9/7/2013

1

Laura Faires Krioukov BSN RN

Legacy Emanuel Medical Center

Operating Room staff nurse

Portland, Oregon

Incorporating SCIP

protocols into the

complex care of

patients undergoing

Head and Neck

Surgery

� KNOWLEDGE OF SAFE POSITIONING

PRINCIPLES

�UNDERSTANDING OF PHYSIOLOGICAL

CONSQUENCES OF POSITIONING

�UTILIZATION OF APPROPRIATE

MATERIALS TO PROTECT PATIENT FROM

PRESSURE SORES, BURNS OR SHEARS.

� INSPECTION OF PATIENT IMMEDIATELY

POST OPERATIVE TO ASSESS

EFFECTIVENESS OF POSITIONING

� DOCUMENTATION OF POSITIONING AND

RESULTS

� DOCUMENTATION CONSIDERATIONS

� PRELOADED POSITIONING DEVICES AND

POSITIONS IN COMPUTERIZED CHARTING

� HARD STOP IN COMPUTER FOR POSITIONING

� IF DESIGNING COMPUTER CHARTING, ALWAYS

LEAVE COMMENT SECTION FOR FREE TEXT

� COMMENTS ON ADDITIONAL AIDS USED

� MOVE TO DOCUMENT PREOP SKIN

CONDITION FOR EARLY SKIN BREAKDOWN

DETECTION

� UTILIZE UNIVERSAL SKIN INTEGRITY GUIDELINES

OR SPECIFIC HOSPITAL GUIDELINES

� DOCUMENT Q 4 HOURS FOR LENGTHY

PROCEDURES

� OPPORTUNITY TO IMPROVE TECHNIQUES BY

STUDYING RESULTS OF CASES

�use

padding

and

positionin

g

equipmen

t to help

with: alignment

pressure points,

preventing shifting during

procedure

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�Length of surgery

�Multiple sites

�Change of position

during surgical

procedure

�Checking position

q4h and charting

�Evaluating

effectiveness

�Developing more

effective methods

Positioning

the patient

for a surgical

procedure is

the shared

responsibilit

y of the

entire OR

team. But

someone has

to LEAD this

team.

�A patient under

anesthesia loses some

or all of his protective

reflexes .

�Proper positioning of

the patient is a simple

and effective method

to help prevent

intraoperative neural

injury.

�There are many

devices on the

market to aid in

safely

positioning

patient

Pillows and

headrests are

cruciaI.

If the patient is

supine or in

Trendelenberg

position, use

"donuts" or

cushioning to

protect the back of

head.

In many procedures,

the buttocks remain

in contact with the

table surface. In

longer procedures,

this can be the

beginning of

pressure sores.

Place padding

underneath the

buttocks to prevent

this.

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Reminder to evaluate

skin condition

PRIOR to

positioning (using

some universal

guidelines on skin

condition or

breakdown)

Document pre-op

AND post op

condition (computer

can ask for

comment)

�After positioning

patients about to

undergo a

procedure, be sure

to take time to

evaluate body

alignment and

tissue integrity.

�Check tubes and

lines at the outset

and at regular

DOCUMENTED

intervals

throughout the

procedure.

Treat or pretreat

sacral or newly

identified skin

breakdown before

leaving the OR or

before beginning

procedure, if

possible or

applicable.

�Remember that

older, more frail,

sicker patients will

be at greater risk for

pressure sores and

positioning/pressure

injuries than less

debilitated patients.

�have a working knowledge of what's

available.

�materials used for positioning, especially

padding, should be able to absorb

compressive force, redistribute pressure,

prevent excessive stretching, and provide

support for optimum stability

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� Studies suggest that

positioning devices

should maintain

normal capillary

interface pressure of

32 mm Hg or less

�Incidence of pressure

ulcers between 12%

and 35% in surgical

patient

�Pay attention to

eyes, ears, nose

even for short

procedures.

�Ears can suffer

pressure injuries

when patients are

lateral

�Noses from NG or

nasal intubation

and traction from

positioning

�Brachial plexus

injuries_LATERA

L

�Pillows and

headrests are

crucial.

�place padding for

other surfaces

that will remain

in contact with

the bed surface.

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� Studies are

incomplete regarding

efficacy of foam, gel or

standard OR bed pad

and outcomes are

different for different

body surfaces and

positions.

�This BEGS for further

study by OR nurses!

�In many procedures, the

buttocks can remain in

contact with the table

surface. But in longer

procedures, this can

cause pressure sores and

other complications, so

place padding

underneath the buttocks

to prevent this.6

�PLACEMENT OF SEQUENTIAL

COMPRESSION DEVICES ON

PATIENTS ESPECIALLY HIGH RISK

PATIENTS

�IDEALLY STARTED BEFORE THE

SURGICAL CASE

�USING

ALTERNATIVE

SITES

� Some studies have

shown that using

SCDs on arms can

decrease LEG DVT.

� Should be a

consideration in

patients with

previous DVT history

� FOLLOW SCIP PROTOCOLS FOR TIMING,

SELECTIONAND DURATIONOF

ANTIBIOTICS.

� TIMING

� 30-60 MINUTES PRIOR TO INCISION

� (PART OF TIME OUT)

� GIVEN BY ANESTHESIOLOGIST (NOT ON CALL),

NOT IN HOLDING AREA

SELECTION

� Cefazolin, Cefuroxime, or

� Vancomycin or Clindamycin if allergic to first choice

DURATION

� REDOSE FOR LONG PROCEDURES

� DISCONTINUE AFTER 24 HOURS (up to half of all

patients receive antibiotics prophylactically longer

than this)

� Prevent heat loss through exposure

� Use warm blankets as temporary

measure

� Utilization of warmed-air blankets

during prolonged surgery—Goal for

patient to be at 36 degrees by transfer to

post-anesthesia unit.

� Warm IV and irrigation fluids

� Utilize temperature monitoring devices

� Temperature foley

� Esophageal probe

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Turning room

temperature up

is not effective

as a warming

intervention, as

it is rarely

turned to body

temperature .

It will merely

slow heat loss.

�Prewarming is essential for patients

undergoing long surgical procedures.

�Prep time for lengthy procedures often

exposes patients to long periods in a cool

operating room.

�Patients can lose up to 1.6 degrees C in

the preincision period.

� Warming should CONTINUE when the

patient is transferred to the operating bed

�Warm early

and

continuously

�Monitor

temperature

throughout

case

�Use warming devices creatively

� Upper body sideways for fibular flaps

�Utilize more than one device if

necessary

� Start with underbody, switch to other shapes

�Alternate sites

� As site changes

�Cost vs outcomes approach to patient

care

� Two forced air blankets are much less

expensive than a post operative infection

�Preventing positioning injuries and DVTS and

maintaining normothermia in complex surgical

procedures is challenging.

�Preop planning,

preparing protocols for

team members is helpful

in providing consistent

intraoperative care

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�Utilizing nursing

expertise gleaned from

�Personal experience

�Expertise from other

disciplines or

providers,

�Anectodal evidence

�Research

�Legal documentation

requirements AND

�Surgical teamworkWill improve patient outcomes and add to

the nursing knowledge base for all

patients.