Exam 2 Positioning [6/13/2024] Flashcards
1
Q
A patient’s position should be as ____ as possible. Joints should always be ____, unless part of the surgical field, and pressure points ____.
A
natural
aligned
padded
S2
2
Q
Standard 8: Patient Positioning
- Collaborate with the surgical or procedure team to?
- What is the purpose of protective measure in regards to positioning?
A
- position, assess, and monitor proper body alignment
- use protective meausures to maintain perfusion and protect pressure points and nerve plexus
S2
3
Q
what kind of changes can occur with improper positioning?
A
pathophysiologic
S2
4
Q
for each position, what should we consider?
A
- the positioning process from head to toe
- proper positioning devices
- how much help is needed
S2
5
Q
- Safety belts must be used in the abdominal/pelvic area, why?
A
- to secure the patient in addition to the securing of the extremities
- avoid placing safety belt too tightly
S2
6
Q
The time it takes for nerve damage and other injuries to occur is ____ and some injuries are ____.
A
short
irreversible
S2
7
Q
What is the most common surgical position?
A
- Supine
Arm boards must be secure if in use.
S3
8
Q
What are initial pathophysiological changes to be expected when moving from sitting to supine?
A
- ↑ Venous return
- ↑ Preload
- ↑ SV
- ↑ CO
- ↓Tidal volume
- ↓ FRC
these are transient changes
S3
9
Q
Describe arm abduction positioning
A
- Arm out to the side, < 90 degrees
- Padded arm boards secured to the table and patient at the axilla
- The arms should be supine (palms up)
- Elbows padded and arm is secured with a Velcro strap
S4
10
Q
Describe arm adduction positioning
A
- Arm tucked alongside the body
- Arms held along the side of body via draw sheet under the body and over the arm
- Hand and forearm are supine (palms up) or neutral position (palms toward body)
- Elbows are padded
- May tuck one arm if surgeon must stand on side of patient
S5
11
Q
Complications of the supine position
A
- Backache
- Pressure alopecia
- Brachial plexus or axillary nerve injury if arms abducted > 90 degrees
- Ulnar nerve injury if hand/arm is pronated (palm down)
- Stretch injury when neck is extended and head turned away (brachial plexus)
S7
12
Q
Why is backache a complication of supine position? We cannot do anything about this but what might help?
A
- The lumbar curvature is lost.
- Loss of tone of the paraspinal muscles when under anesthesia
- Slight flexion of the knees to take pressure off the lower back
S7 - Erikson
13
Q
What is the most common injury?
A
- brachial plexus inury is the most common it used to be ulnar nerve injury
S7 -Erikson in class
14
Q
What position is this patient in?
A
- Trendelenburg (head down)
- Same position as supine, but head tilted downward.
S8
15
Q
Safety/general considerations with Trendelenburg position.
A
- Use a non-sliding mattress/pad to prevent the patient from sliding cephalad
- Avoid using bean bags or shoulder braces [b/c might compress the brachial plexus]
- Consider making a mark at the level of the patient’s head on the sheet or pad so you can determine easily if the patient has slid
S8
16
Q
Pathophysiological considerations with Trendelenburg position.
A
- ↑ ICP, ↑ IOP [intraoccular pressure]
- Edema of face conjunctiva, larynx, and tongue
- can increase with surgery time and in presence of fluid overload
- ↑ CO
- d/t ↑ Venous Return from lower extremities)
- ↓ FRC and ↓ Pulmonary Compliance
- d/t diaphragm shifting cephalad
- May need higher pressure in ventilated patients
- Risk of endobronchial intubation as abdominal contents push the carina cephalad
- ↑ Intraabdominal Presure
S9
17
Q
What position is this patient in?
A
- Reverse Trendelenburg (head up)
- Same as supine, but head positioned upward
S10
18
Q
Safety/general considerations with Reverse Trendelenburg position.
A
- Use a non-sliding mattress/pad to prevent the patient from sliding
- Use a footrest or something under the feet to prevent the patient from sliding
S10
19
Q
Pathophysiological considerations with Reverse Trendelenburg position.
A
- Risk of Hypotension
- ↓ Venous Return, Venous pooling in lower extremities)
- Downward displacement of abdominal contents/ diaphragm (better ventilation)
- ↓ Perfusion to the brain
S11
20
Q
Where do we level the arterial line when the patients head is above the heart? [ie: sitting or reverese trendelenburg]
A
- level to the TRAGUS
- not midaxillary line
S11- erikson in class
21
Q
Name the positions
A
- Left Picture: Beach Chair Position
- Right Picture: True Sitting Position
S12
22
Q
When is Beach chair position most often used??
A
- Shoulder Cases
S12
23
Q
how is beach chair position different than true sitting position?
A
Beach chair position will have less severe hip flexion and slight leg flexion.
S12
24
Q
Describe the set-up of the sitting position
[Beach positiona & true sitting]
A
- Head must be stabilized – taped to special headrest or rigid pins
- Hips are flexed < 90 degrees and knees slightly flexed for balance to reduce stretching of the sciatic nerve
- Feet are supported – prevent sliding
- Compression stockings/wraps to maintain venous return
- Keep at least two finger’s distance between the chin and sternum
Head, Hips, and Feet put me in my seat!
S12
25
Sitting position risk
* Cerebral hypoperfusion and air embolism
* Pneumocephalus- accumulation of air in subdural space, pressure on the intracranial structure
* Quadriplegia and spinal cord infarction- hyperflexion of the neck
* Cerebral ischemia
* Peripheral nerve injuries (Sciatic nerve injury)
Can People Quickly Push Chairs
| S13
26
Pathophysiological consideration of the sitting position?
* Hypotension d/t ↓ venous return.
* ↓ MAP
* ↓ Cardiac Index
* ↓ Perfusion Pressure
* Improved ventilation in non-obese patients
| S14
27
What position is the patient in?
* Prone
| S16
28
Describe the prone position.
* Patient lying on stomach
* Arms at side tucked or outstretched (< 90 degrees), with flexion at elbows
* Head supported face down using a prone pillow, horseshoe headrest, or rigid fixation with pins in a neutral position without pressure on eyes, nose, mouth, and ears
* Avoid compression of breasts, abdomen, and genitalia
* Legs padded and slightly flexed at the knees and hips
* Compression stockings for lower extremities to prevent venous pooling
Proning A Horse Avoids Legal Complications
| S15
29
* How do we intubate a pt that will be placed in the prone position?
* Where do the EKG leads go?
* intubate the patient supine on the stretcher/bed, and then turn prone
* place EKG leads on pts back
| S15
30
Why do you not turn a prone patient’s head to one side or the other?
* Risk of jugular occlusion or carotid occlusion
| S15
31
What kind of device can be used to keep the back nice and rounded and help to reduce pressure in the prone position?
Wilson Frame!
| S16- looks like a vaulting board from gymnastics.
32
what are some devices that can be used to help position patients in prone position?
* wilsons frame
* pins
* headrest with mirror
* horseshoe headrest
* prone pillow
Wilson Has Help Proning Patients
| S16
33
Risk of prone position
* Facial and airway edema
* Nerve Injuries
* Ulnar nerve injury if elbows are not padded
* Brachial plexus injury if arms are abducted > 90 degrees
* Post-op visual loss secondary to decreased perfusion/ischemia (Eye injuries r/t head position)
* ETT dislodgement *biggest complication, document*
* Loss of monitors and IV lines
Proning FLEN is risky!
| S17
34
Pathophysiological considerations for prone patients
* Edema of face, conjunctiva, larynx, and tongue
* ↑ Abdominal pressure
- ↓ Venous return through compression of the inferior vena cava
- ↓ CO
* Improved ventilation and perfusion in the lungs d/t shifting to the dependent areas
| S18
35
What position is the patient in?
* Lithotomy
| S19
36
Describe the Lithotomy position
* Patient laying supine with legs up in padded or “candy cane" stirrups
* Arms tucked or on arm boards
* If using Trendelenburg or reverse Trendelenburg, need non-sliding mattress
* Hips flexed 80 -100 degrees and legs abducted 30 - 45 degrees from midline, knees flexed
* Lower extremities MUST be raised and lowered in synchrony together
* Foot of the bed is lowered, must protect the hands and fingers from crush injury
* Surgery > 2-3 hours, periodically lower the legs
PATHS For Lithotomy
| S19
37
When in lithotomy position, why MUST we raise and lower the lower extremities in synchrony together?
To prevent a torsion injury to the lumbar spine
| S19
38
What type of leg support is shown in this lithotomy position?
Candy Canes
39
In lithotomy, we should place the hands in ____ to prevent crush injuries to the fingers falling in cracks
mittens
The photo shown is the incorrect positioning!!!!
| S20
40
Lithotomy risk
* Back pain [d/t loss of paraspinal muscles]
* Nerve Injuries:
* Brachial plexus injury
* Ulnar nerve injury
* Common peroneal injury
* Lateral femoral cutaneous injury
* Compartment syndrome
| S21
41
For the Lithotomy Position, what nerve is particularly prone to injury as it lies between the fibular head and compression from the leg support.
* Peroneal
| S21
42
For the Lithotomy Position, branches of the ____________nerves often pass directly through the inguinal ligaments and can be impinged and become ischemic within the stretched ligament.
* Lateral femoral cutaneous
| S21
43
Pathophysiological considerations for the lithotomy position.
* ↑ Venous return, ↑ CO, and ↑ ICP
* ↑ Intraabdominal pressure
* Displaces diaphragm cephalad, which ↓FRC which leads to →
* ↓ Lung compliance and ↓ tidal volume
| S22
44
What position is the patient in?
* Lateral Decubitus Position
| S23
45
Describe the Lateral Decubitus position.
* Patient lying on non-operative (dependent) side and requires anterior and posterior support w/ rolls or bean bags
* Adequate head support: no pressure on eyes or ears
* Neutral position
* Dependent ear should be regularly checked
* Arms are in front of the patient and both must be supported and abducted < 90 degrees
* Axillary roll placed between chest wall and bed, caudal to axilla to prevent brachial plexus compression
* Must place padding between the knees
* Dependent leg is slightly flexed
Lateral HAAKD
| S23
46
Where is the axillary role place for lateral decibitus position?
Nipple line
| S24
47
For right Lateral Decubitus, what side of the patient will be down?
* RIGHT lateral decubitus = RIGHT side down
| S23
48
Safety/general considerations for the lateral decubitus position
* If bed flexed or kidney rest used, needs to be placed under iliac crest (C in pic is proper placement)
* Inferior vena cava compression can occur
* Consider proper positioning to allow the best possible expansion of the dependent lung
* Nerve Injuries
* Ulnar nerve injury can occur if elbows are not padded
* Brachial plexus injury can occur if arms are abducted > 90 degrees
* ETT dislodgement; caution with use of LMA
KEN [imagine barbie KEN in this weird position laying on the ground]
| S25
49
Pathophysiological considerations for the Lateral Decubitus position
* Venous pooling in lower extremities (use compression stockings/devices)
* V/Q mismatch due to inadequate ventilation to dependent lung and decreased blood flow to the nondependent lung
| S26
50
Peripheral nerve injury can be caused by what factors?
How quickly can it occur?
* Stretch
* Pressure
* Ischemia
*Peripheral nerve injury can occur in as a little as 30 minutes.*
| S27
51
* What kind [sensory or motor] are most peripheral nerve injuries?
* They can be ____ or ____.
* mostly sensory, but can be combined sensory and motor
* temporary or permanent
| S27
52
Can nerve injury occur even when optimal positioning is performed?
* Yes
*Overall, cases of nerve injuries have decreased, but are still a major legal cause to professional liability claims and **can still occur even when optimal positioning is performed.***
| S27
53
Which AANA standard relates to patient positioning?
* Standard 8: Patient Positioning
| S2
54
* ulnar nerve injuries account for what percentage of nerve injuries?
* what are recommnedations for prevention?
* 14%
* avoid excessive pressure on the postcondylar groove of the humerus
* keep the hand and forearm either supinated or in a neurtal position
| S28
55
* brachial plexus nerve injuries account for what percentage of nerve injuries?
* what are recommnedations for prevention?
* 19%
| S28
56
* Spinal Cord and lubrosacral nerve root or cord nerve injuries account for what percentage of nerve injuries?
* what are recommnedations for prevention?
* spinal cord: 25%
* lumbosacral nerve root/cord: 18%
| S28
57
* sciatic and peroneal nerve injuries account for what percentage of nerve injuries?
* what are recommnedations for prevention?
7%
| S28
58
A patient is supine with the neck extended and the head turned to the right, away from surgical site. Which positioning complication may occur?
* Brachial plexus nerve injury
| S28
59
Shoulder braces used during Trendelenburg increases the risk of compression injury to the ____.
* Brachial plexus
| S28
60
What position is contraindicated in a patient with an increased ICP?
* Trendelenburg
61
If an arterial line is used for pressure monitoring in a patient placed in Reverse Trendelenburg, the transducer should be zeroed at _______.
* The Circle of Willis
*This will represent arterial pressure at the base of the brain.*
62
* What position should the patient be placed in if there is a suspected cerebral air embolism?
* Why?
* The patient should be positioned in a head down/Trendelenburg and left lateral decubitus position (Durant position).
* This aims to trap air in the right atrium and ventricle, thus minimizing the entry of air emboli into the right ventricular and pulmonary artery.
