Abstract

Introduction

Background

Conceptual Framework

Method

Results

Discussion

Appendix A

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Health Care Professionals’ Perceptions of Right-sided Positioning as a Complementary Therapy for Postoperative Nausea and Vomiting

 

Jeffrey M. Miller, BS, RN

Mary Ann Stark, PhD, RN

Western Michigan University, Bronson School of Nursing

 



Abstract

Postoperative nausea and vomiting (PONV) is a common post-surgical complication that can have serious consequences for patients.  Right-sided positioning may use gravity to promote gastric drainage from the stomach to the small intestine, thereby decreasing PONV caused from these secretions accumulating in the stomach. The purpose of this study was to evaluate the perceptions of health care professionals regarding the use of right-sided positioning as a complementary therapy for PONV.   An anonymous questionnaire was used to collect the data from specific groups of health care professionals with extensive knowledge and experience with PONV.  Based on the responses of those who completed the questionnaire (N=41), right-sided positioning may be beneficial in reducing the incidence PONV, and the majority of participants believed a study examining this intervention needs to be conducted (n=28, 68%).

Introduction

Despite technological and pharmacological advances in the surgical setting, postoperative nausea and vomiting (PONV) still affects 20-30% of patients (Watcha & White, 1995).  Many patients consider PONV to be the worst aspect of their surgical experience (Brenner, 2000).  In addition to being an unpleasant experience, PONV can have serious consequences such as aspiration, dehydration, electrolyte disturbances and disruption of the incision site (Thompson, 1999).

Background

Nausea is defined as “a sensation accompanying the urge but not always leading to vomiting” (Anderson, Anderson, & Glanze, 1998, p. 1085) and vomiting refers to “the forcible voluntary or involuntary emptying of the stomach contents through the mouth” (Anderson et al., p. 1720).  Factors that contribute to PONV include decreased gastric motility, retroperistalsis, inhibition of gastric secretion, tachycardia, and increased salivation (Hawthorn, 1995).

 

There are many risk factors that play a role in the occurrence of PONV.  Eating or drinking before surgery, being overweight, a history of motion sickness, and anxiety can increase the likelihood of PONV (Hawthorn, 1995).  Other factors that aggravate PONV include the type and duration of the operation, type of anesthetic agent used, and postoperative factors such as pain, hypotension, opioid analgesics and early oral intake (Thompson, 1999).

Research involving the use of nonpharmacologic interventions for PONV has increased tremendously during recent years.  Behavioral interventions such as distraction and relaxation techniques, as well as holistic therapies including therapeutic touch and acupressure are examples (Thompson, 1999).  Holistic interventions, such as these, are of great value to nurses and other health care professionals because they bring healing to the forefront of health care (Dossey, Keegan, & Guzzetta, 2000).  Another simple and cost-effective holistic nursing therapy to help relieve PONV may occur through right-sided positioning to promote gastric motility.

 

Conceptual  Framework 

 

In order to have a clear understanding of the pathophysiology behind the use of right-sided positioning for PONV, it is first necessary to examine the anatomy and physiology of the stomach and digestive system.  The stomach is located in the epigastric and left hypogastric regions of the body, bounded by the abdominal wall and the diaphragm, between the liver and the spleen (Broomhead, 1995).  Digestion occurs through a system of organs in the digestive tract.  The digestive system includes the mouth, pharynx, esophagus, stomach, small intestine, and large intestine.

One cause of PONV is an accumulation of gastric secretions in the stomach, as many of the medications used during surgery slow gastric motility.  Based on the anatomy and physiology of the gastrointestinal system in the human body, right-sided positioning, with the head of the bed elevated slightly, may promote gastric drainage.  This positioning may use gravity to promote drainage of secretions in the stomach to pass through the pylorus and empty into the duodenum of the small intestine, thereby possibly decreasing PONV.

 

Literature Review

 

The extant knowledge regarding right-sided positioning as a complimentary therapy for PONV is minimal.  Right-sided positioning as a holistic nursing intervention has been found useful for other similar purposes.  For example, placing an infant on the right side after feeding has been found to reduce regurgitation (Olds, London, & Wieland-Ladewig, 2000).  Right-sided positioning has also been used when administering nutrition via a nasogastric or gastrostomy tube to facilitate flow of the feeding from the stomach to the small intestine (Craven & Hirnle, 1996).  An important point to remember when looking at right-siding positioning is that it may be contraindicated in some patients, including certain orthopedic and gastrointestinal surgeries.  While right-sided positioning may be useful for other conditions, there is no research to demonstrate its effectiveness for PONV.

 

Research Purpose and Question

 

The purpose of this study was to determine whether right-sided positioning should be researched as a complimentary nursing therapy for PONV.  This was completed through a survey of health care professionals who are experts in the area of PONV.

 

Method

 

A descriptive correlational survey design was used to evaluate the experts’ perceptions through the use of an anonymous questionnaire (Appendix A).  This questionnaire was dispersed to a convenience sample of post-anesthesia care unit (PACU) registered nurses (RNs), anesthesiologists (MDs), and nurse anesthetists (CRNAs) at two participating hospitals in southwest Michigan. Forty-one health care professionals participated in the study, including five anesthesiologists, four CRNAs and 32 RNs. These health care professionals were chosen because of their expertise in working with patients recovering from surgery and anesthesia.  Before the study began, approval was obtained from the appropriate Institutional Review Boards.

 

The responses from these expert clinicians were aggregated and analyzed by the researchers in order to determine their perceptions regarding the use of right-sided positioning.  Descriptive statistics were determined for all variables using SPSS 11.0.  The feasibility for conducting a future study using this holistic nursing therapy was completed by evaluating the perceptions of the expert clinicians regarding the possible effectiveness of right-sided positioning for PONV.

 

Results

 

The mean years of experience for the participants working in PACU, or as an anesthesia provider was 11.3 (SD=4.6) years.  The majority of this sample estimated that PONV affected 21-40% of their patients (see Table 1) and that PONV was moderately uncomfortable (see Table 2).

 

Table 1: Health Care Professionals’ Estimate of PONV (N=41)

 

Patients who experience PONV

Frequency

Percent

0-20% of all patients

8

19.5

21-40% of all patients

27

65.9

41-60% of all patients

5

12.2

61-80% of all patients

1

2.4

 

Table 2: Health Care Professionals’ Estimate of Discomfort Related to PONV (N=41)

 

 

Frequency

Percent

Not at all uncomfortable

1

2.4

A little uncomfortable

16

39.0

Moderately uncomfortable

20

48.8

Quite a bit uncomfortable

1

2.4

Extremely uncomfortable

3

7.3

 

All 41 participants indicated that right-sided positioning was not a part of regular or routine PONV care.  When asked how likely it is that right-sided positioning may be beneficial for reducing PONV, the majority indicated ‘sometimes’ (see Table 3).

 

Table 3:  Health Care Professionals’ Estimate of Effectiveness of Right-sided Positioning for PONV (N=39)

 

 

To Relieve Nausea

To Relieve Vomiting

Never

2.6% (n=1)

5.1% (n=2)

Almost never

10.3% (n=4)

7.7% (n=3)

Sometimes

74.4% (n=29)

76.9% (n=30)

Fairly often

12.8% (n=5)

10.3% (n=4)

 

Participants were then asked how often they used positioning to relieve PONV in the last month.  The most common response to this question was ‘never’ (n=18, 43.9%).  This question was not specific to right-sided positioning, so some of the responses may be based on other positioning techniques, such as elevating the head of the bed.

Another question asked the health care professionals how likely they would be to use right sided-positioning for appropriate patients to relieve PONV.  The most common answer was sometimes’ (n=19, 46.3%) (see Table 4).

Table 4:Health Care Professionals’ Likeliness to use Right-sided Positioning as a complimentary Therapy for PONV (n=41)

 

 

Frequency

Percent

Never

2

4.9

Almost never

7

17.1

Sometimes

19

46.3

Fairly often

12

29.3

Very often

1

2.4

The participants were then asked to check barriers that might inhibit turning patients on their right side to alleviate PONV.  The results are as follows: 83% (n=34) said that a barrier might be pain during turning, 39% (n=16) indicated difficulty turning patients, 7% (n=3) said there might not be enough time, and 7% (n=3) indicated there may not be an adequate number of pillows available.  Two participants added airway concerns as a possible barrier to right-sided positioning and one indicated that placing the client in a right-sided position may increase the likelihood of nausea secondary to movement.

The final question in the survey asked the participants if they believed a controlled study is needed to determine the efficacy of adding right-sided positioning to routine PONV care; 68% (n=28) indicated that they believe a future study is needed.

Discussion

PONV is one of the most common complications following surgery and can have serious consequences for patients. Medications are available to treat PONV but they often have unpleasant side effects such as drowsiness and dizziness. Complimentary therapies in health care can help to increase comfort without significantly increasing the cost of care. Positioning is usually a nursing responsibility; therefore the use of right-sided positioning for PONV is of particular interest to the nursing profession. There is no research that suggests that right sided positioning might be useful to prevent or treat PONV, some experts in postoperative care were asked to give their opinion on the potential usefulness of this complementary therapy. Many did not use positioning to relieve PONV, yet the majority felt this complimentary therapy was potentially beneficial and warranted further study. Since this nursing practice is not suggested in the literature or used often in practice, much more research is required. This research demonstrates some interest in postoperative health care providers for testing a complimentary therapy that may be useful in treating and preventing PONV.

 

While the providers in this study thought right sided positioning may be effective, this complementary therapy is not used often in routine postoperative care. Several factors may influence this. Other patient care concerns, such as pain and airway issues may make right sided positioning difficult in some cases. The work environment may not support use of complimentary therapies. This sample indicated that turning patients was difficult, there was not enough time for turning, and that there were not enough pillows available to support the patient after turning. Finally, there may be some reluctance to try a complimentary therapy. This may be due to the abundance of medications that are available or that this therapy not been tested. This also demonstrates the need for further testing.

 

A challenge for nursing is finding ways to bring greater comfort and care to patients and families. Right sided positioning is perhaps a complimentary therapy that may bring some relief for PONV. How can nurses introduce new complimentary therapies into nursing practice? The procedure used for this study was to review the literature on the topic, propose how the complimentary therapy might be used and survey expert practitioners on its potential usefulness. The majority of the sample felt that further study was warranted.

The major limitations in the study included a small convenience sample and the use of an anonymous survey.

 

Acknowledgments

 

We would like to acknowledge with gratitude the assistance and support of Juanita Manning-Walsh, PhD, RN and Corey Hitchcock, BS, RN in the completion of this research investigation.

 

References

 

Anderson, K.N., Anderson, L.E., & Glanze, W.D. (Eds.). (1998). Mosby’s Medical, Nursing, & Allied Health Dictionary. St. Louis: Mosby.

 

Brenner, Z.R. (2000). Preventing postoperative complications: what’s old, what’s new, what’s tried-and-true.  Nursing Management, 31(12): 17-23.

 

Broomhead C.J. (1995). Physiology of postoperative nausea and vomiting. British Journal of Hospital Medicine 53, 327-330.

 

Craven, R.F. & Hirnle, C.J. (Eds.). (1996). Fundamentals of Nursing: Human Health and Function. Philadelphia: Lippincott.

 

Dossey, B.M., Keegan, L., & Guzzetta, C.E. (Eds.). (2000). Holistic Nursing: A Handbook for Practice. Gaithersburg, MD: Aspen Publishing, Inc.

Hawthorn J. (1995). Understanding and Management of Nausea and Vomiting. Blackwell Science, Oxford.

 

Olds, S.B., London, M.L., & Wieland-Ladewig, P.A. (Eds.). (2000). Maternal-newborn Nursing. Upper Saddle River, NJ: Prentice-Hall Inc.

 

Thompson, H.J. (1999). The management of post-operative nausea and vomiting. Journal Advanced Nursing 29(5), 1130-1136.

Watcha, M.F., & White, P.F. (1995). New antiemetic drugs. International Anesthesiology Clinics 33, 1-20.
 


 

Appendix A

 

Health Care Professionals’ Perceptions of Right-sided Positioning as a Complimentary Therapy for Postoperative Nausea and Vomiting (PONV)

 

The following questionnaire is to be completed by any PACU RN, CRNA, or Anesthesiologist.  Completing the questionnaire will help a WMU nursing student complete an honor’s thesis.  Your help is appreciated! The purpose of this study is to evaluate the perception of health care professionals regarding the use of right-sided positioning as a complimentary therapy for postoperative nausea and vomiting (PONV).

 

*Please do not put your name anywhere on this form.

 

*Please tear off the informed consent sheet (front) and keep it for your records.

 

*Please return the completed form to the collection box provided.

 

What is your professional role?

_______ MD anesthesiologist

 

_______ CRNA

 

_______  RN

How long have you worked in a PACU (or with post-operative patients)?   ______  years.


Overall, what percentage of patients do you estimate experience PONV?

 

_______ 0-20% of all patients

 

_______ 21-40% of all patients

 

_______ 41-60% of all patients

 

_______ 61-80% of all patients

 

_______81-100% of all patients

 

Overall, how would you rate the discomfort of PONV for patients who experience PONV in PACU?

 

______ not at all uncomfortable

 

______ a little uncomfortable

 

______  moderately uncomfortable

 

______  quite a bit uncomfortable

 

______  extremely uncomfortable

 

Please read the following information before answering the final questions:

 

Many patients consider PONV to be the worst aspect of their surgical experience.  In addition to being an unpleasant experience, PONV can have serious consequences.  Aspiration, dehydration, electrolyte disturbances and disruption of the incision site are a few of the serious complications of PONV.  One cause of PONV occurs from an accumulation of gastric secretions in the stomach, since many of the medications used during the surgery slow down gastric motility.

Based on the anatomy of the gastrointestinal system in the human body, right-sided positioning, with the head of the bed elevated around 15-20 degrees, may promote gastric motility, thereby decreasing PONV caused from gastric secretions in the stomach.  This positioning may use gravity to promote the secretions in the stomach to pass through the pylorus and empty into the duodenum of the small intestine (please see figures 1 & 2 on the following page).

While there is little research regarding the use of right-sided positioning for PONV, this therapy has been found to be beneficial for other similar purposes.  For example, placing an infant on his/her right side after feeding has been found to reduce regurgitation. Right-sided positioning can be used when administering nutrition via a nasogastric or gastrostomy tube to facilitate flow of the feeding into the intestine.  Right-sided positioning may be contraindicated in certain post-operative patients, including certain orthopedic and gastrointestinal surgeries.

Brenner, Z.R. (2000).
Preventing postoperative complications: what’s old, what’s new, what’s tried-and-true. Nursing Management, 31(12), 17-23.

 

Craven, R.F. & Hirnle, C.J. (2nd Ed.). (1996). Fundamentals of Nursing: Human Health and function. Philadelphia: Lippincott.

 

Hawthorn, J. (1995). Understanding and Management of Nausea and Vomiting. Oxford: Blackwell Science.

 

Olds, S.B., London, M.L., & Wieland-Ladewig, P.A. (Eds.). (2000). Maternal-newborn Nursing. Upper Saddle River, NJ: Prentice-Hall Inc.

 

Thompson, H.J. (1999). The management of post-operative nausea and vomiting. Journal Of Advanced Nursing, 29(5), 1130-1136.

 

Is right-sided positioning part of regular or routine PONV care now?

 

_______Yes

 

_______No

 

Based on the information provided above, how likely is it that right-sided positioning may be beneficial for reducing post-operative nausea?

 

_______never

 

______ almost never

 

_______sometimes

 

_______fairly often

 

_______very often

 

Based on the information provided above, how likely is it that right sided positioning may be beneficial for reducing post-operative vomiting?

 

_______never

 

______ almost never

 

_______sometimes

 

_______fairly often

 

_______very often

 

How often have you used positioning to relieve PONV in the last month?

 

_______never

 

______ almost never

 

_______sometimes

 

_______fairly often

 

_______very often

 

How likely are you to use right sided positioning for appropriate patients to relieve PONV?

 

_______never

 

_______almost never

 

_______sometimes

 

_______fairly often

 

_______very often

 

Please indicate what barriers might inhibit turning patients on their right sides to alleviate PONV (check all that apply):

 

______Difficulty turning patients

 

______Not enough time available to turn patients

 

______Lack of pillows to position patients comfortably

 

_______Too painful for patient

 

Do you believe a controlled study is needed to determine the efficacy of adding right-sided positioning to routine PONV care?

 

______Yes

 

______No

 

Do you have any other comments or recommendations:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please return the anonymous questionnaire to the box provided.

 

Thank you for your participation!


 

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