positioning Flashcards
0
Q
documentation for positioning
A
baseline ROM describe intraop position use of padding frame/ body position checks done and frequency
1
Q
purpose of operative positioning
A
- pt comfort
- pt safety
- surgical exposure and/or surgical access
- ** but positioning may have undesirable physiological changes and injuries
2
Q
describe the or table
A
weight limit (270lb/136kg- old) new- 270kg/600lb length- 80.7inches
center of gravity is over the post
3
Q
transfer to the OR table
A
- stretcher along side OR table- BOTH LOCKED
- OR table has draw sheet
- staff members on both sides of beds
- pt transfers self or moved by staff ( head and neck aligned with spine, watch extremities
- appply safety strap
4
Q
most common op positions
A
- supine
- lithotomy
- prone
- lateral decubitus
- sittin
5
Q
another name for supine position
A
dorsal decubitus
- trendelenburg
- RT
6
Q
another name for prone position
A
Ventral decubitus position
7
Q
what IS the most common position
A
supine
8
Q
why does anesthesia like supine
A
access to airway
access to arms for iv/monitor
less physiologic changes than in other positions
9
Q
pillow for supine
A
- under head — facilitate sniffing, avoid dorsal extension and lateral flexion of neck
(doughnut- avoids alopecia0
no pressure on eyes
10
Q
what do you injure hyperextending the neck
A
brachial plexus inj
11
Q
in supine what do you do with arms and why
A
tuck arm- draw sheet under pt NOT mattress- pad elbow
PALM IN
arm boars- abd less than 90 degress, padded, safety straps, hands SUPINATED
AVOID BRACHIAL PLEX INJ
12
Q
arm board in the middle of arm (step off) will damage what nerve
other ex- ether screen, repeat bp inflaiton, surgical retractors
A
radial= wrist drop
weakness in abd of thumb/ numbness 1, 2 and ring finger
bc of the compression
13
Q
what to do with the feet
A
heels not hanging over bed and padded slight flextion of hips and knees with pillow under knees legs/feet NOT CROSSED safety strap scd's
14
Q
how do ppl get nerve injuries
A
stretching compression kinking ischemia transection
15
Q
risk factors for nerve inj
A
position
prolonged surger
technique (GA)
preexisting diseases (obese/diabetes)
16
Q
in supine how do we inj brachial plex
A
- neck extension/head turned to side
- arm board extended/abducted greater than 90 degrees
- arm falls off table
- cardiac retractors
17
Q
how do you know inj to brachial plex
A
electric shock/burning sensation
numbness or weak arm
no or weak motor control of shoulder and elbow
pain
18
Q
ulnar nerve damage
A
1 INJURED
entrapment with arm extension
severe elbow flexion/dislocation
compress against bed
19
Q
what do you get with ulnar nerve inj
A
CLAW HAND
20
Q
S/S OF CLAW HAND
A
inability to abd or oppose 5 finger
weak grip ulnar side of fist
loss sensation of palmar surface 4 or 5 fingers
atrophy of intrinsic muscle of hand
21
Q
how to decrease ulnar nerve injury
A
pad arm boards avoid downwar compression by strap assure pts arm doesn't get compressed place bp cuff prox so not on ulnar groove/cubital tunnel avoid prolonged flexion of elbow
22
Q
cv changes with supine
A
minimal on circ and perfusion
— initially have increase venous return= increased preload/sv/co/bp->activates baroreceptors which decrease sympathetic outflow and increase prasymp impulses= decrease HR and PVR
ivc compression by mass/preg/obese/ascites may decrease venous return and decrease CO
23
Q
supine vent changes
A
FRC decrease +/- 800ml (cephalad displacement of the diaphram and compression of lung bases)
lung vol decreased more bc of muscle relaxants
24
why do lung vol decreased by muscle relaxants
loss of chest wall muscle tone with muscle relaxants
---- reduces opposition to inherent elastic recoil of pulmonary tissues
positive pressure ventilation takes over!
25
supine cerebral blood flow
minimal change- "tight " autoregulation
26
T used for
tx hypotension by increasing venous return
improve surgical exposure during abd and lap surgery
prevent air embolism
facilitates cannulation during central line placement
27
what should you put on a person in T
SHOULDER BRACES----- placed laterally over the arcomioclavicular joint
28
cv changes with T
increased venous return to the heart
causes reduced bf to the lower extremities
may cause compression of heart by abd compents pushing cephalad
activate braoreceptors- P vasodilation and braducardia
29
from T to supine changes?
get hypotensive maybe esp if hypovolemic
30
T vent changes
decrease lung compliance
decrease FRC
PIP increase
-- increases work of breathing for spontaneous vent
-v/q mismatch with perfusion exceeding ventilation in the apex
ett is easily shifted to the right mainstem
aspiration risk
face and airway edma----?> airway obstructionperiorbital/lip/tongue edema!
31
T cerebral blood flow physiological effects and who is this really not good for?
increased intracranial vascular congestion (gravity)
IICP
IIOP
no neuro/glacoma folks
32
RT used?
enhance surg exposure of UPPER abd
for shoulder, neck, intracranial surgery
similar to sitting position for physiologic changes
33
sometimes use a __________ with Rt to keep patient from sliding. what are the cautions
foot board
- excessive plantar flexion= anterior tibial nerve inj=>foot drop
34
Physio cv RT
decreases preload, CO (20-40%), lowers bp=> compensatory increase in SNS, SVR, and HR (+/-30%) *anesthetics may blunt this
- --- activation of RAAs
- venous pooling in the lower extremities--scds
FLUIDS FOR THIS PERSON not presors
35
RT vent changes
FRC increases
36
CBF in RT
decreases proportional to the degree of head up tilt (up to 20%)
ICP decreases
good for neuro
37
lithotomy position
```
should have calf support stirrups
hips flex 80-100 degrees
legs abd 30-45 degrees from midline
- lower leg parallel to torso
---- bewar femoral sciatic, lower leg nerves
```
38
what do we use lithotomy for
GYN, urology, colon
***caution- compartment syndrome in the toes
39
what nerve gets damaged from candy cane stirrups that are on the lateral pt side
common peroneal nerve!
40
lithotomy using the knee crutch style supports watch for what nerves
popliteal! (tibial and common peroneal)
41
risk factors for lower extremity nerve inj
low BMI, prolonged surgery, recent cigarette smoking PVD/Diabetes
42
what degree should hip flexion not go beyond
110
43
if lithotomy is done incorrectly what nerves could be injured
```
femoral
sciatic
obturator
lateral femoral cutaneous
saphenous
common peroneal
```
44
what nerve of the lower ext is most frequently inj
common peroneal nerve
45
s/s of common peroneal inj
foot drop
inability to Evert foot
loss of DORSAL EXTENSION of toes
46
how does the sciatic nerve get inj and s/s
- excessive external rotation
- pressure in the sciatic notch from stretching
- weakness or paralysis of muscles below the knee; numbness foot and lateral half of calf; foot drop
47
how inj fem nerve
compression at pelvic brim by retractor or excessive angulation of thigh/abd of thigh and external rotation of hips
results in loss of flextion at hip and loss of extension of knee; decreased sensation over superior aspect of thigh
48
how do we inj saphenous nerve inj and s/s
medial aspect of lower leg is compressed
paresthesias medial and antermedial side of calf
49
other than nerve inj what else can happen to lower extremity
compartment syndrome
50
what is CS and risk factors for compartment syndrome
perfusion to extremity is inadequat= ischemia/edema= rhabdomyolysis from increased tissue pressure
- long surgical procedures >2-3hr
- lithotomy and lateral decubitus positions
51
lithotomy CV changes
increased venous return/ increased preload with transient increase in CO and increase in BP
52
how much does the perfusion pressure change
2mm Hg for each 2.5 cm above the heart
53
when done with lithotomy and legs come down- what happens
decrease in bp --- try to get another bp
54
vent changes lithotomy
depends on degree hip flex
- decrease excusion= decrease lung compliance and TV= decrease VC
increased aspiration risk
55
lithotomy cerebral changes
transient increase in cerebral venous BF and increase in ICP
56
prone position considerations
watch out for brach plex--- with hyperextended arms
ALSO VESSLE ISSUES--- venous return--- drainage and flow
arms/ eyes/ears
57
special bed for prone
wilson frame
| jackson table- spinal
58
things to be cautious for with head rest
eyes nose airway neck alignment
59
for neuro folks how do we hold their head from moving and considerations
mayfield head tongs/pins
(watch for slippage, neck alignment, nose, metal components touching)
DO NOT LET THIS PERSON WAKE UP- PAINFUL
60
mvt to prone position where and what do you do?
do everything on the stretcher--- intubation/line/ng(o)t/foley/eye protection,,,, secure
remember shit is going to swell- lips tongue
61
after moved pt to prone
CHECK BBS #1
monitors on and working
check iv and aline
check pressure on (eyes, nose, upper extremities, breast, genitals, ant iliac crest)
chest and hips supported
neck alignment
BOOBS DO NOT GO LATERALLY--- MEDIAL WITH GUT
62
prone position head
can be turned to side
if face-down weight should be on bony structurs
neck is neutral alignment--- not excessive flexion or extension
eyes, nose, ears free of pressure
63
prone position- eye inj
corneal abrasions (direct trauma/ dry eye/ swelling) tx abx oint and eye patch
blindess--- ischemic optic neuropathy--- sustained, direct pressure on the eye/retina via the central vein or artery obstruction
64
risk factors for blindness
```
prone position
operative hypotension caution- spinal and cardiac surg
large operative blood loss
large crystalloid use
anemia
smoker
diabetic
pt with vascular pathology
htn male
```
65
prone position extremities
arms- boards by head abd less than 90, extra padding at elbow, prevent should sag, watch for THORACIC OUTLET SYNDROME, tuck at sides
legs:
slightly flex/scd
66
thoracic outlet syndrome
bundle that carries vasculature and lymph-
check by- have pt raise arms and check pulse and ask if they have numbness or tingling
67
prone position CV changes
IVC and Aortic Compression= hypotenstion
- use rolls to improve flow///// scds
venous pooling in lower extremities- hypotension-> decreased preload/CO/BP
68
prone vent changes
V:Q mismatch
posterior ventialtion>perfusion...... anterior perfusion>ventialtion
cephalad displacement of diaphram= decrease lung compliance- PIP increase, increase work of breathing
positive pressure ventilation overcomes compression effects
69
prone postion CBF changes
TURNING OF HEAD- obstructs venous drainage leading to INCREASED CEREBRAL VOLUME AND ICP
excess flexion or turning= obstruction of the vertebral artery flow
70
how do we call "l or R' lateral decubitus
by the hip that is DOWN!
71
why do we use lateral decubitus position
thoracotomy kidney should and hip surgery
72
special lateral decub position requirements
```
head support- neutral position- avoid misalignment of cspine, stretch brachial plex
limited pressure on dependent eye and ear
axillary roll (chest roll or chest support) placed caudad and outside of lower axilla
```
73
lateral decub arms and legs
arms- depend arm on padded board perpendicular to torso, nondepend arm supported over folded bedding or suspended with armrest
legs- padding between knees and flexed depended leg (saph n inj) padding on bed (common peroneal inj)
ant/post support-bean bag/hip posts
safety strap- btw head of femur and iliac crest
74
lateral CV changes
minimal
no change CO- unless venous return obstructed (kidney rest)
noninvasive VP will be different in the 2 arms
higher in dependent arm
lower in nondepend arm
75
lateral vent changes
awake and spontaneous- dependent lung is both better perfused and ventilated--- BUT LUNG VOLUMES DECREASED (FRC/VC AND TV)
anesthetized but spon breathing--- nondepend lung better ventilated and dependent lung is better perfused (V/Q mismatch)
Anesthetized, mech vent--- nondependent lung is overventialted and dependent lung is over perfused (worse V/Q mismatch)
V/Q not sucha big deal when positive pressure is being given
76
lateral post CBF
minimal changes unless extreme flexion of head
77
sitting position for
cranial shoulder humeral
facilitates venous drainage
excellent surgical exposure/access
78
sitting pos- head
fixed in pins/taped
avoid excessive c flexion--- obstructs v flow= congestion/hypoperfusion...... other comp- stretch c nerve roots, obstruct ett, prssure on the tongue 2 FB BTW MANDIBLE AND STERNUM
AVOID RIGID BITE-BLOCK- TONGUE ISCHEMIA
79
sitting position body considerations
arms- avoid pressure on fram, support
butt- positioned in the break of the table
flex knees and hips- decrease strtch of sciatic nerv
elastic compression scd
feet supported and padded
80
sitting cv changes
pooling of blood in LE= hypotention, decreased preload CO and BP-> HR and SVR increase as compensatory (can be blunted by anesthetics)
give IVF, pressors and adjust anesthetic depth, elastic stockins and active leg compression devices
81
vent changes sitting
lung vol and capacities increase
lung compliance increase
work of breathing easier
mech vent and spont= easier
82
sitting position CBF
decrease
ICP- decreased
watch position bc can imped arterial and venous bf= hypoperfusion or venous congestion of the brain
*** can entrain air!!! have to work about venous air embolism****
83
Venous air embolism
is a risk ANY TIME the surgical site is above the level of the heart
inability of the venous sinuses to collapse
could be lethal
s/s- change in heart tones (wind mill murmur)- doppler at parasternal border (2-6 IC space) new murmur, dysrhythmias, hypotension, desat, drastic DECREASE EtCO2, N in exhaled gas, circulatory compromise, cardiac arrest
Detect with TEE or precordial Doppler ultrasound
84
how do you treat venous air embolism
flood surgical field with ns, apply wax to cut bony edges, close any open vessels
- d/c NO--- bc it moves into places with air!!! it would make problem worse air larger
- place on 100% O2 with PEEP
- TBERG position
- Aspirate air from right atrium via a cath
