Who is responsible for positioning of pt?
Shared responsibility
Nurse
Anesthesia
Surgeon
And other Perioperative personnel
Risk of what type injuries with patient positioning?
Compression Stretching Skin, joints, soft tissue Bones Eyes Nerves
Why are pts at risk of injury during surgery?
Unable to feel pain, numbness, tingling
Cannot communicate
Goals of positioning?
Procide optimal exposure to site Maintain proper alignment Support circulatory/resp function Protect neuromuscular and skin integrity Allow access to Iv/monitoring equipment Maintain pt privacy and comfort Secure and safe to avoid moving/shifting
Who is responsibke for selecting neat position for procedure?
Surgeon
Basic surgical positions?
Supine Lithotomy Sitting Trendelenburg Reverse tren Lateral Prone Jack knife
Pre op assessment for positionint?
Skin assessment Medical conditions Age Height Weight/BMI ROM Nutritional status Jewlery
Nutritional status affecting injury risk?
Decressed muscle mass
Dehydration
Low serum albumin may indicate poor wound healing
What are high risk for injury during surgery?
> 2hrs
Vascular sx - blood perfusion may be compromised
Lithotomy position - increased risk of nerve damage
Positions with sustained pressure
Ex. Retraction
Pre op considerations for positioning?
Age - geriatric more at risk
Always follow MIFU when selecting equipment
Medical conditions - resp/circulatory, DM, malnutrition, anemia, demineralizing bone conditions
Mobility concerns
Intra op factors related to patient positioning?
Types of anesthesia
- general, spinal, moderate sensation
Length of surgery
Position required
Basic positioning practices?
Follow procedure protocols Respect pt privacy Head/neck neutrality Protect eyes Physiologic alignment OR beds - padding, avoid metal Safety precautions - belts Repositioning pt - redistribute pressure Monitoring pt - pulses, strap tightness
Why protect head and neck during pt positioning?
Stretching/hyperextension could cause brachial plexus nerve injury or cardiovascular complications
How to protect eyes?
Prevent corneal abrasion, ocular injury by preventing pressure on eyes and taping them shut
Eye protection
-laser
Supine position
Most common
Dorsal recumbent, laying on back
Common with abd, head/neck, vascular and breast sx
Arms at side with palms facing towards body or extended on arm boards with palms up
- protect ulnar nerve
Where is safety strap placed in supine?
2 inch above knee
Legs during supine?
Uncrossed to reduce pressure
Flex knee with pillow under knee to prevent comoression and reduce risk of DVT
Elevate heels
If arms are extended in supine, how far can they be abducted?
No more than 90 degrees
Decreases risk for brachial plexus nerve injury
Tucking patients arms with sheet?
Arms neutral with palms facing body
Pull sheet up between body and arm
Place sheet over arm
Tuck between arm and matress
Sheet should extend from elbow to fingertips
Ensure secure but not too tight to create pressure
Lithotomy position?
Hips flexed until thighs are 80-100 degrees to OR bed
Pt lower legs parallel to OR bed in stirrups
Can be low, hemi, high, exaggerated
Common in vag, rectal, urological, colorectal, reproductive lap procedures
How do patients all start before being positioned in OR?
Supine
- OR bed or stretcher
Once pt under anesthesia patient can be positioned
Safety for lithotomy?
Do not place safety belt on abd
Place leg holders at even height
One team member per leg minimum
Raise and lower legs into stirrups and back to bed together
- avoid sudden shift in circulatory volume
Always check hands and fingers when moving lower part of bed
Safety positioning of legs in lithotmy?
Protect hips from excessive flexion
(> 80-90 degrees)
Or abduction
(> 30-45 degrees)
Puts stress on hip joints and can cause femiral, sciatic, oburator or peroneal neuopathy
What can raising pt legs into stirrups cause?
Shift of blood into central circulation and decrease perfusion in the legs
Result in increased cardiac output and venous return
Why can lithotomy lead to resp compromise?
Organs shift when legs are placed in stirrups which increases pressure on the diaphragm
Sitting position?
Folwers/semi fowlers
Beach chair
Common in shoulder, posterior cervical spine or posterior/lateral head sx
Complications from sitting position?
Venous air embolism Hemodynamic instability Pneumocephalus Quadriplegia Compressive peripheral neuropathy
Positioning pt in sitting?
Elevate head/neck/torso 20-90 degrees
Hips flexed 45-60 degrees
Place pad under coccyx to prevent pressure on sciatic nerve/coccyx
Safety belt over thighs
Knees flexed 30 degrees with pillow
- decrease stretching on sciatric nerve
SCDs - prevent pooling, improve venous return
Arms during sitting position?
Both may be flexed and secured across body
In shoulders non operative arm may be secured across body
Sitting position risk of VAE?
Venous air embolism
Air or gas enters vascular system above level of heart
Advantages of sitting position?
Access to airway Ease of mechanical ventilation Reduced intracranial pressure Reduced facial swelling Reduced blood pooling in surgical field Improved lung expansion
Trendelenburg position?
Feet higher thsn pt head by 15-30 degrees
Moves abd organs toward head to improve acccess to pelvic organs
Treats hypotension
What does trendelenburg position cause?
Movement of blood supply from lower extremity to central and pulmonary circulation
Decreases limb perfusion
Decreases venous return from head
Safety precautions when in trendelenburg?
Do not use shoulder braces
Do not use circumferential wrist restraints
- leads to brachial plexus nerve injury
Keep in trendelenburg for shortest time possible
- intracranial htn, resp deterioration, increased intraocular pressure
Reverse trendelenburg?
Head up and feet down
Pt head 15-30 degrees above feet
Common in head, neck and upper abd sx
Benefits to reverse trendelenburg
Head is above heart to improve drainage of body fluids away from surgical site
Reduces intracranial pressure
Shift intestines lower in abd
Decreases bleeding at surgical field
Why is reverse trendelenburg at risk of VAE?
Benous pooling in the lower body can cause venous air embolism
Safety precautions with reverse trendelenburg?
Padded foot boards to prevent sliding and injury
Lateral position?
Positioned laterally on non operative side
Common with thoracotomy, kidney surgery and hip sx
Minimum of 4 people needed to position pt
Positioning considerations for lateral?
Two level arm boards Pillow under head Monitor dependent ear Secure to table with belt Pillow between knees Pillow under thorax to improve cardiac output Keep in position for short period - decrease risk of rhabdomyolosis Reposition to reduce risk of compartment syndrome
What is rhabdomyolosis?
Breakdown of muscle tissue
Muscle fiber contents released into bloodstream
Causes kidney damage
Prone position?
Laying face down
Arms at side or on arm boards
Common to access back, rectum, and dorsal areas
Anesthesized on stretcher and log rolled onto OR bed
- minimum 4 people
keep stretcher in room
Positioning considerations for prone?
Place pt 5-10 degrees into reverse tren to reduce benous congestion in eyes
Chest supports for to allow abd expansion and decreased abd pressure
Protect genitals from torsion
Pad pt knees and elevate toes
Common complications from prone?
Increased abd pressure Increased bleeding Compartment syndrome Nerve/pressure injuries Cardiovascular compromise Eye injuries Airway dislodgement
Jack knife position?
Kraske position
Modification of prone
Common in rectal procedures
Same as prone with bed control positioned into jack knife (head and feet lowered)
Risks of jack knife?
Circulatory changes Causes pooling - use SCDs Compromises respiration Exerts pressure on diaphragm - use chest rolls
What can cause position related injuries?
Pressure from body, equipment or team members ex. Leaning
Can be intact or open
What is an OR acquired pressure injury?
Appears 48-72 hrs post op
Tissues that were subjected to pressure during sx
May be deep tissue
Seldom visible at end of procedure or appears red
Sometimes incorrectly identifiedas a burn
What is a HAPI?
Hospital acquired pressure injury Occurs during hospital stay Can develop from pressure, shear or both Associated with pt factors ex. Age Preventable Nursing quality error Expensive to hospital
Stage 1 pressure injury?
Intact, red skin
Does not blanch
Stage 2 pressure injury
Partial skin loss involving epidermis and or dermis
Skin abraded, blistered or has shallow craters
Stage 3 pressure injury?
Full thickness skin loss possibly down to but not through fascial layer
Deep craters with or w/o undermining
Stage 4 pressure injury?
Full thickness skin loss with extensive destruction, necrosis or damage to muscle, bone or supporting structures
Pressure injuries that do not fit into stages?
Unstageable
Deep tissue
Mucosal membrane
Medical device related
Risk assessment tools?
Braden scale - does not include perioperative factors
Braden Q scale - pediatric
Munro scale - surgical
Scott triggers - surgical
Munro scale?
Risk factors for pressure injury in surgical pts
Calculates a cumulative score of pre op, intra op wnd post op factors
Scott triggers tool?
Pressure injury assessment took for sx pt
Assess patient factors
- age, albumin, or BMI, estimated length of surgery
6 factors causing pressure injury?
Friction Shear Moisture Heat Cold Negativity - layers of material
*duration of pressure
Anterior pressure points?
Ear Wrist Ilium Patella Toes
Posterior pressure points?
Occiput Scapula Vertebra Elbow Rib Sacrum Greater trochanter Ischial tuberosity Medial/lateral condyles Heel Malleous
What is brachial plexus?
Consists of a bundle of nerve cords that innervate the shoulder, arm and hand
Risk and causes of brachial plexus injuries?
Supine position - arms > 90 degrees Trendelenburg - use of shoulder braces Jack knife Obese pt Hyperextension of neck
Peroneal nerve injuries?
Branch of sciatic nerve that supplies movement and sensation to lower leg, foot, toes
Positions that increase risk of peroneal nerve injury and solutions?
Supine - place safety strap 2 inch above knee
Lithotomy- prevent excessive flexion, abduction
R. Trendelenburg - use padded foot board
Lateral - support pillows
Positioning considerations for geriatic pts?
Skin protection
Lift never slide
Decreased ROM
Positioning considerations for pregnant woman?
Uterus can compress aorta and interior vena cava
- causes hypotension
Woman over 18 weeks positon in a left lateral tilt
Place wedge cushion or tilt bed 15-45 degrees to left
