the basics of positioning patients in surgery€¦ · posi;on are pressure ulcers on the occiput,...
TRANSCRIPT
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The Basics of Positioning Patients in Surgery
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Objectives
1. Describe the most commonly used surgical positions.
2. State techniques for preventing injury to surgical patients.
3. Describe collaborative process for positioning patients.
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• When our patients enter the surgical suite their safety and well-being are in the hands of the perioperative team. It is our responsibility to ensure each and every patient is positioned correctly for his/her procedure • This education is being implemented to create a safe environment for our patients and staff
Introduction
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Applies to: • Downtown and Community Campuses • RNs, anesthesiologists, surgeons, residents, surgical
technologists, medical students, NPs, PAs, CRNAs, anesthesia techs • Corresponding Procedures
• PROC OPER P-04A - Lateral Positioning • PROC OPER P-04B - Lithotomy Positioning • PROC OPER P-04C - Prone Positioning • PROC OPER P-04D - Supine Positioning • PROC OPER P-04E - Trendelenburg/Reverse Trendelenburg Positioning
Intraoperative Positioning Policy OPER P-04
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Goals of Positioning Providing adequate exposure
Maintaining patient dignity
Optimal ventilation & airway management
Providing adequate access
Avoiding poor perfusion
Protecting fingers, toes, genitals
Protecting muscles, nerves, bony prominences
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• General/Regional anesthesia – Physiologic changes – Reduced movement/sensation
Positioning Injuries
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Positioning Injuries
• Force placed on underlying tissue Pressure
• Folding of underlying tissue Shear
• Force of two surfaces rubbing against one another
Friction
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Positioning Injuries Moisture • Produces maceration
Heat • Increases Metabolism
Cold • Reduces O2 delivery
Negativity • Increases Pressure
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Positioning Injuries Nerves • Stretching or compression • Transient or permanent damage
Most common sites • Brachial plexus • Peroneal • Facial
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• Brachial plexus – Shoulder – Arm – Hand
Positioning Injuries
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• Brachial plexus injury due to: – Arm boards extended beyond 90 degrees – Arm boards higher or lower than the OR bed – Lateral rotation of the patient’s head – Leaning against the shoulder or arm – Shoulder braces
Positioning Injuries
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Positioning Injuries
• Common peroneal – Lower leg – Foot – Toes
Sciatic
Common Peroneal
Tibial
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• Common peroneal injury due to: – Direct compression – Patients who are thin – Hyperextension of knees – Pressure behind knee – Graduated compression stockings too tight – Foot drop/Lower-extremity paresthesia
Positioning Injuries
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Positioning Injuries
Pulmonary • Hypoxia • Respiratory compromise • Decreased O2 saturation • Pulmonary edema • Congestion • Atelectasis
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Positioning Injuries Ocular • Corneal abrasion • Central retinal artery occlusion
Risk factors • Prone • Length of procedure • Blood loss
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Increased Risk for Positioning Injuries Obese or underweight
Poor nutritional status
Advanced age (>70 years)
Preexisting conditions
History of skin breakdown/pressure ulcers
Smoking (vasoconstriction)
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Positioning Process
• Collaborative process – Selection of equipment – Preoperative assessment – Positioning – Documentation – Postoperative evaluation
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Preoperative Assessment • Age/Height/Weight/Body mass index (BMI) • Nutritional status • Blood pressure • Skin integrity • ROM/Physical limitations • Internal/External devices • Preexisting conditions • Medical history • Diagnostic studies • Psychological/Cultural considerations • Length of surgery
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Selection of Equipment
Inspected and
maintained
Checked prior to
procedure
Competent surgical
personnel
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Selection of Equipment
• Pressure relieving surface – Disperses weight – Prevents “bottoming out” – Relieves shear and friction
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Selection of Position S
Supine Prone Lithotomy
Lateral Trendelenburg ReverseTrendelenburg
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• Assess the patient: – Body alignment, tissue perfusion, and skin integrity – Checking pressure points during surgery, is especially important in cases that are greater than 2 hours. This is always dependent on the ability to access the patient without compromising the surgical procedure or sterile field.
Positioning Check
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• Care should be taken to prevent laying of instruments and power cords on the patient during the case. • Scrubbed members of the surgical team should
not lean against the patient during surgery.
Safety
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Supine
• Mostcommonlyusedsurgicalposi;on• Commoninjuriesrelatedtothesupine
posi;onarepressureulcersontheocciput,scapulae,thoracicvertebrae,elbows,sacrum,andheels
• Armsshouldeitherbesecuredatthesidesorextendedonarmboards
• Safetystrapshouldbeplacedacrossthethighs,approximately2inchesabovethekneeswithasheetorblanketplacedbetweenthestrapandthepa;ent’sskin
• Pa;ent'sheelsshouldbeelevatedofftheunderlyingsurfacewhenpossible
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Supine
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Supine
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Trendelenburg
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Reverse Trendelenburg
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Sitting/Modified-Sitting
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Lithotomy Lo
w
Sta
nd
ard
H
emi
Hig
h
Exag
ger
ated
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Lithotomy
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Lithotomy
Common peroneal
Femoral
Obturator
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Prone
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Prone
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Jackknife
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Lateral
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Lateral
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HealthCondi;ons
• TypeIIdiabetes• HTN• Artherosclerosis• Sleepapnea
RespiratoryIssues
• Airwaycompromise• Difficultintuba;on• Aspira;on• Hypoxia• Intra-abdominalpressure
CirculatoryIssues
• Increasedcardiacoutput• Increasedpressureonpulmonaryartery• Riskofinferiorvenacavacompression
SkinIssues
• Difficultassessments• Skinbreakdown• Moisture
Obese Patients
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SpecialEquipment
• Procedurebeds • Extra-wide/longsafetystraps• SideaRachments• Pressurerelievingsurfaces
Posi;on
• SiSng/Modified-siSng• Lateral• Supinewithwedgeunderrightside
Obese Patients
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– Prior to draping, the patient’s positioning should be tested for sliding, limb impingement, respiratory and circulatory problems.
– Periodic checks throughout the procedure to assess for positional shifts are required. This is always dependent on the ability to access the patient without compromising the surgical procedure or sterile field.
– After the team docks the robot and periodically throughout the procedure, safety checks should be performed to ensure proper positioning of the robotic arms and that they are not in contact with the patient.
– Eye goggles can be used to protect the eyes from the robotic arms, if they are going to be in close proximity to the face.
Robotic Positioning
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Documentation
• Preoperative assessment • Names/titles of participants • Patient position • Upper extremities • Lower extremities • Equipment/Padding • Specific actions • Positioning checks • Repositioning • Postoperative assessment
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• Nerve injury • Pressure injury • Reposition • Transfer of care
Postoperative Assessment
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1. Guideline for positioning the patient. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2017.
References