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
