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health assessment > positioning > Flashcards

positioning Flashcards

0
Q

documentation for positioning

A 
baseline ROM
describe intraop position
use of padding
frame/ body position
checks done and frequency
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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
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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

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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
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4
Q

most common op positions

A
  • supine
  • lithotomy
  • prone
  • lateral decubitus
  • sittin
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5
Q

another name for supine position

A

dorsal decubitus

  • trendelenburg
  • RT
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6
Q

another name for prone position

A

Ventral decubitus position

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7
Q

what IS the most common position

A

supine

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8
Q

why does anesthesia like supine

A

access to airway
access to arms for iv/monitor
less physiologic changes than in other positions

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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
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10
Q

what do you injure hyperextending the neck

A

brachial plexus inj

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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

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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

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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
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14
Q

how do ppl get nerve injuries

A 
stretching
compression
kinking
ischemia
transection
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15
Q

risk factors for nerve inj

A

position
prolonged surger
technique (GA)
preexisting diseases (obese/diabetes)

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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
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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

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18
Q

ulnar nerve damage

A

1 INJURED

entrapment with arm extension
severe elbow flexion/dislocation
compress against bed

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19
Q

what do you get with ulnar nerve inj

A

CLAW HAND

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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

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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
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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

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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

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24
Q

why do lung vol decreased by muscle relaxants

A

loss of chest wall muscle tone with muscle relaxants
—- reduces opposition to inherent elastic recoil of pulmonary tissues

positive pressure ventilation takes over!

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25
Q

supine cerebral blood flow

A

minimal change- “tight “ autoregulation

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26
Q

T used for

A

tx hypotension by increasing venous return
improve surgical exposure during abd and lap surgery
prevent air embolism
facilitates cannulation during central line placement

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27
Q

what should you put on a person in T

A

SHOULDER BRACES—– placed laterally over the arcomioclavicular joint

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28
Q

cv changes with T

A

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

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29
Q

from T to supine changes?

A

get hypotensive maybe esp if hypovolemic

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30
Q

T vent changes

A

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!

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31
Q

T cerebral blood flow physiological effects and who is this really not good for?

A

increased intracranial vascular congestion (gravity)
IICP
IIOP

no neuro/glacoma folks

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32
Q

RT used?

A

enhance surg exposure of UPPER abd
for shoulder, neck, intracranial surgery

similar to sitting position for physiologic changes

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33
Q

sometimes use a __________ with Rt to keep patient from sliding. what are the cautions

A

foot board

  • excessive plantar flexion= anterior tibial nerve inj=>foot drop
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34
Q

Physio cv RT

A

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
Q

RT vent changes

A

FRC increases

36
Q

CBF in RT

A

decreases proportional to the degree of head up tilt (up to 20%)
ICP decreases

good for neuro

37
Q

lithotomy position

A 
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
Q

what do we use lithotomy for

A

GYN, urology, colon

***caution- compartment syndrome in the toes

39
Q

what nerve gets damaged from candy cane stirrups that are on the lateral pt side

A

common peroneal nerve!

40
Q

lithotomy using the knee crutch style supports watch for what nerves

A

popliteal! (tibial and common peroneal)

41
Q

risk factors for lower extremity nerve inj

A

low BMI, prolonged surgery, recent cigarette smoking PVD/Diabetes

42
Q

what degree should hip flexion not go beyond

A

110

43
Q

if lithotomy is done incorrectly what nerves could be injured

A 
femoral 
sciatic
obturator
lateral femoral cutaneous
saphenous
common peroneal
44
Q

what nerve of the lower ext is most frequently inj

A

common peroneal nerve

45
Q

s/s of common peroneal inj

A

foot drop
inability to Evert foot
loss of DORSAL EXTENSION of toes

46
Q

how does the sciatic nerve get inj and s/s

A
  • 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
Q

how inj fem nerve

A

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
Q

how do we inj saphenous nerve inj and s/s

A

medial aspect of lower leg is compressed

paresthesias medial and antermedial side of calf

49
Q

other than nerve inj what else can happen to lower extremity

A

compartment syndrome

50
Q

what is CS and risk factors for compartment syndrome

A

perfusion to extremity is inadequat= ischemia/edema= rhabdomyolysis from increased tissue pressure

  • long surgical procedures >2-3hr
  • lithotomy and lateral decubitus positions
51
Q

lithotomy CV changes

A

increased venous return/ increased preload with transient increase in CO and increase in BP

52
Q

how much does the perfusion pressure change

A

2mm Hg for each 2.5 cm above the heart

53
Q

when done with lithotomy and legs come down- what happens

A

decrease in bp — try to get another bp

54
Q

vent changes lithotomy

A

depends on degree hip flex

  • decrease excusion= decrease lung compliance and TV= decrease VC
    increased aspiration risk
55
Q

lithotomy cerebral changes

A

transient increase in cerebral venous BF and increase in ICP

56
Q

prone position considerations

A

watch out for brach plex— with hyperextended arms
ALSO VESSLE ISSUES— venous return— drainage and flow
arms/ eyes/ears

57
Q

special bed for prone

A

wilson frame

jackson table- spinal

58
Q

things to be cautious for with head rest

A

eyes nose airway neck alignment

59
Q

for neuro folks how do we hold their head from moving and considerations

A

mayfield head tongs/pins
(watch for slippage, neck alignment, nose, metal components touching)
DO NOT LET THIS PERSON WAKE UP- PAINFUL

60
Q

mvt to prone position where and what do you do?

A

do everything on the stretcher— intubation/line/ng(o)t/foley/eye protection,,,, secure

remember shit is going to swell- lips tongue

61
Q

after moved pt to prone

A

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
Q

prone position head

A

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
Q

prone position- eye inj

A

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
Q

risk factors for blindness

A 
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
Q

prone position extremities

A

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
Q

thoracic outlet syndrome

A

bundle that carries vasculature and lymph-

check by- have pt raise arms and check pulse and ask if they have numbness or tingling

67
Q

prone position CV changes

A

IVC and Aortic Compression= hypotenstion
- use rolls to improve flow///// scds
venous pooling in lower extremities- hypotension-> decreased preload/CO/BP

68
Q

prone vent changes

A

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
Q

prone postion CBF changes

A

TURNING OF HEAD- obstructs venous drainage leading to INCREASED CEREBRAL VOLUME AND ICP

excess flexion or turning= obstruction of the vertebral artery flow

70
Q

how do we call “l or R’ lateral decubitus

A

by the hip that is DOWN!

71
Q

why do we use lateral decubitus position

A

thoracotomy kidney should and hip surgery

72
Q

special lateral decub position requirements

A 
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
Q

lateral decub arms and legs

A

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
Q

lateral CV changes

A

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
Q

lateral vent changes

A

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
Q

lateral post CBF

A

minimal changes unless extreme flexion of head

77
Q

sitting position for

A

cranial shoulder humeral

facilitates venous drainage
excellent surgical exposure/access

78
Q

sitting pos- head

A

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
Q

sitting position body considerations

A

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
Q

sitting cv changes

A

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
Q

vent changes sitting

A

lung vol and capacities increase
lung compliance increase
work of breathing easier

mech vent and spont= easier

82
Q

sitting position CBF

A

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
Q

Venous air embolism

A

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
Q

how do you treat venous air embolism

A

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

health assessment (4 decks)

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