VOL: 102, ISSUE: 25, PAGE NO: 28
Phil Jevon, PGCE, BSc, RN, is resuscitation officer/clinical skills lead, Manor Hospital, Walsall
In an unconscious patient the airway is at risk. Regurgitated gastric contents, debris in the mouth or upper airway, loose dentures or mechanical obstruction from structures in the mouth, such as the tongue and epiglottis, can all compromise the airway (Quinn, 1998).
The recovery position is designed to maintain a patent airway and reduce the risk of airway obstruction and aspiration. It is recommended in unconscious patients who are breathing normally and have an effective circulation (American Heart Association (AHA), 2005).
The recovery position is advocated for most unconscious patients. After a cardiac arrest, if the patient is breathing spontaneously and does not require any further resuscitation, positioning in the recommended recovery position promotes the maintenance of a clear airway. This helps prevent vomit or secretions from obstructing the airway and potentially causing aspiration.
The recovery position is recommended in many situations where the patient’s conscious level is compromised, for example following a major seizure (Hayes, 2004) and during a hypoglycaemic coma (Diebel, 1999).
Patients with a known or suspected spinal injury should only be moved if an open airway cannot otherwise be maintained. Ideally they should be kept still in the position in which they are found while awaiting the emergency services.
However, if repositioning is necessary, for example due to a compromised airway, the patient should be carefully log-rolled, with the head and neck kept in alignment. Extension of the lower arm above the head together with bending both legs, while rolling the head onto the arm, may be feasible (AHA, 2005).
Right or left lateral
Historically the left lateral position has been advocated for the recovery position (Eastwick-Field, 1996). However, there appears to be no cardiac autonomic tone advantages to be gained from placing patients in the recovery position on one side compared with the other (Ryan et al, 2003). In practical terms, the environment may dictate which side is used. For example, if the patient has collapsed next to a wall, she or he will have to be rolled away from it to be placed on one side so the other may be used.
There are several variations of the recovery position, each with its own advantages. However, no single technique is perfect for all patients (Turner et al, 1998). The position used should be stable, near a true lateral position with the head dependent and no pressure applied to the chest, as this could impair breathing (AHA, 2005).
- Check the environment and decide which is the best side to roll the patient onto. Remove any obstacles.
- If necessary, remove the patient’s spectacles and place them in a safe place. Some authorities also recommend checking the patient’s pockets and removing any sharp instruments, for example keys. If doing this proceed with extreme caution in case of hazardous items.
- Loosen any clothing around the patient’s neck.
- Kneel beside the patient. To minimise the risk of self-injury, adopt a stable base with your knees shoulder-width apart, avoid twisting your back and keep your spine in a neutral position.
- Ensure that both the patient’s legs are straight.
- Position the patient’s arm that is nearest to yourself perpendicular to her or his body with the elbow bent and the hand palm uppermost (Fig 1).
- Grasp the far arm and bring it across the patient’s chest and hold the back of the hand against the patient’s cheek (Figs 2-3).
- Using your free hand, grasp the patient’s far leg just above the knee and pull it up, keeping her or his foot on the ground (Fig 4).
- While holding the patient’s hand against her or his cheek, pull on the far leg to roll the patient towards you onto her or his side (Fig 5).
- Adjust the patient’s upper leg ensuring that the hip and knee are bent at right angles (Fig 6).
- Tilt the patient’s head back to ensure the airway remains open.
- If necessary, adjust the hand under the patient’s cheek in order to maintain the head in a tilted position.
- Monitor the patient’s vital signs (Resuscitation Council (UK), 2005).
Guidelines on safer handling during resuscitation should be observed to reduce the risk of self-injury (RCUK, 2005; 2001):
- Assess the situation before proceeding with the procedure.
- Adopt a position close to and directly facing the patient.
- Avoid twisting your back.
- Ensure you keep your spine in a neutral position.
- Face the patient straight on.
All nurses who carry out clinical procedures must have received approved training, undertaken supervised practice and demonstrated competence in the clinical area. The onus is also on the individual to ensure that knowledge and skills are maintained from both a theoretical and a practical perspective. Nurses should also undertake this role in accordance with an organisation’s protocols, policies and guidelines.