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Basic Principles N928 > Positioning > Flashcards

Positioning Flashcards

1
Q

What standard is positioning according to the AANA?

A

Standard 8: patient positioning collaborate with the surgical or procedure team to position, assess, and monitor proper body alignment. Use protective measures to maintain perfusion and protect pressure points and nerve plexus

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2
Q

What is the most common closed claim analysis?

A

ulnar and brachial plexus nerve

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3
Q

Goals of Positioning

A 
patient safety
optimize surgical exposure
preserve patient dignity
maintain hemodynamic stability
maintain cardiorespiratory function
no ischemia, injury or compression
JC Patient Safety Goal #14- prevent healthcare associated pressure ulcers
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4
Q

How do volatile agents effect our cardiovascular system?

A

myocardial depressants

decrease CO and BP

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5
Q

How do NMB effect our cardiovascular system?

A

Decrease muscle tone and venous return

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6
Q

How do opioids effect our cardiovascular system?

A

decrease HR (CO and BP)

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7
Q

Cardiovascular concerns while positioning

A

redistribution of circulating blood volume
depressed CO
compression of extremities or great vessels
impaired autonomic NS function
anatomy cephalad to heart risks hypoperfusion/ischemia

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8
Q

Pulmonary Problems d/t Positioning

A

Barriers to thoracic excursion
Positive pressure ventilation
Gravity related effects

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9
Q

Mechanisms associated with nerve injury

A

compression
stretch
traction
transection

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10
Q

Risk factors of Integumertary Issues:

A 
elderly
diabetes
PVD
surgical time
chronic hypotension
increased Body temperature
body habitus
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11
Q

Nerve Sheath Ischemia can be

A

direct and indirect

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12
Q

Pressure Points in Supine

A

heel, toes, thighs, sacrum, elbow, humerous, vertebrae, occiput

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13
Q

Describe the Supine position

A

arms secured, armboards padding w/ straps
Arms are laterally or abducted at less then 90degree angle and supinated
Legs are flat, uncrossed with heels padded

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14
Q

If the arms are proned in supine, which is erroneous, what will it cause?

A

ulnar nerve compression (at the cubital tunnel at elbow)

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15
Q

describe arms are tucked in supine position

A 
palmar aspects of hands parallel to thighs/trunk
elbows padded (ulnar nerve)
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16
Q

Cardiopulmonary Implications in Supine

A 
BP stable
ANS mechanisms to compensate
Reduced TLC and FRC
diagraphm shifted cephalad
GA and NM enhance
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17
Q

Ventral Decubitus

A 
Prone
often intubated
induction/intubation occurs on stretcher
head and neck are neutral
Arms <90
elbow, axilia
body/trunk support
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18
Q

What type of cases are performed prone?

A

spine, buttocks, rectum, peri-rectal, ankle, intracranial

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19
Q

Cardiovascular and Pulmonary Implications for Prone

A

pooling of blood in (lower extremities/gut)
compression of IVC
epidural engorgement
Decreased compliance if chest not freely hanging
increased FRC

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20
Q

Post-Operative Vision Loss

A 
prolonged surgical time spine surgeries
central retinal artery occulsion
central retinal vein occulsion
ischemic optic neuropathy
cortical blindness
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21
Q

What is the most common POVL?

A

ischemic optic neuropathy at 89%
associated with: extended surgical time and excessive blood loss
not associated with global pressure
obesity, male gender, wilson frame,

22
Q

Prevention of POVL

A

surgical duration <6hrs
10-15 degrees head up (reduce orbital edema)
BP 20% of pre-operative baseline (MAP >70mmHg)
Maintain Hct >25

23
Q

Ocular Perfusion Pressure

A

OPP= MAP-IOP

24
Q

Central Retinal Artery Occlusion Clinical

A

eye stroke
sudden, profound vision loss
painless, monocular

25
Q

Central Retinal Artery Occlusion Etiology

A 
Embolism
vasculitis
vasospasm
sickle cell
trauma
glaucoma
26
Q

Central Retinal Artery Occlusion Diagnosis

A

retinal pallow
macular cherry red spot
+/- afferent pupillary defect

27
Q

Central Retinal Artery Occlusion Treatment

A

consult Optho + neurology
case reports of intra-arterial TPA
limited evidence- digital massage, lowering IOP

28
Q

Central Retinal Vein Occlusion Clinical

A

Eye DVT
variable- blurred vision to sudden vision loss
painless
monocular

29
Q

Central Retinal Vein Occlusion Etiology

A

typical stroke risk factors
hyper coagulability states
glaucoma
compression of the vein in the thyroid or orbital tumors

30
Q

Central Retinal Vein Occlusion Diagnosis

A

Optic disk edema

diffuse retinal hemorrhages (blood and thunder)

31
Q

Central Retinal Vein Occlusion Treatment

A

optho + neuro consult

no specific treatment

32
Q

Lithotomy Position

A

legs abducted, elevated
fingers free watch footboard
legs free watch peroneal nerve

33
Q

Hip Flexion in lithotomy position

A

sciatic/ obturator stretch

femoral nerve palsy

34
Q

Lithotomy facilitates access to

A

perineal structures
gynecological
urology

35
Q

Cardiovascular and Respiratory Implications of Lithotomy

A 
20% reduced FRC 
Reduced VC
hypoventilation breathing spontaneously
increased CVP
auto-transfusion 250-300ml/leg when raised
36
Q

Describe Lateral Positioning

A

head neutral and supported
pressure free eyes/ears/face
shoulders, hips, head, and legs aligned
chest and hips supports or bean baf
regularly assess perfusion of arms
dependent arm on padded arm board, less then 90 degrees and perpendicular to torso
axillary roll under dependent side of thorax (slightly caudad, not directly in axilla)

37
Q

When is lateral positioning used?

A

kidney
shoulder
orthopedic (THA, Hip)
thorax

38
Q

Cardiovascular and Respiratory Implications of Lateral Position

A

Euvolemic, minimal changes
V/Q mismatch possible
FRC: increased in nondependent lung (top)
decreased in dependent lung (buttom)
Dependent lung lower then left atrium, prone to: atelectasis and fluid accumulation

39
Q

Sitting position is used for

A

cervical spine surgery
shoulder surgery
posterior fossa
breast reconstruction

40
Q

When kidney rest is elevated in the lateral position, cardiovascular changes include

A

slowly, under iliac crest
great vessels compressed
decreased venous return

41
Q

Describe the sitting position

A

HOB 30-90 degrees above horizontal plane
OR table flexed and backrest elevated
Head secured (2 fingerbreadths b/t neck and mandible)
endobronchial intubation
dislodge head w/ headrest w/ vigrous surgical manipulation
pad heels, legs flexed (prevent sciatic stretch)
arms secured (padded arm boards or patients lap with drawsheet

42
Q

Potential Complications of Sitting

A

VAE d/t negative pressure gradient
pnemocephalus
quadriplegia

43
Q

VAE

A

negative pressure gradient
RA and operative site veins
most common

44
Q

Pnemocephalus

A

Neuro procedures, often benign

air enters open dura, CSF drainage, surgical decompression

45
Q

Quadriplegia

A

spinal cord stretch when head flexed + loss of autoregulation with GA
ensure 2 fingerbreadths = limit strain at C5 verbetra

46
Q

Sitting Cardiovascular and Respiratory Implications

A 
reduced SV and CO (up to 20%)
decreased MAP and CVP
lower extremity venous pooling
decreased cerebral perfusion
increased FRC
increased compliance
47
Q

Trendelenburg

A

head down
degree T burg (dependent edem)
increased ICP, IOP, CVP)
shoulder braces- plexus stretch, plexus compression

48
Q

Reverse T

A

bed flat, head up
increased pulmonary compliance, FRC
decreased IOP,ICP, CPP and BP

49
Q

Brachial Plexus

A

supine- arms abducted >90, humeral head rotated
lateral decubits: stretch/traction/tension
chest- dependent compression

50
Q

Avoid

A

excessive pressure at peripheral nerves, bony prominences, eye pressure, abrasions, irritants
extremity injury
strain/dislocation of joints and muscles

51
Q

Ensure

A

adequate circulation, head and neck support, airway protection, antatomical alignment
access

Basic Principles N928 (10 decks)

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