Ex3 Positioning Flashcards
Biggest problem with position changes
Hypotension
What must be checked after head, neck, whole body is moved?
Breath sounds
- also document
if breath sounds in R>L, pull tube back (it is in mainstem)
Before prone, what should always be checked?
PIP, shape of ETCO2, breath sounds
Supine - where should focus be on arms?
Olecranon - must be padded
Supine - how should arms be positioned
Supinated (back of hand down, arm with hand up)
NOT proned
Physiologic changes with supine position
Decreased FRC (20%), pulm compliance
Gravity increases to zone III
Compression of IVC
What should never be used in trendelenberg position?
Shoulder brace (d/t brachial plexus injury)
Who should never be placed in trendelenberg?
Increased ICP patients
Prone position - head monitoring
Maintain cervical spine in neutral position
Prone - arm positioning
Avoid extending above shoulders (brachial plexus injury)
Physiologic changes - lateral decubitus (ventilated, anesthetized patient)
Perfusion - gravity dependent
Ventilation - favors non dependent lung
What is always going to occur in lateral decubitus position (ventilated patient)?
V/Q mismatch = decreased PaO2
Awake, spontaneous patient in lateral decubitus
Only change = blood flow/ventilation in dependent lung are greater than non dependent lung
NO V/Q MISMATCH
Mnemonic for nerve damage in lithotomy position
FOPSS
FOPSS
Femoral Obturator Peroneal Saphenous Sciatic
(nerves at risk for damage in lithotomy position)
F in FOPSS
Femoral nerve: stretched by excessive angulation of thigh
—> FRONT
O in FOPSS
Obturator Nerve - stretched by excessive flexion of thigh to groin
*** confirm position????
P in FOPSS
Peroneal (common) nerve: compression of LATERAL aspect of legs at head of fibula against stirrup
S in FOPSS
Saphenous Nerve - compression of MEDIAL aspect of legs against stirrup supports
2nd S in FOPSS
Sciatic nerve - stretched by excessive external rotation of leg when placing pt in lithotomy position
(In the BACK)
Biggest risk of sitting position
VAE (venous air embolism)
How to counteract risks in sitting
Venodynes, TEDS
Radial nerve - how is it injured?
Compression against underlying humerus when lateral upper arm is compressed on table
Result of radial nerve injury
- inability to extend wrist, abduct thumb
- wrist drop
- decreased sensation over dorsal surface of later 3.5 fingers (thumb->half ring finger)
Cause of ulnar nerve injury
Compression between medial epicondyle of humerus —> sharp edge of bed/head frame
Result of ulnar nerve injury
Sensory loss in 5th digit (pinky)
“Claw hand”
Where would claw hand be seen?
Ulnar nerve injury
Cause of median nerve injury
Indiscriminate probing (fishing) in AC fossa during IV placement
Result of median nerve injury
- loss of sensation of finger tips from thumb to mid-point of ring finger
- inability to oppose 1st/5th digits
- decreased sensation on palmar surface of lateral 3.5 fingers
Cause of sciatic nerve injury
- sitting: pressure on ischial tuberosity
- lithotomy: thigh/nerves externally rotated, knees extended
- excessive hip flexion =nerve stretch
- IM injection
Result of sciatic nerve injury
- weakness of all muscles below knee/diminished sensation over lateral 1/2 of leg/all of foot
- foot drop
- pain/numbness of lower leg/thigh/foot
Candy Cane Stirrups cause damage from what?
Lateral thighs hyperflexed
Physiologic changes in Supine - obese/pregnant
compression of IVC
Awake vs anesthetized pt in supine
Awake - SNS can compensate
Blood flow = gravity
Physiologic changes in Supine position
Decreased - FRC, pulm compliance Increased - blood flow to Lung ZoneIII Cephaled shift of abd Minimal CVS changes Pressure on occiput
If shoulder braces are used, where should they be placed?
NOT near neck (compression of brachial plexus)
Physiologic changes in Trendelenberg Position
Same as supine except –> increased cerebral circulation
Increased: CBF, venous pressure
Decreased: FRC, pulm compliance
Greatest decline in FRC is in which position?
Trendelenberg
Jack Knife position
prone + kneeling
Physiologic changes in prone position
Increased: ventilation, venous return
Decreased: intrathoracic/vena cava/abd pressure
Best for Prone position
- Jackson Table
- Wilson Frame
- 2 padded chest rolls from shoulder –> hips
Ideal face position in prone
face down in doughnut/Mayfield
V/Q in proning
optimal matching
Avoid what in proning?
- pressure on facial nerve/any pendulous soft tissue
- extending arms above shoulders
- turning head to the side
Turning head to the side in prone position - Risk
paralysis
obstruction of jugular venous/vert. artery flow
Kidney rest position
lateral decub with flexion at iliac crest
Lateral Decub - head injury presents as
Horner’s Syndrome – nerve damage
Lateral Decub - monitor
distal circulation of dependent arm frequently to avoid compression of axillary artery
Best for non-dependent arm in Lateral Decub
Mayo Stand
V/Q effect in Lateral Decubitus Position
V/Q mismatch – decreased PaO2
*only in anesthetized/MV patients
Lateral decub - effects on lungs
perfusion favors dependent lung
ventilation favors nondependent lung
(decreased compliance in dep lung)
Compartment syndrome is most common in which position?
Lithotomy
Increased risk of compartment syndrome if
time > 2-3h
Obesity
Hypoperfusion
Trendelenberg +Lithotomy position can result in
atelectasis (dec lung volume 20% d/t abd pressure)
Femoral nerve damage can be reduced by
avoiding hip flexion > 90d
excessive angulation of thigh
Femoral nerve damage results in
absent knee jerk, decreased sensation in thigh
Obturator nerve damage can be reduced by
avoiding excessive flexion of thigh
avoiding forceps delivery
Obturator nerve damage results in
unable to adduct leg
decreased sensation in medial thigh
most common nerve damage in lithotomy position
peroneal
Peroneal nerve damage can be reduced by
avoid candy cane stirrups
padding lateral aspect of fibula
Result of peroneal nerve damage
Foot drop, unable to evert foot/dorsal extend toes
How to reduce saphenous nerve damage
pad medial side of knee
result of saphenous nerve damage
decreased sensation of anteromedial leg
how to reduce sciatic nerve damage
avoid excessive external rotation of leg/flex hip, pad butt
result of sciatic nerve damage
weak below knee
dec. sensation in lateral leg/all foot
foot drop
pain/numb in lower leg/thigh, foot
Nerves which damage causes foot drop
Sciatic
Peroneal
Most common nerve injured
ulnar
Nerve injury d/t IV AC attempt, carpal tunnel
Median
Nerve damage results in wrist drop
Radial Nerve
Weak arm function d/t _____ nerve injury
Brachial plexus
