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Pre‐procedural considerations

It is important to ensure regular positional changes, as with any patient unable to move themselves, to help prevent pressure damage and reduce the complications of prolonged bedrest (NHS Improvement [85]). Ideally, the patient should be moved every 2 hours and positioned alternating between side‐lying and supine.

Equipment

Artificial airway

When the patient has an artificial airway, such as a tracheostomy or endotracheal tube, ensure that the appropriate equipment is at the bedside and that the airway tapes are tightly secured (NCEPOD [80]).

Procedure guideline 7.8

Positioning an unconscious patient or a patient with an artificial airway in supine

Procedure guideline 7.9

Positioning an unconscious patient or a patient with an artificial airway in side‐lying

Table 7.3 Prevention and resolution (Procedure guidelines 7.8 and 7.9)

Problem	Cause	Prevention	Action
Change in medical condition	With any change in position, transient changes in vital signs also occur.	Any changes in respiratory or cardiovascular status should be closely monitored with any positional change or intervention ( Hodgson et al. [47]).	If oxygen saturation (SpO₂) drops and does not return to its usual value within 5 minutes, or heart rate increases or decreases by over 10 beats per minute and does not settle, the patient should be returned gently to the previous position ( Hodgson et al. [47]). Inform the medical team about the change in the patient's condition and increase the frequency of observation.
Intensive‐care‐acquired muscle weakness	Muscle atrophy can start to develop within hours of a patient being mechanically ventilated ( Hodgson and Tipping [48], Paratz et al. [97]).	Ensure upon changing the patient's position that all limbs are in appropriate positions and not overstretched.	Once the patient has been repositioned, ensure the limbs are well supported and use resting splints to maintain muscle length.
Risk of excess pressure on body parts	Body parts, such as ears, positioned without due care and attention.	If the patient is in side‐lying, ensure the ear is not twisted under the head ( NICE [87]).	Check all bony prominences and pressure areas regularly. Move the patient's head to shift the ear to a more comfortable position.
Loss of artificial airway patency (e.g. blocked, displaced or dislodged)	Change of position of neck or of airway.	Ensure the endotracheal or tracheostomy tube is secure. This will involve checking the position of the tube, the cuff pressure, and the endotracheal or tracheostomy ties, as movement will alter the soft tissue distribution, which will affect all of these ( McGrath [71]). Monitor vital signs closely to ensure the values return to normal within 5 minutes of position change. Ensure there are enough persons present to assist with the movement. Ensure one person is in sole charge of the airway when moving. Ensure there is visible signage at the patient's beside about the type of altered airway and the appropriate emergency algorithm (McGrath [71], NCEPOD [80])	Call for assistance immediately. Refer to Chapter c12: Respiratory care, CPR and blood transfusion for more specific guidance on emergency management of the airway.