Which of the following positions does the nurse assist the patient in to best assess respiratory status?

Patient positioning is vital to a safe and effective surgical procedure. Fowler’s position is the most common position for patients resting comfortably, whether in-patient or in the emergency department. Also known as sitting position, Fowler’s patient positioning is typically used for neurosurgery and shoulder surgeries. Variations of the Standard Fowler’s Position include Low Fowler’s Position, Semi Fowler’s Position, and High/Full Fowler’s Position.

With numerous applications, Fowler’s position is used for patients who have difficulty breathing because, in this position, gravity pulls the diaphragm downward allowing greater chest and lung expansion.2 Learn more about Fowler’s position use cases in common medical procedures, and the differences between the positions.

What is Standard Fowler’s Position

Standard Fowler's position, also known as sitting position, is typically used for neurosurgery and shoulder surgeries. The bed angle is between 45 degrees and 60 degrees. The legs of the patient may be straight or slightly bent. This position is often used for head, chest, and shoulder surgeries.

Standard Fowler’s position is the preferred position to combat respiratory distress syndrome. Due to the positioning of the bed, Standard Fowler's position allows for better chest expansion, improving breathing by facilitating oxygenation.3 Other advantages include an increase in blood and cerebral spinal fluid drainage and improved hemostasis.

Low Fowler’s, like Supine Position, is when a patient’s head is included at a 15–30-degree angle. This position can be used post-procedure, to reduce lower back pain, administer drugs and prevent aspiration during tube feeding. Low Fowler’s position is considered the best position for patients to rest.

What is Semi Fowler’s Position

In Semi Fowler’s Position, the patient is usually on their back. The bed angle is between 30 degrees and 45 degrees. The legs of the patient may be straight or bent.

Semi Fowler’s Position can be used when the patient faces difficulty breathing or is undergoing breathing treatments and when drainage occurs after an abdominoplasty. Due to the positioning Semi Fowler’s position is the preferred position during childbirth to improve the comfort of the mother.4 Also, patients experience less nausea in this position compared to patients lying down.

What is High/Full Fowler’s Position

In High Fowler’s position, the patient is usually seated upright with their spine straight. The upper body is between 60 degrees and 90 degrees. The legs of the patient may be straight or bent. This Position is commonly used when the patient is defecating, eating, swallowing, taking X-Rays, or to help with breathing.

High Fowler’s position is usually prescribed to elderly patients as it is scientifically proven to aid in the digestion process and help the patient overcome breathing problems.3 Resting in a High Fowler’s position for an extended period can cause discomfort and increase the development of pressure ulcers.

Contradictions of Fowler’s Position

Positioning of the patient is primarily for reasons of anatomical exposure for the surgical procedure. In instances where the patient does not tolerate the sitting position well, adjustments can be made to accommodate any intolerances of the patient. For Example, patients with pressure ulcers in the lower back or buttocks may not be able to tolerate the sitting position.

Additional measures to reduce pressure and contact of the injured area with hard surfaces may be needed. These can include extra padding, changing angles, employing tilt to remove pressure where the injury is lateral. Additionally, patients with previous spine surgery may have range of motion limitations that make this position contraindicated. Patients should be assessed for their ability to tolerate this position and for any intrinsic patient factors that may pose any additional risk to the patient.

Patient Positioning Considerations for Fowler’s Position

Fowler’s position can be achieved in many different ways using either the native sections of a general surgical table or through the addition of surgical table accessories and positioning aids. Common surgical table accessories & positioning aids used when employing Fowler’s position include Beach Chair positioners or foam body positioners.

Beach Chair Positioners are most often used for High Fowler’s positioning in orthopedic shoulder procedures (total shoulder replacement, shoulder arthroscopy, rotator cuff, etc.). Beach Chairs often have removable left & right back sections that provide surgical site access to the patient’s shoulder. It is also common for Beach Chairs to have a lateral support that is employed to keep the patient positioned upright and restricts lateral torso movement during the rigors of upper extremity procedures.

Limb Positioners are commonly used in collaboration with Beach Chairs when employing High Fowler’s positioning in orthopedic shoulder procedures. Basic limb positioners can include arm and elbow positioners for neutral positioning of the patient’s operative arm for surgical site access or the non-operative arm(s) to get them out the surgeon’s way. More advanced limb positioners allow the surgical team to position the patient arms in unique, spatial positions that enable surgical site access to the shoulder across a spectrum of shoulder joint procedures. OR staff can also employ advanced limb positioners for positions other than Fowlers; for instance, in lateral patient position to enable suspended arm positioning for orthopedic shoulder procedures.

Multi-position armboards are similar to basic limb positioners in that they facilitate neutral positioning of the patient’s operative arm for surgical site access or the non-operative arm(s) to get them out the surgeon's way to access the target anatomy.

Neurosurgical headrests and head positioners are commonly used in Semi-Fowler’s and High Fowler’s positioning to attain surgical site access to the patient’s skull, facial and neck anatomy. The general table is often positioned using native table sections (no Beach Chair used) to achieve the desired Fowler’s position. The native head section of the surgical table is often removed, and the desired anterior or posterior positioning accessories are attached to facilitate immobilization of the head and surgical site access.

Gel and foam positioners are often used across all Fowler's positioning variations. Common positioning aids that support the patient across Fowler's positions include headrest donuts, face masks (for Beach Chairs), arm cradles, wedge positioners (for the legs or feet), heel & ankle cradles, and egg-crate foam sheets to protect or bolster key anatomical areas. Pre-operative patient assessments are always advised to assess the patient’s skin, body morphology, bony prominences, and any special anatomical areas that need unique consideration during surgery. See STERIS's Healthcare Knowledge Center article on Pressure Management to learn more.

Conclusion

One of the most common patient positions, the Fowler’s position provides better surgical exposure and improved breathing. Surgical staff should consider risks and complications associated with the Fowler’s position such as:

• a decrease in the return of blood to the heart
• venous embolism
• air or gas inside the skull
• an increased potential for airway loss
• an increased risk for nerve damage and facial edema

Variations to the Fowler’s position include the Standard Fowler’s, Low-Fowler’s, Semi-Fowler’s, and High-Fowler’s position.

Regardless of what position is being used for a patient during a procedure, it’s important to follow best practices for positioning.1 Surgical Staff should always refer to their facility's positioning policies, procedures, and training when positioning a patient.

• Have an adequate number of personnel, devices, and equipment available during positioning activities helps to ensure patient and personnel safety.
• Respect the patient’s dignity and privacy during positioning: only necessary personnel in the room when the patient is exposed.
• Maintain the patient in a natural neutral alignment. Keep the patient’s head and neck in a neutral position without extreme lateral rotation and avoid hyperextending.
• Verify the patient's complete body is in physiologic alignment and that the hands, fingers, feet, and toes are protected from surgical table articulations.
• Operating Room staff should always use safe body mechanics during transfers and positioning.
• Ensure that the patient is not in contact with any metal portions of the surgical table or positioning devices.
• Never exceed the weight limits for the table or the accessories used and always follow the manufacture’s guidelines and recommendations when using the surgical table and accessories.
• Inspect all equipment, pads, and accessories before use and replace them as needed.

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References

1Guideline for positioning the patient. (2017). AORN Journal, 105(4), P8-P10. doi:10.1016/s0001-2092(17)30237-5

2 https://nurseslabs.com/patient-positioning/#fowlers_position

3 https://www.topregisterednurse.com/fowlers-position/

4 https://nurse.plus/nclex-terminology/terms-abbreviations/semi-fowlers-position/

The stats speak for themselves. Respiratory distress is what sends 10% of children to emergency departments. Additionally, one in seven seniors has a lung disease. Between 1980-2014, more than 4.6 million American adults died from chronic respiratory diseases. 

Performing comprehensive respiratory assessments can detect problems before they become emergencies. Additionally, in hypoxic patients or those with airway obstructions, a respiratory assessment provides important information about the patient’s status and clues about next treatment steps.

Let’s look at the basics of performing an effective and comprehensive respiratory assessment.

Patient History

A respiratory assessment must begin with a detailed patient history. Ask about previous respiratory illnesses, chronic respiratory conditions, and cardiovascular health. If the patient has an infection or is in respiratory distress, get as many details as possible about the event preceding the emergency. Ask about the patient’s vaccine history, as well.

This is also an ideal chance to determine whether the patient has special needs that might affect the assessment. Preterm infants, for example, have weaker respiratory muscles than children and adults, while infants and young children have a more rapid rate of respiration. Ensure you know what’s normal for the patient population you serve, as well as the specific patient you are treating.

Observe the patient for important respiratory clues:

• Check the rate of respiration.
• Look for abnormalities in the shape of the patient’s chest.
• Ask about shortness of breath and watch for signs of labored breathing.
• Check the patient’s pulse and blood pressure.
• Assess oxygen saturation. If it is below 90 percent, the patient likely needs oxygen.

In infants and newborns:

• Check for flaring nostrils, which could indicate breathing problems.
• Look for retractions or bulging of the muscles between the ribs, which suggest difficulty getting enough air.

Auscultation

Hearing the sounds of the patient breathing provides vital information about the patient’s overall health. Auscultate the chest, back, and sides with a focus on signs of loud or labored breathing. Signs of abnormal breathing include:

• Crackling, popping, or bubbling sounds, which may indicate pneumonia or pulmonary edema.
• Wheezing, which can signal pulmonary disease, asthma, allergies, or an infection.
• Pleural friction. This grating sound occurs when the pleural surfaces rub together and suggests pneumonia.

A hands-on exam is critical for detecting abnormalities that simple observation and auscultation cannot. To examine the patient:

1. Palpate the back at the tenth rib, positioning a thumb on each rib as the patient breathes deeply. Patients with decreased lung expansion may have a tumor or pneumonia on one side. Poor lung expansion could also indicate pneumothorax.
2. Evaluate the thorax by positioning the palms over the thorax and feeling for bulging, tenderness, and retractions while breathing. Feel the ribs for lumps, scars, and swelling.

3. Have the patient fold their arms across their chest. Then position both palms on either side of the back, touching the patient’s back with your fingers while the patient says a sentence.

4. You should feel buzzing as the patient speaks. If there is fluid in the lungs or a lower respiratory obstruction, the vibrating will be intense because of the ability of fluid to more effectively transmit sound.
   

Percussion

Percussion can provide additional information about respiratory status. Use the middle or index finger of your dominant hand to tap the areas between each rib through the chest or back. Avoid touching the skin with your other fingers, since this can cause vibrations that compromise the assessment.

Sounds to monitor for include:

• A short and high-pitched or very dull sound over muscle or bone. This suggests respiratory consolidation.
• A loud, long, low-pitched and hollow sound over the lungs or stomach that may suggest bronchitis.
• A dull, thudding sound over large organs such as the liver. This may also be a sign of consolidation.
• A loud, low-pitched sound over the stomach that can indicate pneumothorax or emphysema.
• A high-pitched drum sound is heard when the chest is expanded. This suggests excess air, often due to a collapsed lung.

A respiratory assessment provides important details about treatment, and the right treatment may include clearing the airway of obstructions. For help selecting the right equipment for your agency, download our free guide, The Ultimate Guide to Purchasing a Portable Emergency Suction Device.

Editor's Note: This blog was originally published in December 2018. It has been re-published with additional up to date content.