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ARCHIVED: Assessment > Exam 1: Positioning > Flashcards

Exam 1: Positioning Flashcards

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1
Q

Documentation of operative positioning should include (4):

A

Baseline ROM
Intra-op position
Padding, frame, equipment
Checks & frequency

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2
Q

OR length and weight limits (old and new):

A

80.7 inches
Old: 136kg (300lb)
New: 270kg (600lb)

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3
Q

Patient’s torso should be centered over which part of the bed?

A

The column

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4
Q

Always make sure the OR table has this before transferring patient:

A

Draw sheet

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5
Q

Last step of transferring pt to table:

A

Safety/reminder strap

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6
Q

Advantages of supine position:

A

Access to airway
Access to arms
Less physiologic changes

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7
Q

Head support in supine:

A

Pillow under head (allows sniffing position, avoids excess extension/flexion)

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8
Q

Arm position in supine:

A

Tucked, (using draw sheet, hand against thigh) or out using arm boards (less than 90º abduction, hands supinated, well padded)

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9
Q

Lower extremity position in supine (5):

A 
Heels padded and on bed, not hanging
Feet/legs uncrossed
Hips/knees slightly flexed
Pillow under knees
SCDs/TEDs
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10
Q

Mechanisms of nerve injury:

A 
STICK:
Stretch
Transection
Ischemia
Compression
Kinking
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11
Q

Supine position injuries to brachial plexus (4):

A

Arm extension past 90º (stretch)

Shoulder brace pressed on clavicle (compression)

Arm falling off table (stretch)

Neck extension (stretch)

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12
Q

Two fixed points of brachial plexus pathway:

A

Vertebral foramina fascia

Axilla

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13
Q

Sitting position injuries to brachial plexus:

A

Shoulder sagging with relaxation (stretch)

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14
Q

Lateral position injuries to brachial plexus:

A

Clavicle/scapula/humerus shifted excessively forward (stretch)

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15
Q

Most common peripheral nerve injury:

A

Ulnar

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16
Q

2nd most common peripheral nerve injury:

A

Brachial plexus

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17
Q

S/s of brachial nerve plexus injury:

A

Electric shocks/burning sensation shooting down arm

Numbness/weak arm function

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18
Q

Causes of radial nerve injury in supine position:

A

Surgical retractors
Ether screen
Arm board not level with bed
BP cuff inflation

All compression injuries!

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19
Q

S/s of radial nerve injury:

A

Wrist drop

Weakness in thumb abduction

Numbness of fingers 1, 2, 4

Inability to extend arm at elbow

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20
Q

Causes of ulnar nerve injury in supine position:

A

Entrapment from arm extension

Stretch from severe elbow flexion

Compression against bed

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21
Q

S/s of ulnar nerve injury:

A

Inability to abduct or oppose 5th finger

Weak grip on outside of fist

Loss of palmar sensation
4th/5th fingers

Claw hand

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22
Q

CV changes in supine position (3):

A

Minimal overall

Initial increased return to heart (inc. preload, SV, CO, BP) but baroreceptors compensate

Exception: abdominal masses or pregnancy - pressure on IVC may decrease venous return

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23
Q

Ventilatory changes in supine position:

A 
Decreased FRC (800ml)
Muscle relaxants also decrease lung volume
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24
Q

CBF changes in supine position:

A

Minimal change

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25
Advantages of Trendelenberg (4):
Treats hypotension (short term) Improves lower abdominal exposure Prevents air embolism Makes CVC placement easier
26
Equipment caution in Trendelenberg:
Shoulder braces - use extreme caution and position them out on the joints, not at the root of the neck
27
How much blood does Trendelenberg return to central circulation?
1L
28
CV changes in Trendelenberg:
Reduced blood to LEs Compression of heart possible Baroreceptors cause peripheral vasodilation, bradycardia
29
What happens when pt returns from Trendelenberg to supine?
Blood pools in extremities --> hypotension
30
Ventilation changes in Trendelenberg (5):
Increased work of breathing d/t pressure from abdo contents Perfusion > ventilation at apex of lung Easier R mainstem ETT d/t shifting abdominal contents, flex/extend of head Inc. risk of aspiration Face/airway edema --> airway obstruction
31
CBF changes in Trendelenberg (3):
Increased intracranial vascular congestion Increased ICP Increased intraocular pressure
32
Patients who are not good candidates for Trendelenberg:
Glaucoma | CNS disease
33
Advantages of reverse Trendelenberg:
Increases upper abdomen exposure Useful for shoulder, neck, intracranial surgery
34
Equipment caution with reverse Trendelenberg:
Footboard use for extended time can kink anterior tibial nerve and lead to foot drop
35
CV changes in reverse Trendelenberg (4):
Reduced preload, CO, BP Compensatory increase in SNS tone, SVR, HR RAAS activation Venous pooling in LEs
36
% change in CO and HR in reverse Trendelenberg:
20-40% decrease in CO 30% change in HR (if not blunted by anesthesia)
37
Ventilation changes in reverse Trendelenberg:
Increase in FRC Easier ventilation
38
CBF changes in reverse Trendelenberg:
Decreases proportional to degree of tilt (up to 20%)
39
Hip and leg abduction angles in lithotomy position:
80-100º flexion at hips 30-45º abduction of legs from midline
40
Possible nerve injuries in calf support lithotomy position (4):
Femoral n. (kink) Sciatic n. (stretch) Saphenous n. (compression) Common peroneal/fibular n. (compression)
41
Three types of lithotomy supports:
Calf support Candy cane stirrups Knee crutches
42
Possible nerve damage with candy cane stirrups:
Femoral n. (kink) Sciatic n. (stretch) Common peroneal nerve (compression)
43
Possible nerve damage with knee crutch stirrups:
Popliteal n. (compression)
44
Most common three lower extremity nerve injuries:
Common peroneal (78%) Sciatic (15%) Femoral (7%)
45
S/s of common peroneal nerve injury:
Foot drop Inability to evert foot Loss of dorsal extension of toes
46
S/s of sciatic nerve injury:
Weakness or paralysis of muscles below knee Numbness of foot, lateral half of calf Foot drop
47
S/s of femoral nerve injury:
Loss of hip flexion, knee extension Decreased sensation on superior thigh
48
S/s of saphenous nerve injury:
Medial and anteromedial calf parasthesias
49
Risk factors for LE compartment syndrome:
Long procedures Lithotomy or lateral decub position
50
CV effects of lithotomy:
Elevation of legs transiently increases preload/CO/BP
51
Perfusion pressure to extremities lowers ____ for each _____ that they are raised above the heart.
2 mmHg for each 2.5 cm
52
Ventilatory effects of lithotomy:
Abdominal contents may get pushed up by hip flexion and decrease compliance/TV/VC
53
CBF effects of lithotomy:
Transient increase in CBF and ICP when legs are elevated
54
Keep pressure off abdomen in prone position in order to:
Improve caval return/perfusion
55
Frame used for prone position:
Wilson frame
56
Special table used for prone position:
Jackson table
57
Steps to take after turning prone (5):
Check breath sounds again Monitors on/working Check IV, A-line, etc Check pressure points Check neck alignment
58
Head position in prone (4):
Side to side if patient is sedated Head supported face-down for GA, with weight on bony structures Eyes, ears, nose free of pressure Neutral neck alignment!!
59
Arm position in prone (4):
Abducted less than 90º Extra padding at elbow Watch shoulders - keep from sagging Tucked at sides
60
What is thoracic outlet syndrome? What is a quick test for it?
Impingement of IJ, EJ, lymphatics by the clavicle when arms are raised Test: Put hands behind head for 2 mins - look for dec. pulses, numbness, tingling
61
CV changes in prone:
Hypotension d/t caval/aortic compression Hypotension d/t venous pooling in LEs
62
Biggest immediate physiological concern with prone position:
Hypotension!! Can lead to blindness when combined with pressure on face/eyes
63
Ventilatory changes in prone (2 big ones, with details):
V:Q mismatch: Posterior ventilation > perfusion Anterior perfusion > ventilation Diaphragm displaced cephalad; compliance decreases, airway pressure increases, WoB increases
64
CBF changes in prone:
Turning head obstructs venous return, increasing ICP Excessive flexion/rotation obstructs verts
65
Uses of lateral decubitus position:
Thoracotomy, kidney, shoulder, hip surgeries
66
Arm position in lateral decubitus:
Dependent arm on arm board, perpendicular to torso Non-dependent arm supported over bedding or another armrest
67
Leg position in lateral decubitus:
Padding between knees Dependent leg flexed Padding on bed below dependent leg
68
Torso position in lateral decubitus:
Axilla roll under side chest Anterior/posterior support - rolls or bean-bag support Safety strap between head of femur and iliac crest
69
CV changes in lateral decubitus:
Minimal changes unless venous return is obstructed (kidney rest) BP measurements will be different in dependent vs. non-dependent arms
70
Ventilation changes in lateral decubitus, related to pt status/ventilation:
Biggest V/Q mismatch of any position In awake/spontaneously breathing pt: dependent lung better vent/perf but lung volumes decreased In asleep/spontaneously breathing pt: nondependent lung better vent, dependent lung better perf In asleep/mechanically ventilated pt: nondependent lung overvented, dependent lung overperfused
71
CBF changes in lateral decubitus:
Minimal change unless head extremely flexed
72
Advantages of sitting position:
Facilitates venous drainage Excellent surgical access Cranial, shoulder, humeral surgery
73
Head position in sitting:
Head in pins or taped in place *Avoid excessive cervical flexion* - obstructs venous outflow - at least 2 FB between mandible + sternum
74
Negative sequelae of excessive cervical flexion (4):
Cerebral hypoperfusion/venous congestion Stretch injury to cervical nerve roots Obstruction of ETT Pressure/ischemia of tongue
75
Arm position in sitting:
Avoid pressure on frame Support the arms to avoid pulling/traction on shoulders (brachial plexus injury)
76
CV changes in sitting:
Pooling of blood into LE s --> dec preload, CO, BP Hypotension HR/SVR increase as compensatory change
77
Ventilatory changes in sitting:
Lung volumes/capacities increase - easier WOB
78
CBF changes in sitting:
Gravity decreases CBF, ICP
79
Biggest risk with sitting position:
Venous air embolism
80
S/s of VAE (5):
Change in heart tones ("wind mill" murmur) via doppler Desaturation/decreased ETCO2 Nitrogen in exhaled gas Circulatory compromise Cardiac arrest
81
Detection of VAE:
TEE | Precordial Doppler ultrasound
82
Treatment of VAE (5):
Surgical: flood surgical field with NS, wax bony edges, achieve hemostasis D/C nitrous oxide 100% O2, PEEP Trendelenberg Aspirate air from RA via catheter

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