Positioning Flashcards
Which AANA standard relates to patient positioning?
Standard 8: Patient Positioning
Safety belts/straps must be used where?
abdominal/pelvic area
abdominal/pelvic area to secure the patient in addition to the securing of extremities
The most common surgical position
supine
Which initial physiologic changes are to be expected when moving from sitting to supine?
↑ Venous return, preload, SV, and CO
↓Tidal volume, ↓ FRC (cephalad displacement of the diaphragm)
A patient is supine with the left arm adducted and the right arm abducted. What positioning is expected for the right 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)
The elbows padded and arm is secured with a Velcro strap
A patient is supine with the left arm adducted and the right arm abducted. What positioning is expected for the left 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
A patient is supine with the neck extended and the head turned to the right, away from the surgical site. Which positioning complication may occur?
-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)
Where should arm boards be secrured
axilla / armpit
cause of back pain with supine position
normal lumbar lordotic curvature is often lost due toloss of tone in the paraspinous muscles.
Cause of Ulnar nerve injury
pronated (hand down)
flexed > 110 deg
Shoulder braces used during Trendelenburg increasing the risk of:
risk of compression injury to 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
Which pathophysiologic changes can occur in Trendelenburg position?
-↑ CO
-↑ ICP and IOP
-Edema of face, conjunctiva, larynx, and tongue
-↑ Intraabdominal pressure
-↓ FRC and pulmonary compliance
-May need higher pressures in ventilated patients for adequate ventilation
-Risk of endobronchial intubation as abdominal contents push the carina cephalad
-increased potential for postoperative upper airway obstruction
-increases intraabdominal pressure and displaces the stomach placing the patient at a higher risk for aspiration.
-Possibility of postoperative visual loss (POVL)
Which position is contraindicated in a patient with an increased ICP?
trendelenburg
REVERSE TRENDELENBURGPathophysiologic considerations
Hypotension risk
↓ Venous return – venous pooling in lower extremities
Downward displacement of abdominal contents and diaphragm
↓ Perfusion to brain
If invasive arterial pressure monitoring is used during reverse trendelenburg then the arterial pressure transducer should be zeroed at the level
of the Circle of Willis
Beach chair position used frequently in ….. cases
shoulder
Less severe hip flexion and slight leg flexion
Sitting position should have ………distance between the chin and sternum
two fingers
Chin and sternum - adequate distance should be maintained between the mandible and the sternum when the cervical spine is flexed in order to provide for adequate arterial and venous blood flow.
Reason for Hips are flexed < 90 degrees and knees slightly flexed for balance for sitting position
Reduce stretching of the sciatic nerve
SittingRisks
-Cerebral hypoperfusion and air embolism
Pneumocephalus
Quadriplegia and spinal cord infarction
Cerebral ischemia
Peripheral nerve injuries; Sciatic nerve injury
Venous air embolism in the Sitting position
VAE is a constant concern in the sitting position due to the position of the surgical field above the level of the heart and the tented open dural venous sinuses. VAE can cause arrhythmias, oxygen (O2) desaturation, acute pulmonary hypertension, circulatory compromise, and cardiac arrest. (50ml)
small venous air embolism < 10 mm of air
can only be detected by a TEE.
what is a tension pneumocephalus
which is the accumulation of air in the subdural or ventricular space causing pressure on intracranial structures, is very rare
SittingPATHOPHYSIOLOGIC CONSIDERATIONS
Hypotension risk; ↓ Venous return – venous pooling in lower extremities
↓ MAP, CI, and cerebral perfusion pressure
Decreased systolic BP
Improved ventilation in non-obese patients
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 pooling
Intubate the patient supine on the bed and then turn prone
Place EKG leads on patient’s back
Do not turn the patient’s head to one side or the other due to risk of jugular occlusion or carotid occlusion
ProneRisks
-Facial and airway edema
-Nerve injuries
-Post-op visual loss secondary to decreased perfusion/ischemia
-ETT dislodgement
-Loss of monitors and IV lines
PronePathophysiology considerations
Edema of face, conjunctiva, larynx, and tongue
↑ Abdominal pressure
↓ Venous return through compression of the inferior vena cava
↓ CO
Improved ventilation
LITHOTOMY
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
Lithotomy leg positioning
patient’s hips are flexed 80 to 100 degrees from the trunk, and the legs are abducted 30 to 45 degrees from the midline. The knees are flexed until the lower legs are parallel to the torso.
The legs should be raised together; simultaneously, the knees and hips are flexed. This prevents torsion and injury to the lumbar spine.
LithotomyRisks
Back pain
Nerve injuries
Compartment syndrome
Lithotomy nerve injuries
Brachial plexus
Ulnar nerve injury
Common peroneal injury
Lateral femoral cutaneous injury
The peroneal nerve is particularly prone to injury as it lies between the fibular head and compression from the leg support
Branches of the lateral femoral cutaneous nerves often pass directly through the inguinal ligaments and can be impinged and become ischemic within the stretched ligament.
LithotomyPathophysiological considerations
↑ Venous return, CO, and ICP
↑ Intraabdominal pressure; Displaces diaphragm cephalad
↓ Lung compliance and tidal volume
LATERAL DECUBITUS
Patient lying on non-operative (dependent) side and requires anterior and posterior support w/ rolls or bean bags
leg is slightly flexed
Arms are in front of the patient and both must be supported Abducted < 90 degrees
Axillary roll placed between chest wall and bed, caudal to axilla
place padding between the knees
If bed flexed or kidney rest used, needs to be placed under_____
iliac crest
Inferior vena cava compression can occur
Allowing best possible expansion of the dependent lung
LATERAL DECUBITUSPathophysiologic considerations
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
Peripheral nerve injuries occur in as little as…..
30 min
Peripheral nerve injuries are mostly
sensory but can be Combined sensory and motor
Surgeon is going to stand on the patients L side, how would the arms be positioned for the patient
Adduct the L arm
What causes the back pain with supine position
normal lumbar lordotic curvature is often lost due toloss of tone in the paraspinous muscles.
Patients with extensive kyphosis, scoliosis, or a history of back painmay require extra padding of the spine or slight flexion at the hip and knee.
In beach chair position what must be stabilized / strapped
head must be stabilized
Position for suspected venous air embolism
L lateral decubitus and trendelenburg
Prone position ventilation changes
ventilation and perfusion to dependent areas
Patient is in Right lateral decubitus, what side is the patient having an operation on?
L side
R side is down
Patient is in Right lateral decubitus, what side is the patient having an operation on?
L side
R side is down
Surgeon is going to stand on the patients L side, how would the arms be positioned for the patient
Adduct the L arm
Peripheral nerve injuries results form______
Result of stretch, pressure, and/or ischemia
Mechanism of injury unclear
In beach chair position what must be stabilized / strapped
head must be stabilized
What causes the back pain with supine position
normal lumbar lordotic curvature is often lost due toloss of tone in the paraspinous muscles.
Patients with extensive kyphosis, scoliosis, or a history of back painmay require extra padding of the spine or slight flexion at the hip and knee.
Prone position ventilation changes
ventilation and perfusion to dependent areas
Position for suspected venous air embolism
L lateral decubitus and trendelenburg
Patient is in Right lateral decubitus, what side is the patient having an operation on?
L side
R side is down
Prone position ventilation changes
ventilation and perfusion to dependent areas
Surgeon is going to stand on the patients L side, how would the arms be positioned for the patient
Adduct the L arm
What causes the back pain with supine position
normal lumbar lordotic curvature is often lost due toloss of tone in the paraspinous muscles.
Patients with extensive kyphosis, scoliosis, or a history of back painmay require extra padding of the spine or slight flexion at the hip and knee.
Position for suspected venous air embolism
L lateral decubitus and trendelenburg
In beach chair position what must be stabilized / strapped
head must be stabilized
