Thursday, May 19, 2005

To Turn or Not To Turn - part 2

Back in October, I started a discussion on whether or not to turn patients who are dying based on information I was researching on death rattle.

The question of turning still plagues me.

Personally, I always turn patients who are dying. For multiple reasons:

1. turning mobilizes secretions and prevents/decreases type I death rattle
2. turning prevents bed sores from developing and/or worsening (bed sores, if they develop, are very painful)
3. turning promotes physical contact and provides an opportunity for modeling touch for family members
4. turning ensures I check in with the patient and the family at least every two hours
5. opportunity to check for soiled linens (incontinence is common at the end of life)
6. opportunity to check for fecal impaction (patients receiving opioids for pain are at highest risk for this)

Some colleagues have been concerned, reporting that when turning a patient who was close to death, the patient died.

If the patient is not turned over a period of several hours, atelectasis (a collapsing of part of the lung) will likely occur. If the lung collapses on one side and the patient is abruptly turned to the other side, the lungs may not have time to adjust to the change in hemodynamics (change in center of gravity) and consequently, the patient may stop breathing.

The way to prevent this?

1. Turn all patients, no matter how close to death you think they may be, every two to three hours. If you don't turn the patient for your entire 8 or 12 hour shift and the patient lives into the next shift, they may in fact die when the new nurse coming on turns them.

2. Turn slowly. Turning slowly allows the patient's lungs (and other organs) more time to adjust to the change in gravity.

If you have access to four pillows at home, I also recommend trying out the positions on yourself to find what is comfortable. This may help you when positioning immobile patients at work. One pillow generally goes between the knees, ensuring at least one ankle is floating above the mattress (can alternate the floating ankle with the next turn). This is to prevent a bedsore from developing on the bony areas of the ankle. One pillow goes behind the back. The patient does not need to be lying on their side; a small tilt is sufficient for our purposes. One pillow under the head (obviously). And one pillow to rest the patients hands on comfortably.

And always remember to get help when turning patients.

When I recently went to the doctor, complaining of a sore back, he answered, "You're a nurse, right? Isn't that redundant?"

Let's change that stereotype by asking our colleagues for help - for our sake and for our patient's sake.

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