Positioning (Exam 2) Flashcards
What must be used in the abdominal/pelvic area to secure the patient?
Safety belts/straps
What is the most common surgical position?
- Supine
Arm boards must be secure if in use.
What are the pathophysiological considerations for the supine position?
- ↑ Venous return, ↑ preload, ↑ SV, and ↑ CO (transient)
- ↓Tidal volume, ↓ FRC
Describe the arm abduction process (4)
- Arm out to the side, < 90º
- Padded arm boards secured to the table and patient at the axilla
- The arms should be supine (palms up)
- Elbows padded and arm is secured with a Velcro strap
Describe arm adduction process (5)
- Arm tucked alongside body
- Arms held along the side of body via draw sheet under body and over 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
Complications of the supine position (5)
- 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)
What position is this patient in?
- Trendelenburg (head down)
Safety/general considerations with Trendelenburg position.
- Use a non-sliding mattress/pad to prevent the patient from sliding cephalad
- Avoid using bean bags or shoulder braces
- 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
Hemodynamic and Pressure considerations with Trendelenburg position. (6)
- ↑ CO (↑ Venous Return from lower extremities)
- ↑ ICP, ↑ IOP, Facial Edema
- ↑ Intraabdominal Pressure
Respiratory considerations with Trendelenburg position.
- ↓ FRC and ↓ Pulmonary Compliance
- May need higher pressure in ventilated patients
- Risk of endobronchial intubation as abdominal contents push the carina cephalad
What position is this patient in?
- Reverse Trendelenburg (head up)
Safety/general considerations with Reverse Trendelenburg position. (2)
- Use a non-sliding mattress/pad to prevent the patient from sliding
- Use a footrest or something under the feet to prevent the patient from sliding
Pathophysiological considerations with Reverse Trendelenburg position. (3)
- Risk of Hypotension (↓ Venous Return, Venous pooling in LE)
- Downward displacement of abdominal contents/ diaphragm (better ventilation)
- ↓ Perfusion to the brain
Name the positions
- Left Picture: Beach Chair Position
- Right Picture: Full Sitting Position
Where should an art line be leveled when sitting or head up?
At the tragus
When will the patient be in the Beach chair position?
- frequently in Shoulder Cases
Beach chair position will have less severe hip flexion and slight leg flexion.
Describe the set-up of the full sitting position (5)
- Head must be stabilized – taped to special headrest or rigid pins
- Hips are flexed < 90 degrees and knees slightly flexed for balance to reduce stretching of the sciatic nerve
- Feet are supported – prevent sliding
- Compression stockings/wraps to maintain venous return
- Keep at least two finger’s distance between the chin and sternum (prevent overflexion of C-spine)
What 5 risks are associated with sitting position?
- Cerebral hypoperfusion and air embolism
- Pneumocephalus
- Quadriplegia and spinal cord infarction
- Cerebral ischemia
- Peripheral nerve injuries (Sciatic nerve injury)
Hemodynamic/Pathophysiological considerations of the sitting position? (2)
- Risk of hypotension d/t ↓ venous return and venous pooling
- ↓ MAP, ↓ Cardiac Index, and ↓ CPP
What position is the patient in?
- Prone with Wilson Frame
Describe the prone position. (6)
- 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
What risks are associated with prone positioning? (6)
- Facial and airway edema
- Nerve injuries: Ulnar nerve injury if elbows are not padded. Brachial plexus injury if arms are abducted > 90 degrees
- Post-op visual loss secondary to decreased perfusion/ischemia
- Eye injuries r/t head position
- ETT dislodgement
- Loss of monitors and IV lines
Hemodynamic/Pathophysiological considerations for prone patients (4)
- Edema of face, conjunctiva, larynx, and tongue
- ↑ Abdominal pressure
- ↓ Venous return through compression of the inferior vena cava ➡︎ ↓CO
- Improved ventilation ➡︎ Ventilation and perfusion in the lungs shift to the dependent areas
What position is the patient in?
- Lithotomy
Describe the Lithotomy position
- 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 -100º and legs abducted 30 - 45º from midline, knees flexed
- Lower extremities MUST be raised and lowered in synchrony together (prevent torsion)
- Foot of the bed is lowered, must protect the hands and fingers from crush injury
- Surgery > 2-3 hours, periodically lower the legs
What position is the patient in?
- Lateral Decubitus Position
What is done to prevent brachial plexus compression for lateral decubitus positioning?
Axillary rolls caudal to axilla
