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ARCHIVED: Assessment > Exam 1: Positioning > Flashcards

Exam 1: Positioning Flashcards

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
Q

Advantages of Trendelenberg (4):

A

Treats hypotension (short term)

Improves lower abdominal exposure

Prevents air embolism

Makes CVC placement easier

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26
Q

Equipment caution in Trendelenberg:

A

Shoulder braces - use extreme caution and position them out on the joints, not at the root of the neck

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27
Q

How much blood does Trendelenberg return to central circulation?

A

1L

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28
Q

CV changes in Trendelenberg:

A

Reduced blood to LEs

Compression of heart possible

Baroreceptors cause peripheral vasodilation, bradycardia

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29
Q

What happens when pt returns from Trendelenberg to supine?

A

Blood pools in extremities –> hypotension

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30
Q

Ventilation changes in Trendelenberg (5):

A

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

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31
Q

CBF changes in Trendelenberg (3):

A

Increased intracranial vascular congestion

Increased ICP

Increased intraocular pressure

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32
Q

Patients who are not good candidates for Trendelenberg:

A

Glaucoma

CNS disease

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33
Q

Advantages of reverse Trendelenberg:

A

Increases upper abdomen exposure

Useful for shoulder, neck, intracranial surgery

34
Q

Equipment caution with reverse Trendelenberg:

A

Footboard use for extended time can kink anterior tibial nerve and lead to foot drop

35
Q

CV changes in reverse Trendelenberg (4):

A

Reduced preload, CO, BP

Compensatory increase in SNS tone, SVR, HR

RAAS activation

Venous pooling in LEs

36
Q

% change in CO and HR in reverse Trendelenberg:

A

20-40% decrease in CO

30% change in HR (if not blunted by anesthesia)

37
Q

Ventilation changes in reverse Trendelenberg:

A

Increase in FRC

Easier ventilation

38
Q

CBF changes in reverse Trendelenberg:

A

Decreases proportional to degree of tilt (up to 20%)

39
Q

Hip and leg abduction angles in lithotomy position:

A

80-100º flexion at hips

30-45º abduction of legs from midline

40
Q

Possible nerve injuries in calf support lithotomy position (4):

A

Femoral n. (kink)
Sciatic n. (stretch)
Saphenous n. (compression)
Common peroneal/fibular n. (compression)

41
Q

Three types of lithotomy supports:

A

Calf support
Candy cane stirrups
Knee crutches

42
Q

Possible nerve damage with candy cane stirrups:

A

Femoral n. (kink)
Sciatic n. (stretch)
Common peroneal nerve (compression)

43
Q

Possible nerve damage with knee crutch stirrups:

A

Popliteal n. (compression)

44
Q

Most common three lower extremity nerve injuries:

A

Common peroneal (78%)
Sciatic (15%)
Femoral (7%)

45
Q

S/s of common peroneal nerve injury:

A

Foot drop

Inability to evert foot

Loss of dorsal extension of toes

46
Q

S/s of sciatic nerve injury:

A

Weakness or paralysis of muscles below knee

Numbness of foot, lateral half of calf

Foot drop

47
Q

S/s of femoral nerve injury:

A

Loss of hip flexion, knee extension

Decreased sensation on superior thigh

48
Q

S/s of saphenous nerve injury:

A

Medial and anteromedial calf parasthesias

49
Q

Risk factors for LE compartment syndrome:

A

Long procedures

Lithotomy or lateral decub position

50
Q

CV effects of lithotomy:

A

Elevation of legs transiently increases preload/CO/BP

51
Q

Perfusion pressure to extremities lowers ____ for each _____ that they are raised above the heart.

A

2 mmHg for each 2.5 cm

52
Q

Ventilatory effects of lithotomy:

A

Abdominal contents may get pushed up by hip flexion and decrease compliance/TV/VC

53
Q

CBF effects of lithotomy:

A

Transient increase in CBF and ICP when legs are elevated

54
Q

Keep pressure off abdomen in prone position in order to:

A

Improve caval return/perfusion

55
Q

Frame used for prone position:

A

Wilson frame

56
Q

Special table used for prone position:

A

Jackson table

57
Q

Steps to take after turning prone (5):

A

Check breath sounds again

Monitors on/working

Check IV, A-line, etc

Check pressure points

Check neck alignment

58
Q

Head position in prone (4):

A

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
Q

Arm position in prone (4):

A

Abducted less than 90º

Extra padding at elbow

Watch shoulders - keep from sagging

Tucked at sides

60
Q

What is thoracic outlet syndrome? What is a quick test for it?

A

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
Q

CV changes in prone:

A

Hypotension d/t caval/aortic compression

Hypotension d/t venous pooling in LEs

62
Q

Biggest immediate physiological concern with prone position:

A

Hypotension!!

Can lead to blindness when combined with pressure on face/eyes

63
Q

Ventilatory changes in prone (2 big ones, with details):

A

V:Q mismatch:
Posterior ventilation > perfusion
Anterior perfusion > ventilation

Diaphragm displaced cephalad; compliance decreases, airway pressure increases, WoB increases

64
Q

CBF changes in prone:

A

Turning head obstructs venous return, increasing ICP

Excessive flexion/rotation obstructs verts

65
Q

Uses of lateral decubitus position:

A

Thoracotomy, kidney, shoulder, hip surgeries

66
Q

Arm position in lateral decubitus:

A

Dependent arm on arm board, perpendicular to torso

Non-dependent arm supported over bedding or another armrest

67
Q

Leg position in lateral decubitus:

A

Padding between knees

Dependent leg flexed

Padding on bed below dependent leg

68
Q

Torso position in lateral decubitus:

A

Axilla roll under side chest

Anterior/posterior support - rolls or bean-bag support

Safety strap between head of femur and iliac crest

69
Q

CV changes in lateral decubitus:

A

Minimal changes unless venous return is obstructed (kidney rest)

BP measurements will be different in dependent vs. non-dependent arms

70
Q

Ventilation changes in lateral decubitus, related to pt status/ventilation:

A

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
Q

CBF changes in lateral decubitus:

A

Minimal change unless head extremely flexed

72
Q

Advantages of sitting position:

A

Facilitates venous drainage

Excellent surgical access

Cranial, shoulder, humeral surgery

73
Q

Head position in sitting:

A

Head in pins or taped in place

Avoid excessive cervical flexion - obstructs venous outflow - at least 2 FB between mandible + sternum

74
Q

Negative sequelae of excessive cervical flexion (4):

A

Cerebral hypoperfusion/venous congestion

Stretch injury to cervical nerve roots

Obstruction of ETT

Pressure/ischemia of tongue

75
Q

Arm position in sitting:

A

Avoid pressure on frame

Support the arms to avoid pulling/traction on shoulders (brachial plexus injury)

76
Q

CV changes in sitting:

A

Pooling of blood into LE s –> dec preload, CO, BP

Hypotension

HR/SVR increase as compensatory change

77
Q

Ventilatory changes in sitting:

A

Lung volumes/capacities increase - easier WOB

78
Q

CBF changes in sitting:

A

Gravity decreases CBF, ICP

79
Q

Biggest risk with sitting position:

A

Venous air embolism

80
Q

S/s of VAE (5):

A

Change in heart tones (“wind mill” murmur) via doppler

Desaturation/decreased ETCO2

Nitrogen in exhaled gas

Circulatory compromise

Cardiac arrest

81
Q

Detection of VAE:

A

TEE

Precordial Doppler ultrasound

82
Q

Treatment of VAE (5):

A

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

ARCHIVED: Assessment (11 decks)

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