through as you are turning the patient.
7. Patient should be laying directly on the arm that is going to be pulled through. EKG
voltage may be altered as the heart shifts within the thorax. If a 12 lead EKG is
needed, place precordial leads on the posterior thorax.
8. Begin by turning patient towards the ventilator and onto their side THEN stop. With
the patient in the lateral position, reposition the patient’s ECG leads on the patient’s
posterior thorax. Evaluate the quality of waveform and assess for arrhythmias. May
consider delaying the reposition of the patient’s 5 lead ECG until the patient is in the
prone position based on clinical stability and ease of turn.
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9. The staff member at the head of the bed supports the head during the turn and
ensures all tubes and lines are intact.
10. Under the direction of the person at the head of the bed, at the count of 3, the
patient is carefully turned over by pulling the tucked arm and new flat sheet
through.
11. The patient is now prone. Pull and center the patient. Straighten and reconnect
lines. Position the head to prevent pressure areas. Position arms in a modified
swimmers position or aligned with the body.
12. Every attempt is made to prevent pressure injuries. Alternate arms and head every 2
hours. Utilize gel donuts to support the shoulders, abdomen, penile tip and pelvis
where necessary.
Nursing Considerations
1. Collaborate with the team to assess the patient’s response to the prone position:
● Pulse Oximetry
● Mixed venous oxygenation or central venous mixed oxygenation saturation (Scvo2)
● Hemodynamics
● Arterial blood gases
● PaO2/FiO2 ratio (P/F ratio)
● The team will determine the frequency of blood gases and enter the order as
indicated.
3. Provide frequent oral care and suctioning of the airway as needed. The prone
position promotes postural drainage.
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8. Document the patient’s response to the prone positioning, ability to tolerate the
turning procedure, length of time in the prone position, complications noted during
or after the procedure, and patient and family education.
3. Disconnect arterial line from the pressure bag. Cap the arterial line at the t-piece
4. The person on the side of the bed closest to the patient maintains body contact with
the bed at all times to serve as a side rail and prevent a fall. The RT at the head of
the bed is responsible for securing the ETT, ventilator tubing.
5. Pull patient using the underlying flat sheet while in the prone position to the side of
the bed away from the ventilator.
a. Cross the leg next to the edge of the bed over the opposite ankle.
c. Tuck a new flat sheet, and the arm closest to the ventilator with palm facing
up, underneath the patient to the side you are turning. The new flat sheet
will pull through as you are turning the patient.
a. Begin by turning patient towards the ventilator and onto their side THEN
stop.
7. With the patient in the lateral position, reposition the patient’s ECG leads on the
patient’s anterior thorax. Evaluate the quality of waveform and assess for
arrhythmias. May consider delaying the reposition of the patient’s 5 lead
8. ECG until the patient is in the supine position based on clinical stability and ease of
turn.
9. Under the direction of the person at the head of the bed, at the count of 3, the
patient is carefully turned over by pulling the tucked arm and new flat sheet
through.
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10. The patient is now supine. Pull and center the patient. Straighten and connect lines
and tubes.
11. Collaborate with the team to assess the patient’s response to the supine position:
References:
Drahnak, D., & Custer, N. (2015). Prone Positioning of Patients with Acute Respiratory Distress
Guerin C, Reignier J, Richard J et al. Prone positioning in severe acute respiratory distress
study on prone positioning of ARDS patients: the APRONET (ARDS prone position network)
Vollman, K, Dickinson, S, & Powers, J. (2017). Pronation Therapy. AACN Procedure Manual
for Critical Care 7th ed. Elsevier Sanders, St Louis, Missouri pp. 142-163.
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