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Health Assessment > Positioning > Flashcards

Positioning Flashcards

1
Q

What should be documented about positioning?

A

baseline range of motion, intra-operative positioning, use of padding, frame, body position, checks done and frequency

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2
Q

What is the weight limit of a standard OR table?

A

136 kg or 300 lb

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3
Q

What are some advantages of the supine position?

A

access to airway, access to arms for IV’s/monitors, less physiologic changes

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4
Q

What are some considerations when tucking arms?

A

draw sheet under patient (not mattress), elbow padded, palm in

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5
Q

What are some considerations when using arm boards?

A

properly secured to OR table, arm abducted less than 90 degrees, arms padded, safety straps applied, hands supine

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6
Q

Describe the positioning of feet in the supine position.

A

Heels not hanging over bed, heels padded

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7
Q

Describe the lumbar support needed in supine position.

A

Slight flexion in hips and knees, pillow under knees, legs should not be crossed, compression stockings or SCDs in use

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8
Q

What are some mechanisms of nerve injury?

A

Stretching, compression, kinking, ischemia, transection

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9
Q

What are some mechanisms of brachial plexus injury?

A

Neck extension or head turned to side, excessive abduction of arm greater than 90 degrees, arm falling off of arm board or table (mostly stretching injuries)

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10
Q

What are some symptoms of brachial plexus injury?

A

Electric shocks or burning sensation shooting down arm, numbness or weak arm function

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11
Q

What are some mechanisms of radial nerve injury in the supine position?

A

Injury due to compression can happen from

  • surgical retractors
  • ether screen
  • mismatched arm board “step off”
  • repeat BP cuff inflation
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12
Q

What are the symptoms of radial nerve injury?

A

wrist drop, weakness in abduction of the thumb, numbness in 1st, 2nd and ring fingers, inability to extend elbow

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13
Q

What is the most common postoperative peripheral nerve injury?

A

ulnar nerve

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14
Q

What are some mechanisms of ulnar nerve injury?

A
  • compression of the nerve in the cubital tunnel between the olecranon of ulna and the medial epicondyle of humerus with arm extension
  • stretch with elbow flexion
  • dislocation over medial epicondyle and stretching with pronated hand
  • compression against bed
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15
Q

What are some symptoms of ulnar nerve injury?

A
  • inability to abduct or oppose 5th finger
  • weak grip on the ulnar side of first
  • loss of sensation on the palmar surface of the 4th and 5th fingers
  • atrophy of intrinsic muscles of the hand (claw hand)
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16
Q

What are some ways to reduce the risk of injury to the ulnar nerve?

A

pad arm boards, avoid downward compression by strap, assuring surgical personnel do not compress patient’s arm, proximal placement of BP cuff so that it doens’t impose on ulnar groove or cubital tunnel, avoid prolonged flexion of elbow

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17
Q

What are some cardiovascular changes in the supine position?

A
  • minimal effects on circulation and perfusion
  • initial increased venous return with increased preload, stroke volume, cardiac output and blood pressure
  • eventually baroreceptors are activated decreasing sympathetic outflow and increasing parasympathetic impulses causing compensatory decreases in HR and PVR
  • Reduced venous drainage from lower extremities-uncross legs, pad heels, pillow beneath knees, flexed hips and knees to improve venous return
  • IVC compression if abdominal mass, pregnancy or obese
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18
Q

What are some ventilatory changes in the supine position?

A

-FRC decreased ~800ml, lung volumes further reduced by muscle relaxants, overcome this with ppv

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19
Q

What are some changes to cerebral blood flow in the supine position?

A

minimal due to autoregulation

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20
Q

What are some uses for the trendelenberg position?

A
  • Used to treat hypotension by increasing venous return
  • Improves surgical exposure during abdominal laparoscopic surgery
  • Helps prevent air embolism
  • Facilitates cannulation during central line placement
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21
Q

How should shoulder braces be placed?

A

They should be well padded and placed laterally away from the root of the neck over the acromioclavicular joint

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22
Q

What are some cardiovascular changes in trendelenberg position?

A
  • short term counteracting of hypotension because of increased venous return to the heart
  • reduced blood flow to the lower extremities
  • may cause compression of the heart by abdominal contents
  • baroreceptors activated-peripheral vasodilation and bradycardia
  • hypotension when supine position is resumed
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23
Q

What are some ventilatory changes in the trendelenberg position?

A
  • Contents of the abdomen are are displaced impeding diaphragmatic excursion, compressing lung bases, decreasing lung compliance, decreasing FRC, and increasing PIP
  • Work of breathing is increased with spontaneous ventilation
  • V:Q mismatch with perfusion exceeding ventilation in the apex of the lung
  • ETT is easily shifted into the right mainstem bronchus
  • risk of aspiration
  • face and airway edema can lead to airway obstruction
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24
Q

What are some changes to cerebral blood flow in the trendelenberg position?

A
  • increases intracranial vascular congestion
  • increased ICP
  • intraocular pressure increases
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25
Q

What are some uses for reverse trendelenberg?

A
  • enhanced surgical exposure of the upper abdomen
  • can be used for shoulder, neck, intracranial surgery
  • variation of the sitting position in terms of physiologic changes
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26
Q

What cautions with the foot board should you take in the reverse trendelenberg position

A
  • Can cause excessive plantar flexion of the feet for extended periods of time
  • Anterior tibial nerve injury
  • Results in foot drop
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27
Q

What are some cardiovascular changes in the reverse trendelenberg position?

A
  • Reduced preload, reduced CO, and lower BP
  • Compensatory increases in SNS tone, SVR and HR
  • Activation of the renin-angiotensin-aldosterone system
  • Venous pooling in the lower extremities-use compression stockings
  • Hypertension when the supine position is resumed
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28
Q

What are some ventilatory changes in the reverse trendelenberg position?

A

FRC increases, abdomen does not impede diaphragmatic excursion, ventilation is easier

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29
Q

What are some changes to cerebral blood flow in the reverse trendelenberg position?

A
  • Cerebral blood flow decreases proportional to the degree of head up tilt
  • ICP decreases
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30
Q

Describe lithotomy position using calf support stirrups and what nerves are vulnerable.

A
  • Hips flexed 80-100 degrees
  • Legs abducted 30-45 degrees from midline
  • Lower legs parallel to torso
  • Watch femoral, sciatic, and lower leg nerves
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31
Q

Describe lithotomy position using candy cane stirrups and what nerves are vulnerable.

A
  • Usually more acute flexion of the knees and/or hips

- Watch injury to common peroneal nerve, sciatic and femoral

32
Q

What nerves are vulnerable in the lithotomy position using knee crutches?

A

-popliteal, tibial, and common peroneal

33
Q

What are some nerve injuries associated with the lithotomy position?

A

-common peroneal (most common)
-sciatic
-femoral
obturator
-lateral femoral cutaneous
-saphenous
-higher risk with low body mass index, prolonged surgery, recent cigarette smoking, pvd, dm, and obesity

34
Q

What are some procedures that the lithotomy position are used for?

A

-GYN, GU, and rectal procedures

35
Q

Describe the lithotomy position

A

Both legs are positioned into stirups together to avoid torsion of the lumbar spine and hip flexion beyond 110 degrees is avoided

36
Q

What is the most frequently damaged nerve of the lower extremity?

A

common peroneal

37
Q

What are some ways the common peroneal nerve can be injured?

A

compression of the lateral aspect of the knee against a stirrup of a lateral position

38
Q

What are symptoms of common peroneal nerve damage?

A

Foot drop, inability to evert the foot, loss of dorsal extension of toes

39
Q

What are some mechanisms of sciatic nerve injury?

A
  • Excessive external rotation of hips

- Pressure in sciatic notch from stretching

40
Q

What are the symptoms of sciatic nerve injury?

A
  • Paralysis of muscles below the knee
  • Numbness of the foot and lateral half of the calf
  • Foot drop
41
Q

What are some mechanisms of femoral nerve injury?

A
  • Compression at pelvic brim by retractor
  • Excessive angulation of the thigh
  • Abduction of thighs and external rotation of hips
42
Q

What are the symptoms of femoral nerve injury?

A
  • Loss of flexion of hip
  • Loss of extension of knee
  • Decreased sensation over superior aspect of thigh
43
Q

What is the mechanism of saphenous nerve injury?

A

-compression of the medial aspect of the lower leg against a support bar

44
Q

What are the symptoms of saphenous nerve injury?

A

Parasthesias to the medial and anteriomedial side of calf

45
Q

Describe lower extremity compartment syndrome.

A

-Occurs when perfusion to an extremity is inadequate, resulting in ischemia, edema, and extensive rhabdomyolysis from increased tissue pressure.

46
Q

What are some causes of lower extremity compartment syndrome?

A
  • Long surgical procedures (greater than 2-3 hours)

- Occurs with lithotomy and lateral decubitus positions

47
Q

What cardiovascular changes occur in the lithotomy position?

A
  • Increased venous return, preload, CO, and BP

- Perfusion to lower extremities is reduced- 2 mmHg for every 2.5cm variation in vertical height

48
Q

What ventilatory changes occur with lithotomy position?

A
  • Abdominal contents may push up on the diaphragm and impede excursion
  • Reduction in lung compliance
  • Decrease in TV and vital capacity
  • Increased aspiration risk
49
Q

What are some cerebral changes in lithotomy position?

A

-Transient increase in cerebral blood flow and increase in ICP with elevated legs

50
Q

What are some precautions to take with head rests?

A

Watch eyes, nose, bony structures of face, airway, and neck alignment

51
Q

What are some precautions to take with head tongs?

A

Watch for slippage, neck alignment, nose, and metal components touching

52
Q

What should be done on the stretcher before positioning a patient in the prone position?

A
  • Induction/intubation
  • Line placement
  • NGT/OGT, esophageal stethoscope, bite blocks
  • Foley
  • Good eye protection
  • Secure everything
53
Q

What should be done after moving a patient to the prone position?

A
  • Check breath sounds again
  • Monitors on and working
  • Check IV and A-line working
  • Check for excessive pressure on eyes, nose, upper extremities, breasts, genitals
  • Chest and hips supported to allow for free abdomen and for diaphragmatic movement and increased venous return
  • Check neck alignment
54
Q

Describe the position of the head in prone position.

A
  • May be turned to the side if adequate mobility
  • Head supported face-down with its weight on bony structures
  • Neck is in neutral alignment, not excessive flexion or extension
  • Eyes, nose, ears free of pressure
55
Q

What eye injuries can occur in the prone position, what are their causes, and what can you do to prevent them?

A
  1. Corneal abrasions: caused by direct trauma to the eye or swelling. Can be treated with atibiotic ointment and eye patch.
  2. Blindness: can be caused by ischemia due to optic neuropathy via central vein or artery obstruction or via sustained, direct pressure on the eye/retina.
56
Q

What are some risk factors for blindness?

A

Prone position, operative hypotension, large operative blood loss, large crystalloid use, anemia, smoker, diabetic, patients with vascular pathology of HTN, males. Use caution in spinal surgery and cardiac surgery

57
Q

Describe the positioning of arms in the prone position.

A

-On boards by head, abducted less than 90 degrees, extra padding at the elbow, prevent shoulders from sagging, watch for thoracic outlet syndrome, tucked at sides

58
Q

Describe the position of the legs in the prone position.

A

-Slightly flexed, compression stockings or SCDs

59
Q

What cardiovascular changes occur in the prone position?

A
  • IVC and aortic compression causing hypotension-rolls that free the abdomen can improve flow
  • Venous pooling in the lower extremities can cause hypotension leading to decreased preload, CO, and BP
  • Hypotension associated with the move to prone position should be anticipated
60
Q

What ventilatory changes occur in the prone position?

A
  • V:Q mismatch
  • Cephalad displacement of diaphragm, decreasing lung compliance, increasing peak airway pressure, increasing work of breathing
  • Use rolls or bolsters to free chest and positive pressure ventilation to overcome compression effects
61
Q

What are some changes to cerebral blood flow that occur in the prone position?

A
  • Turning the head obstructs venous drainage leading to increased cerebral volume and ICP
  • Excess flexion or turning can obstruct vertebral artery flow
62
Q

What are some surgeries that use the lateral decubitus position?

A

Thoracotomy, kidney, shoulder and hip

63
Q

Describe the lateral decubitus position and supports needed.

A

Head support-head in neutral position, avoid misalignment of cervical spine or stretching of brachial plexus

Axillary roll-placed caudad and outside of lower axilla

64
Q

Describe the position of the arms and legs in the lateral position.

A

Arms: dependent arm on padded arm board perpendicular to torso. Non-dependent arm supported over folded bedding or suspended with armrest

Legs: padding between knees and flexed dependent leg to avoid saphenous nerve injury. Padding on bed to prevent common peroneal nerve injury

Use safety strap between head of femur and the iliac crest

65
Q

What cardiovascular changes occur in the lateral position?

A

Minimal cardiovascular changes, no change in CO unless venous return is obstructed. BP cuff measurements will be different in two arms(higher in dependent)

66
Q

Describe ventilatory changes in the lateral position.

A

Awake and spontaneous breathing: the dependent lung is both better perfused and better ventilated, but lung volumes decrease

Anesthetized but spontaneous breathing: nondependent lung better ventilated and dependent lung is better perfused

Anesthetized and mechanically ventilated: nondependent lung is overventilated and depended lung is overperfused

67
Q

What changes to cerebral blood flow occur in the lateral position?

A

Minimal change unless there is extreme flexion of the head

68
Q

What surgeries is the sitting position used for?

A

Cranial, shoulder and humeral procedures

69
Q

Describe the position of the head in the sitting position.

A
  • Fixed in pins or taped in place
  • Avoid excessive cervical flexion- can obstruct venous outflow causing hypoperfusion or venous congestion in the brain, stretch cervical nerve roots, can obstruct ETT, can place pressure on the tongue
  • Want at least 2 FB between the mandible and sternum
  • Avoid rigid bite-block due to risk of tongue ischemia
70
Q

Describe the position of the arms, buttocks, knees, hips in the sitting position.

A
  • Avoid pressure on the frame
  • Support arms, avoid traction pulling down on the shoulders
  • Buttocks: position in the break of the table
  • Knees and hips: flexed to decrease stretch of sciatic nerve
  • Feet: supported and padded
  • SCDs or compression stockings used
71
Q

Describe the cardiovascular changes that occur in the sitting position.

A

-Pooling of blood in the lower extremities, decreasing preload, CO and BP
-Hypotension
-Compensatory increase in HR and SVR
Treatment includes IVF, vasopressors, adjustments or anesthetic depth, elastic stockings and SCDs

72
Q

What are some ventilatory changes that occur in the sitting position?

A
  • Lung volumes and capacities increase
  • Lung compliance increases
  • Work of breathing is easier
  • Mechanical ventilation and spontaneous breathing easier in this position
73
Q

What are some changes to cerebral blood flow that occur in the sitting position?

A
  • Cerebral blood flow is decreased
  • ICP is decreased
  • Watch positioning which can impede arterial and venous blood flow, causing hypoperfusion or venous congestion of the brain
74
Q

When is there a risk for venous air embolism?

A

Anytime the surgical site is above the level of the heart

75
Q

What are some signs of a venous air embolism?

A

Change in heart tones (wind mill murmur), new murmur, dysrhythmias, hypotension, desaturation, decreased ET CO2, nitrogen in exhaled gas, circulatory compromise, and cardiac arrest. Entrained air can be detected with TEE or precordial doppler ultrasound

76
Q

What is the treatment for a venous air embolism?

A

Flood surgical field with NS, apply wax to cut bony edges, close any open vessels, d/c nitrous oxide, place on 100% O2, PEEP, trendelenberg position, aspirate air from right atrium via a catheter

Health Assessment (5 decks)

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