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Mar: Sem 3 - Principles I > Exam 2 Positioning [6/13/2024] > Flashcards

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

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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

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3
Q

what kind of changes can occur with improper positioning?

A

pathophysiologic

S2

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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

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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

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6
Q

The time it takes for nerve damage and other injuries to occur is ____ and some injuries are ____.

A

short
irreversible

S2

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7
Q

What is the most common surgical position?

A
  • Supine

Arm boards must be secure if in use.

S3

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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

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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

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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

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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

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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

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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

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14
Q

What position is this patient in?

A
  • Trendelenburg (head down)
  • Same position as supine, but head tilted downward.

S8

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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

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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

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17
Q

What position is this patient in?

A
  • Reverse Trendelenburg (head up)
  • Same as supine, but head positioned upward

S10

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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

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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

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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

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21
Q

Name the positions

A
  • Left Picture: Beach Chair Position
  • Right Picture: True Sitting Position

S12

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22
Q

When is Beach chair position most often used??

A
  • Shoulder Cases

S12

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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

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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

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25
Q

Sitting position risk

A
  • 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
Q

Pathophysiological consideration of the sitting position?

A
  • Hypotension d/t ↓ venous return.
  • ↓ MAP
  • ↓ Cardiac Index
  • ↓ Perfusion Pressure
  • Improved ventilation in non-obese patients

S14

27
Q

What position is the patient in?

A
  • Prone

S16

28
Q

Describe the prone position.

A
  • 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
Q
  • How do we intubate a pt that will be placed in the prone position?
  • Where do the EKG leads go?
A
  • intubate the patient supine on the stretcher/bed, and then turn prone
  • place EKG leads on pts back

S15

30
Q

Why do you not turn a prone patient’s head to one side or the other?

A
  • Risk of jugular occlusion or carotid occlusion

S15

31
Q

What kind of device can be used to keep the back nice and rounded and help to reduce pressure in the prone position?

A

Wilson Frame!

S16- looks like a vaulting board from gymnastics.

32
Q

what are some devices that can be used to help position patients in prone position?

A
  • wilsons frame
  • pins
  • headrest with mirror
  • horseshoe headrest
  • prone pillow

Wilson Has Help Proning Patients

S16

33
Q

Risk of prone position

A
  • 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
Q

Pathophysiological considerations for prone patients

A
  • 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
Q

What position is the patient in?

A
  • Lithotomy

S19

36
Q

Describe the Lithotomy position

A
  • 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
Q

When in lithotomy position, why MUST we raise and lower the lower extremities in synchrony together?

A

To prevent a torsion injury to the lumbar spine

S19

38
Q

What type of leg support is shown in this lithotomy position?

A

Candy Canes

39
Q

In lithotomy, we should place the hands in ____ to prevent crush injuries to the fingers falling in cracks

A

mittens
The photo shown is the incorrect positioning!!!!

S20

40
Q

Lithotomy risk

A
  • 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
Q

For the Lithotomy Position, what nerve is particularly prone to injury as it lies between the fibular head and compression from the leg support.

A
  • Peroneal

S21

42
Q

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.

A
  • Lateral femoral cutaneous

S21

43
Q

Pathophysiological considerations for the lithotomy position.

A
  • ↑ Venous return, ↑ CO, and ↑ ICP
  • ↑ Intraabdominal pressure
    • Displaces diaphragm cephalad, which ↓FRC which leads to →
  • ↓ Lung compliance and ↓ tidal volume

S22

44
Q

What position is the patient in?

A
  • Lateral Decubitus Position

S23

45
Q

Describe the Lateral Decubitus position.

A
  • 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
Q

Where is the axillary role place for lateral decibitus position?

A

Nipple line

S24

47
Q

For right Lateral Decubitus, what side of the patient will be down?

A
  • RIGHT lateral decubitus = RIGHT side down

S23

48
Q

Safety/general considerations for the lateral decubitus position

A
  • 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
Q

Pathophysiological considerations for the Lateral Decubitus position

A
  • 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
Q

Peripheral nerve injury can be caused by what factors?
How quickly can it occur?

A
  • Stretch
  • Pressure
  • Ischemia

Peripheral nerve injury can occur in as a little as 30 minutes.

S27

51
Q
  • What kind [sensory or motor] are most peripheral nerve injuries?
  • They can be ____ or ____.
A
  • mostly sensory, but can be combined sensory and motor
  • temporary or permanent

S27

52
Q

Can nerve injury occur even when optimal positioning is performed?

A
  • 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
Q

Which AANA standard relates to patient positioning?

A
  • Standard 8: Patient Positioning

S2

54
Q
  • ulnar nerve injuries account for what percentage of nerve injuries?
  • what are recommnedations for prevention?
A
  • 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
Q
  • brachial plexus nerve injuries account for what percentage of nerve injuries?
  • what are recommnedations for prevention?
A
  • 19%

S28

56
Q
  • Spinal Cord and lubrosacral nerve root or cord nerve injuries account for what percentage of nerve injuries?
  • what are recommnedations for prevention?
A
  • spinal cord: 25%
  • lumbosacral nerve root/cord: 18%

S28

57
Q
  • sciatic and peroneal nerve injuries account for what percentage of nerve injuries?
  • what are recommnedations for prevention?
A

7%

S28

58
Q

A patient is supine with the neck extended and the head turned to the right, away from surgical site. Which positioning complication may occur?

A
  • Brachial plexus nerve injury

S28

59
Q

Shoulder braces used during Trendelenburg increases the risk of compression injury to the ____.

A
  • Brachial plexus

S28

60
Q

What position is contraindicated in a patient with an increased ICP?

A
  • Trendelenburg
61
Q

If an arterial line is used for pressure monitoring in a patient placed in Reverse Trendelenburg, the transducer should be zeroed at _______.

A
  • The Circle of Willis

This will represent arterial pressure at the base of the brain.

62
Q
  • What position should the patient be placed in if there is a suspected cerebral air embolism?
  • Why?
A
  • 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.

Mar: Sem 3 - Principles I (29 decks)

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