What should be monitored when changing position of prone patients?

September 24, 2025 •

4 min read

Over 70 million new blog posts are published each month, many failing to prioritize patient safety in critical care. When handling a patient requiring prone positioning, a highly coordinated and meticulous approach is critical. A team must be vigilant, systematically checking multiple systems to ensure patient stability and prevent serious complications. Understanding what should be monitored when changing position of prone patients is a cornerstone of patient safety.

Quick Summary

Monitoring a prone patient during and after repositioning involves a comprehensive assessment of airway patency, hemodynamic stability, skin integrity, and the securement of all medical devices. It requires a coordinated team effort and meticulous attention to detail to minimize risks such as extubation, pressure injuries, and nerve damage.

Key Points

Airway Safety: The endotracheal (ET) tube's position must be verified and protected from dislodgement during the turn by a designated clinician.
Hemodynamic Stability: Continuously monitor vital signs (heart rate, blood pressure, $SpO_2$) and watch for any signs of cardiovascular compromise or changes in response to repositioning.
Pressure Injury Prevention: Assess skin integrity both before and after the repositioning, paying special attention to pressure points and areas under medical devices, using proper padding and redistribution surfaces.
Nerve and Ocular Protection: Protect the eyes from direct pressure and shield vulnerable nerves like the brachial plexus with correct head and limb positioning.
Device Management: Meticulously manage all medical lines, tubes, and catheters to prevent kinking, disconnection, or dislodgement throughout the procedure.
Team Coordination: Ensure all caregivers involved are trained and communicate effectively, with a designated leader orchestrating the precise movements.

Critical Care: Ensuring Patient Safety during Prone Repositioning

Prone positioning, where a patient lies on their stomach, is a critical intervention often used in intensive care, particularly for patients with acute respiratory distress syndrome (ARDS). While it offers significant benefits for lung function, the process of repositioning carries inherent risks that demand meticulous monitoring. The safety and effectiveness of this procedure depend heavily on a coordinated team, clear communication, and a systematic approach to monitoring key physiological parameters and equipment.

Airway and Respiratory Monitoring

Maintaining a secure airway is arguably the most critical aspect of caring for an intubated patient during repositioning. A designated clinician, often a respiratory therapist, must be dedicated solely to managing the airway at the head of the bed.

Endotracheal (ET) tube position: Before, during, and after the turn, the ET tube's position at the lip should be verified to detect any migration. The tube must be securely taped or tied to prevent accidental extubation.
Ventilator and circuit integrity: The ventilator tubing must be carefully managed to avoid disconnection or kinking during the move. Audible alarms for pressure changes or disconnections are crucial.
Oxygen saturation ($SpO_2$) and end-tidal $CO_2$: Continuous monitoring of oxygen saturation via pulse oximetry is essential to detect hypoxemia. For intubated patients, end-tidal $CO_2$ monitoring confirms adequate ventilation.
Work of breathing: For awake or non-intubated patients, monitoring for increased work of breathing is crucial. Signs like accessory muscle use or increased respiratory rate can indicate intolerance.

Hemodynamic Stability

The change in position and resulting fluid shifts can significantly impact a patient's cardiovascular system. Continuous monitoring helps identify and address any instability promptly.

Vital signs: Heart rate, blood pressure, and respiratory rate must be monitored closely, especially during the turn. Baseline data should be recorded before the procedure to evaluate the effects of the repositioning.
Vasoactive drug infusions: Doses of vasopressors or other vasoactive medications may need adjustment based on hemodynamic response. All lines for these infusions must be protected from kinking or disconnection.
Cardiac rhythm: Continuous electrocardiogram (ECG) monitoring is standard practice for critically ill patients to detect any arrhythmias triggered by the procedure.

Skin Integrity and Pressure Injury Prevention

Pressure injuries are a common complication of prone positioning, and vigilance is required to prevent them, both during and after the turn.

Pre-turn skin assessment: A thorough assessment of the patient's anterior skin and bony prominences should be performed before proning.
Post-turn skin assessment: Once in the prone position, regular assessments should continue, with particular attention to areas under medical devices and anatomical pressure points like the face, elbows, knees, and feet.
Positioning and padding: Proper use of pressure-redistribution surfaces and positioning aids, such as pillows and specialized head supports, is vital to off-load vulnerable areas. Avoid using ring or donut-shaped devices, which can cause localized pressure.

Neurological and Ocular Monitoring

Protecting the patient's nerves and eyes is a critical, yet often overlooked, aspect of prone positioning.

Ocular safety: The eyes are at high risk of injury from pressure or corneal abrasion. Ointment should be applied, and eyelids taped shut, with a face positioner used to prevent direct pressure on the eyes. Assess the eyes for any sign of injury or excessive edema.
Brachial plexus and ulnar safety: Nerve injuries can occur from excessive traction or compression. Maintain straight spinal alignment and use specific arm positioning techniques, such as the 'swimmer's position' with careful arm rotation, to prevent hyperextension.

Medical Device and Line Management

All lines, tubes, and catheters must be managed meticulously to prevent dislodgement or kinking. This includes enteral feeding lines, central lines, arterial lines, and urinary catheters.

Comparison of Monitoring during Repositioning


Monitoring Category	During Repositioning	After Repositioning (Ongoing)
Airway/Breathing	Designate one person for airway; visually confirm ET tube placement; monitor for disconnections or kinks.	Verify ET tube position; monitor $SpO_2$ and end-tidal $CO_2$ constantly; assess for signs of respiratory distress.
Hemodynamics	Monitor vital signs continuously; have vasopressors ready; watch ECG for arrhythmias.	Ongoing vital sign monitoring; adjust medication drips as needed; assess tolerance.
Skin Integrity	Perform focused skin assessment before the turn; inspect under devices; use proper padding.	Perform regular skin assessments (e.g., every 2 hours) of prone pressure points; assess under devices.
Neurological	Ensure head is neutrally aligned; protect eyes from pressure; ensure limbs are properly positioned.	Assess for signs of nerve injury or pain; re-evaluate head and limb positioning regularly.
Equipment	Manage all lines and tubes to prevent kinking or dislodgement; confirm connections.	Check all lines and devices for integrity and function; ensure accessibility.

The Importance of Team Coordination

A minimum of five trained caregivers is often needed for manual proning, led by a designated team leader. The team leader ensures a systematic review of the procedure and counts down for coordinated movements. Effective communication and teamwork are paramount to execute the turn safely. For complex cases, a respiratory therapist should be present to manage the airway, and additional personnel may be needed to secure lines and support heavier patients.

Conclusion

Monitoring prone patients during position changes is a complex, multi-faceted process that demands a high level of vigilance and teamwork. Beyond the immediate respiratory and hemodynamic checks, attention to skin integrity, nerve protection, and device management is essential to prevent harm. By following a systematic and coordinated approach, healthcare teams can minimize the risks associated with this critical procedure. For more detailed information on critical care procedures, consult authoritative guidelines like the AACN Procedure Manual for High Acuity, Progressive, and Critical Care.

Continuous Education and Auditing

To ensure ongoing patient safety, institutions should develop and enforce clear prone positioning protocols, including initial training and annual refreshers for staff. Auditing specific complication rates, such as pressure injuries and unplanned extubations, helps identify areas for improvement and maintain high standards of care. This commitment to continuous quality improvement is essential for any facility utilizing prone therapy for critically ill patients.

Frequently Asked Questions

Monitoring vital signs is critical because turning a patient prone can cause significant fluid shifts and changes in cardiac output, potentially leading to hemodynamic instability. Continuous monitoring helps detect changes in heart rate, blood pressure, and respiratory rate, allowing for immediate intervention.

Pressure injury prevention starts with a thorough skin assessment before the turn. Use pressure-redistribution surfaces, proper padding to off-load vulnerable areas like the face, knees, and elbows, and perform regular skin checks after the patient is prone. Also, ensure medical devices are not causing excessive pressure.

The primary risk is accidental extubation or tube disconnection. A dedicated team member must manage the airway, confirming the endotracheal tube's position and security before, during, and after the turn to ensure uninterrupted ventilation.

Protect the patient's eyes by applying lubricating ointment, taping the eyelids shut, and using a specialized head support that prevents any direct pressure on the orbital region. The eyes should be checked regularly for signs of injury or swelling.

Signs of intolerance can include a significant drop in oxygen saturation ($SpO_2$), increased work of breathing (in awake patients), hemodynamic instability such as a severe drop in blood pressure, or persistent arrhythmias. Vigilant monitoring is key to catching these signs early.

All medical lines and devices must be carefully managed to prevent kinking or dislodgement. The team must identify all lines and tubes beforehand and move them together, ensuring they are accessible and secure after the patient is in the new position.

Repositioning a critically ill patient prone requires a coordinated effort to be done safely. A trained team, typically with a designated leader, ensures that all critical monitoring steps are followed, equipment is managed, and movements are synchronized to minimize risks to the patient and staff.