Evidence-based nursing guidelines for prone positioning of adult, ventilated patients

Acute respiratory distress syndrome (ARDS) is associated with high mortality rates . The aim of treatment and ventilation is to improve oxygenation. Prone positioning improves oxygenation in patients with ARDS by shifting blood flow to undamaged or better ventilated regions of the lung. Critical care nurses follow the current guidelines with respect to prone positioning, which are mostly based on the medical aspects of the treatment. Prone positioning challenges nursing care of these patients. The research question that emerges is: Which nursing interventions during prone positioning will benefit the patient and reduce or eliminate complications? The purpose of this research is to do a systematic review in order to: Explore the evidence in support of the beneficial nursing interventions during prone positioning of ventilated patients and to develop evidence-based nursing guidelines with regard to the nursing process. The research design can be described as an exploratory, descriptive and retrospective systematic review. The population consisted of experimental study designs, as well as comparative, non-randomised and observational studies on nursing interventions during the prone positioning process. Selected studies included a population of adult or paediatric subjects who were ventilated and turned into the prone position, and the search strategy was restricted to articles published or translated into English. Studies that included animals or neonates were excluded from this review. The data collection process involved the systematic extraction of relevant data onto standardised data abstraction forms and the assessment of the methodological quality of each study. Data were summarised into evidence tables and data from randomised controlled trials were used for meta-analysis. There were thirteen randomised controlled trials, of which only seven could be included for quantitative analysis. Forty five clinical trials involving prone positioning were identified, with a total population of 2 148 patients. Outcomes that were measured, included oxygenation outcomes, responder and non-responder groups, haemodynamic outcomes, complications in the prone position, mortality, the length of sta y in the intensive care units and the total number of ventilated days. Prone positioning showed significant increases in the PaO2 and PaO2 / FiO2 ratio. The effect of the outcomes compared against the different ventilation, sedation, nutrition and positioning protocols had inconclusive results. Haemodynamic variables had insignificant increases in the prone position. Pulmonary artery wedge pressure (PAWP) however, did show a significant increase in the prone position. Complications related to prone positioning were insignificantly less than expected. Patients treated in the prone position were ventilated for an insignificantly shorter period of time, but had a longer ICU stay, although the results were also insignificant. The mortality of patients in the selected trials was 33.5%. Evidence gained from the selected studies could be used to develop nursing guidelines, despite inconclusive results related to some of the measured outcomes.Dr. Elzabé Ne