Intraoperative Nursing Management PDF

INTRAOPERATIVE NURSING MANAGEMENT BENJIE SILVA MN, RN Glossary anesthesia: a state of narcosis, analgesia, relaxation, and loss of reflexes anesthesiologist: physician trained to deliver anesthesia and to monitor the patient’s condition during surg...

INTRAOPERATIVE NURSING MANAGEMENT BENJIE SILVA MN, RN Glossary anesthesia: a state of narcosis, analgesia, relaxation, and loss of reflexes anesthesiologist: physician trained to deliver anesthesia and to monitor the patient’s condition during surgery anesthetic agent: the substance, such as a chemical or gas, used to induce anesthesia anesthetist: health care professional, such as a nurse anesthetist, who is trained to deliver anesthesia and to monitor the patient’s condition during surgery circulating nurse (or registered nurse who coordinates and documents patient care in the operating circulator): room epidural anesthesia: state of narcosis, analgesia, relaxation, and loss of reflexes achieved by injecting an anesthetic agent into the epidural space of the spinal cord general anesthesia: state of narcosis, analgesia, relaxation, and loss of reflexes produced by pharmacologic agents local anesthesia: injection of a solution containing the anesthetic agent into the tissues at the planned incision site Malignant a rare life-threatening condition triggered by exposure to most anesthetic agents Hyperthermia: inducing a drastic and uncontrolled increase in skeletal muscle oxidative metabolism that can overwhelm the body’s capacity to supply oxygen, remove carbon dioxide, and regulate body temperature, eventually leading to circulatory collapse and death if untreated. Malignant hyperthermia is often inherited as an autosomal dominant disorder Moderate sedation: previously referred to as conscious sedation, involves use of sedation to depress the level of consciousness without altering the patient’s ability to maintain a patent airway and to respond to physical stimuli and verbal commands Monitored anesthesia moderate sedation administered by an anesthesiologist or anesthetist care: Regional anesthesia: an anesthetic agent is injected around nerves so that the area supplied by these nerves is anesthetized Restricted zone: area in the operating room where scrub attire and surgical masks are required; includes operating room and sterile core areas Scrub role: registered nurse, licensed practical nurse, or surgical technologist who scrubs and dons sterile surgical attire, prepares instruments and supplies, and hands instruments to the surgeon during the procedure Semi-restricted zone: area in the operating room where scrub attire is required; may include areas where surgical instruments are processed Spinal anesthesia: achieved when a local anesthetic agent is introduced into the subarachnoid space of the spinal cord Surgical asepsis: absence of microorganisms in the surgical environment to reduce the risk for infection Unrestricted zone: area in the operating room that interfaces with other departments; includes patient reception area and holding area Goals Asepsis Homeostasis Safe Administration of Anesthesia Hemostasis BENJIE SILVA RN,MN LSU-Clinical Instructor Member of the Surgical Team The Patient As the patient enters the OR, he or she may feel either relaxed and prepared or fearful and highly stressed. Fears about loss of control, the unknown, pain, death, changes in body structure or function, and disruption of lifestyle all contribute to anxiety. Fears can increase the amount of anesthetic medication needed, the level of postoperative pain, and overall recovery time. Patient is also subject to several risks. Infection, failure of the surgery to relieve symptoms or correct a deformity, temporary or permanent complications related to the procedure or the anesthetic agent, and death are uncommon but potential outcomes of the surgical experience. Fears and risks, the patient undergoing sedation and anesthesia temporarily loses both cognitive function and biologic self- protective mechanisms. Loss of pain or sense, reflexes, and ability to communicate subjects the intraoperative patient to possible injury Potential Adverse Effects of Surgery and Anesthesia Agitation or disorientation, especially in older adult patients Allergic reactions Anesthesia awareness Bleeding Cardiac arrhythmia from electrolyte imbalance or adverse effect of anesthetic agents Central nervous system agitation, seizures, and respiratory arrest Drug toxicity, faulty equipment, and other types of human error Electrical shock or burns Hypotension from blood loss or adverse effect of anesthesia Hypothermia from cool operating room temperatures, exposure of body cavities, and impaired thermoregulation secondary to anesthetic agents Hypoxemia or hypercarbia from hypoventilation and inadequate respiratory support during anesthesia  Infection Laryngeal trauma, oral trauma, and broken teeth from difficult intubation Laser burns Malignant hyperthermia secondary to adverse effect of anesthesia Myocardial depression, bradycardia, and circulatory collapse Nerve damage and skin breakdown from prolonged or inappropriate positioning Oversedation or undersedation Retained foreign body or object Thrombosis from compression of blood vessels or stasis Gerontologic Considerations Other factors that affect the elderly surgical patient in the intraoperative period include the following: Impaired ability to increase metabolic rate and impaired thermoregulatory mechanisms increase susceptibility to hypothermia. Application of intraoperative warming techniques to reduce unintentional hypothermia Bone loss (25% in women, 12% in men) necessitates careful manipulation and positioning during surgery. Reduced ability to adjust rapidly to emotional and physical stress influences surgical outcomes and requires meticulous observation of vital functions Application of intraoperative warming techniques to reduce unintentional hypothermia BENJIE SILVA RN,MN LSU-Clinical Instructor  Careful transfer and positioning on the OR bed. Protect pressure points and bony prominences with extra padding. Support the back and neck to prevent stiffness while maintaining respiratory and circulatory support Use of antiembolic stockings or a sequential compression device to prevent VTE formation, Venous thromboembolism (VTE) includes both deep vein thrombosis (DVT) and pulmonary embolism (PE) Careful fluid and electrolyte monitoring via accurate blood loss measurement, urinary output, and blood gases Nursing Care Throughout surgery, nursing responsibilities include: Providing for the safety and well-being of the patient Coordinating the OR personnel, and performing scrub and circulating activities Patient’s emotional state remains a concern, the care initiated by preoperative nurses is continued by the intraoperative nursing staff that provides the patient with information and reassurance. The nurse supports coping strategies and reinforces the patient’s ability to influence outcomes by encouraging active participation in the plan of care incorporating cultural, ethnic, and religious considerations as appropriate. As patient advocates, intraoperative nurses monitor factors that can cause injury, such as: patient position, equipment malfunction, environmental hazards protect the patient’s dignity and interests while the patient is anesthetized. maintaining surgical standards of care and identifying and minimizing risks and complications. BENJIE SILVA RN,MN LSU-Clinical Instructor Cultural Diversity Cultural, ethnic, and religious diversity are important considerations for all health care professionals. Nurses in the perioperative area should be aware of medications that may be prohibited by certain groups (ie, Muslims and those of the Jewish faith cannot use porcine-based products [heparin (porcine or bovine)], Buddhists may choose not to use bovine products). In certain cultures, the head is a sacred area and staff should allow patients to apply their own surgical cap in this case. When English is the second language of the patient having surgery under local anesthesia, personnel can be provided who speak the patient’s native language BENJIE SILVA RN,MN LSU-Clinical Instructor The Circulating Nurse Circulating nurse, a qualified registered nurse, works in collaboration with surgeons, anesthesia providers, and other health care providers to plan the best course of action for each patient. Protects the patient’s safety and health by monitoring the activities of the surgical team, checking the OR conditions, and continually assessing the patient for signs of injury and implementing appropriate interventions. Main responsibilities include: verifying consent coordinating the team ensuring cleanliness proper temperature humidity lighting safe function of equipment availability of supplies and materials. Monitors aseptic practices to avoid breaks in technique while coordinating the movement of related personnel (medical, x-ray, and laboratory), as well as implementing fire safety precautions. Monitors the patient and documents specific activities throughout the operation to BENJIE SILVA RN,MN ensure the patient’s safety and well-being. LSU-Clinical Instructor The Scrub Role Who can scrub? Registered nurse Licensed practical nurse Surgical technologist (or assistant) performs the activities of the scrub role, including performing a surgical hand scrub Setting up the sterile tables Preparing sutures Ligatures, special equipment (eg, laparoscope) Assisting the surgeon and the surgical assistants during the procedure by anticipating the instruments and supplies that will be required, such as : Sponges, Drains, and other equipment. As the surgical incision is closed, the scrub person and the circulator count all needles, sponges, instruments to be sure they are accounted for and not retained as a foreign body in the patient. Tissue specimens obtained during surgery are labeled by the person in the scrub role and sent to the laboratory by the circulator. The Surgeon The surgeon performs the surgical procedure, heads the surgical team, and is a licensed physician (MD), osteopath (DO), oral surgeon (DDS or DMD), or podiatrist (DPM) who is specially trained and qualified. BENJIE SILVA RN,MN LSU-Clinical Instructor The Registered Nurse First Assistant The registered nurse first assistant (RNFA) is another member of the OR team. Although the scope of practice of the RNFA depends on each state’s nurse practice act, the RNFA practices under the direct supervision of the surgeon. Responsibilities may include: handling tissue, providing exposure at the operative field, Suturing, maintaining hemostasis. The role requires a thorough understanding of anatomy and physiology, tissue handling, and the principles of surgical asepsis. The RNFA must be aware of the objectives of the surgery, must have the knowledge and ability to anticipate needs and to work as a skilled member of a team, and must be able to handle any emergency situation in the OR. BENJIE SILVA RN,MN LSU-Clinical Instructor  The Anesthesiologist and Anesthetist An anesthesiologist is a physician specifically trained in the art and science of anesthesiology. An anesthetist is also a qualified and specifically trained health care professional who administers anesthetic medications. The anesthesiologist or anesthetist assesses the patient before surgery, selects the anesthesia, administers it, intubates the patient if necessary, manages any technical problems related to the administration of the anesthetic agent, supervises the patient’s condition throughout the surgical procedure. Before the patient enters the OR, often at preadmission testing, the anesthesiologist or anesthetist visits the patient to perform an assessment, supply information, and answer questions. The type of anesthetic agent to be administered, previous reactions to anesthetic medications, and known anatomic abnormalities that BENJIE SILVA RN,MN would make airway management difficult are among the topics LSU-Clinical Instructor discussed. The Surgical Environment The surgical environment is known for its stark appearance and cool temperature. The surgical suite is behind double doors, and access is limited to authorized personnel. External precautions include adherence to principles of surgical asepsis; strict control of the OR environment is required, including traffic pattern restrictions. Policies governing this environment address such issues as the health of the staff; the cleanliness of the rooms; the sterility of equipment and surfaces; processes for scrubbing, gowning, and gloving; and OR attire BENJIE SILVA RN,MN LSU-Clinical Instructor Three Zones To help decrease microbes, the surgical area is divided into three zones: the unrestricted zone, where street clothes are allowed; the semi-restricted zone, where attire consists of scrub clothes and caps; and the restricted zone, where scrub clothes, shoe covers, caps, and masks are worn. The surgeons and other surgical team members wear additional sterile clothing and protective devices during surgery.  Health Hazards Associated With the Surgical Environment Faulty equipment, improper use of equipment, exposure to toxic substances, as well as infectious waste, cuts, needlestick injuries, and lasers are some of the associated hazards in the surgical environment. Unintentional retention of an object (eg, sponge, instrument) can occur. A retained object can cause wound infection or disruption, an abscess can form, and fistulas may develop. Laser Risks Exposure to Blood and Body Fluids BENJIE SILVA RN,MN LSU-Clinical Instructor Types of Anesthesia and Sedation General Anesthesia Anesthesia is a state of narcosis (severe central nervous system depression produced by pharmacologic agents), analgesia, relaxation, and reflex loss. General Anesthesia are not arousable, not even to painful stimuli. They lose the ability to maintain ventilatory function and require assistance in maintaining a patent airway. Cardiovascular function may be impaired as well. General anesthesia consists of four stages: Stage I: beginning anesthesia. As the patient breathes in the anesthetic mixture, warmth, dizziness, and a feeling of detachment may be experienced. The patient may have a ringing, roaring, or buzzing in the ears and, although still conscious, may sense an inability to move the extremities easily. During this stage, noises are exaggerated; even low voices or minor sounds seem loud and unreal. For this reason, unnecessary noises and motions are avoided when anesthesia begins. BENJIE SILVA RN,MN LSU-Clinical Instructor  Stage II: Excitement. The excitement stage, characterized variously by struggling, shouting, talking, singing, laughing, or crying, is often avoided if the anesthetic agent is administered smoothly and quickly. The pupils dilate, but they contract if exposed to light; the pulse rate is rapid, and respirations may be irregular. Because of the possibility of uncontrolled movements of the patient during this stage, the anesthesiologist or anesthetist must always be assisted by someone ready to help restrain the patient. Manipulation increases circulation to the operative site and thereby increases the potential for bleeding. Stage III: surgical anesthesia. Surgical anesthesia is reached by continued administration of the anesthetic vapor or gas. The patient is unconscious and lies quietly on the table. The pupils are small but contract when exposed to light. Respirations are regular, the pulse rate and volume are normal, and the skin is pink or slightly flushed. Stage IV: medullary depression. This stage is reached if too much anesthesia has been administered. Respirations become shallow, the pulse is weak and thready, and the pupils become widely dilated and no longer contract when exposed to light. Cyanosis develops and, without prompt intervention, death rapidly follows. I BENJIE SILVA RN,MN LSU-Clinical Instructor Inhalation Inhaled anesthetic agents include volatile liquid agents and gases. Volatile liquid anesthetic agents produce anesthesia when their vapors are inhaled. BENJIE SILVA RN,MN LSU-Clinical Instructor Anesthetic Delivery System BENJIE SILVA RN,MN LSU-Clinical Instructor Regional Anesthesia, an anesthetic agent is injected around nerves so that the region supplied by these nerves is anesthetized. Epidural anesthesia is achieved by injecting a local anesthetic agent into the epidural space that surrounds the dura mater of the spinal cord. Intravenous Administration, General anesthesia can also be produced by the IV administration of various substances, such as barbiturates, benzodiazepines, nonbarbiturate hypnotics, dissociative agents, and opioid agents. Local Conduction Blocks Examples of common local conduction blocks are: Brachial plexus block, which produces anesthesia of the arm BENJIE SILVA RN,MN LSU-Clinical Instructor  Paravertebral anesthesia, which produces anesthesia of the nerves supplying the chest, abdominal wall, and extremities Cervical Paravertebral Block Thoracic Paravertebral Block BENJIE SILVA RN,MN LSU-Clinical Instructor  Transsacral (caudal) block, which produces anesthesia of the perineum and, occasionally, the lower abdomen Moderate sedation, previously referred to as conscious sedation, is a form of anesthesia that involves the IV administration of sedatives or analgesic medications to reduce patient anxiety and control pain during diagnostic or therapeutic procedures. It is being used increasingly for specific short-term surgical procedures in hospitals and ambulatory care centers BENJIE SILVA RN,MN LSU-Clinical Instructor  Monitored anesthesia care (MAC), also referred to as monitored sedation, is moderate sedation administered by an anesthesiologist or anesthetist who must be prepared and qualified to convert to general anesthesia if necessary. Local anesthesia is the injection of a solution containing the anesthetic agent into the tissues at the planned incision site. Often it is combined with a local regional block by injecting around the nerves immediately supplying the area. Advantages of local anesthesia are as follows: It is simple, economical, and nonexplosive. Equipment needed is minimal. Postoperative recovery is brief. Undesirable effects of general anesthesia are avoided. It is ideal for short and minor surgical procedures. Local anesthesia is often administered in combination with epinephrine. Epinephrine constricts blood vessels, which prevents rapid absorption of the anesthetic agent and thus prolongs its local action. BENJIE SILVA RN,MN LSU-Clinical Instructor Local Anesthetic Systemic Toxicity Metallic taste Oral numbness Auditory changes Slurred speech Arrhythmias Seizure Respiratory arrest LAST is a rare event that occurs in approximately 1 of every 1000 patients (Wadlund, 2017). Early detection and treatment may prevent symptom progression and can lead to a better outcome for the patient. Initial treatment of LAST should focus on airway management. Hypoxemia and acidosis intensify the effects of LAST. The nurse calls for help and maintains the patient’s airway while administering 100% oxygen and confirming IV access.  Potential Intraoperative Complications Nausea and vomiting, or regurgitation, may affect patients during the intraoperative period If gagging occurs, the patient is turned to the side, the head of the table is lowered, and a basin is provided to collect the vomitus Suction is used to remove saliva and vomited gastric contents Anaphylaxis medications are the most common cause of anaphylaxis, intraoperative nurses must be aware of the type and method of anesthesia used as well as the specific agents. anaphylactic reaction can occur in response to many medications, latex, or other substances. The reaction may be immediate or delayed. Anaphylaxis is a life-threatening acute allergic reaction Hypoxia and other Respiratory Complications Inadequate ventilation, occlusion of the airway, inadvertent intubation of the esophagus, and hypoxia are significant potential complications associated with general anesthesia Respiratory depression caused by anesthetic agents, aspiration of respiratory tract secretions or vomitus, and the patient’s position on the operating table can compromise the exchange of gases. Anatomic variation can make the trachea difficult to visualize and result in insertion of the artificial airway into the esophagus rather than into the trachea. Peripheral perfusion is checked frequently, and pulse oximetry values are monitored continuously. BENJIE SILVA RN,MN LSU-Clinical Instructor  Hypothermia ▪ During anesthesia, the patient’s temperature may fall. Glucose metabolism is reduced, and, as a result, metabolic acidosis may develop. This condition is called hypothermia and is indicated by a core body temperature that is lower than normal (36.6C [98.0F] or less). ▪ Inadvertent hypothermia may occur as a result of a low temperature in the OR, infusion of cold fluids, inhalation of cold gases, open body wounds or cavities, decreased muscle activity, advanced age, or the pharmaceutical agents used (eg, vasodilators, phenothiazines, general anesthetic medications) Malignant hyperthermia (MH) is a rare inherited muscle disorder that is chemically induced by anesthetic agents. MH can be triggered by myopathies, emotional stress, heatstroke, neuroleptic malignant syndrome, strenuous exercise exertion, and trauma. BENJIE SILVA RN,MN LSU-Clinical Instructor Pathophysiology of Hyperthermia Exposure to ↑Lactate ↑O2 use Acidosis Triggering Agent Production ↑Sympathetic ↑Calcium Release ↑CO2 Activity Tachycardia / Arrythmias ↑K+ Sustained Muscle Cell Damage and Rigidity Destruction Myoglubinuria ↑Myoglobin Increase Heat Hypermetabolic MH Response ↑PO4 Renal Failure ↑Magnesium Clinical Manifestations (MH) Initial Symptom: Cardiovascular, respiratory, and abnormal musculoskeletal activity Tachycardia (heart rate greater than 150 bpm) an early sign Sympathetic nervous stimulation also leads to ventricular arrhythmia, hypotension, decreased cardiac output, oliguria, and, later, cardiac arrest Hypercapnia, an increase in carbon dioxide (CO2), an early respiratory sign Abnormal transport of calcium, rigidity or tetanus like movements occur, often in the jaw Generalized muscle rigidity is one of the earliest signs. Rise in temperature is actually a late sign that develops rapidly; body temperature can increase 1° to 2°C (2° to 4°F) every 5 minutes, and core body temperature can exceed 42°C (107°F) (Rothrock, 2019) Medical Management Goals of treatment are: Decrease metabolism, reverse metabolic and respiratory acidosis, correct arrhythmias, decrease body temperature, provide oxygen and nutrition to tissues, and correct electrolyte imbalance. The treatment for MH is well known. Dantrolene has lowered mortality rates to 10% in current practice (Ho et al., 2018). Anesthesia and surgery should be postponed. However, if end-tidal CO2 monitoring and dantrolene sodium are available and the anesthesiologist is experienced in managing MH, the surgery may continue using a different anesthetic agent (Barash et al., 2017). MH usually manifests about 10 to 20 minutes after induction of anesthesia, it can also occur during the first 24 hours after surgery. The effects of anesthesia are monitored by considering the following parameters: Respiration O2 saturation CO2 levels HR and BP Urine output Nursing Management Assessment Diagnosis Planning Intervention Evaluation Complications and Discomforts of Anesthesia Hypoventilation - inadequate ventilatory support after paralysis of respiratory muscles. Oral Trauma Malignant Hyperthermia - uncontrolled skeletal muscle contraction Hypotension - due to preoperative hypovolemia or untoward reactions to anesthetic agents. Cardiac Dysrhythmia - due to preexisting cardiovascular compromise, electrolyte imbalance or untoward reaction to anesthesia. Hypothermia - due to exposure to a cool ambient OR environment and loss of thermoregulation capacity from anesthesia. Peripheral Nerve Damage - due to improper positioning of patient or use of restraints. Nausea and Vomiting BENJIE SILVA RN,MN Headache LSU-Clinical Instructor NURSING DIAGNOSES Anxiety associated with surgical or environmental concerns Risk for latex allergy Risk for perioperative positioning injury associated with positioning in the OR Risk for injury associated with anesthesia and surgical procedure Risk for compromised dignity associated with general anesthesia or sedation COLLABORATIVE PROBLEMS/POTENTIAL COMPLICATIONS Based on the assessment data, potential complications may include the following: Anesthesia awareness Nausea and vomiting Anaphylaxis Hypoxia Unintentional hypothermia Malignant hyperthermia Infection Preventing Intraoperative Positioning Injury Patient should be in as comfortable a position as possible, whether conscious or unconscious. Operative field must be adequately exposed. An awkward position, undue pressure on a body part, or use of stirrups or traction should not obstruct the vascular supply. Respiration should not be impeded by pressure of arms on the chest or by a gown that constricts the neck or chest. Nerves must be protected from undue pressure. Improper positioning of the arms, hands, legs, or feet can cause serious injury or paralysis. Shoulder braces must be well padded to prevent irreparable nerve injury, especially when the Trendelenburg position is necessary. Precautions for patient safety must be observed, particularly with thin, elderly, or obese patients and those with a physical deformity. Patient may need light restraint before induction in case of excitement. BENJIE SILVA RN,MN LSU-Clinical Instructor  Common OR Patients Position C. Patient in lithotomy position. Note that the hips extend over the edge of the table. A. Patient in position on the operating table for a laparotomy. Note the strap above the knees. D. Patient lies on unaffected side for kidney surgery. B. Patient in Trendelenburg position on operating table. Table is spread apart to provide space between Note padded shoulder braces in place. Be sure that the lower ribs and the pelvis. The upper leg is brace does not press on brachial plexus. extended; the lower leg is flexed at the knee and hip joints; a pillow is placed between the legs. Position During Surgery Supine ( Dorsal Recumbent ) Abdominal, extremity, vascular, chest, neck, facial, ear breast surgery Positioning Techniques Patient lies flat on back with arms either extended on arm boards or placed along side of body. Small padding placed under patient’s head, neck and under knees Vulnerable pressure points should be padded. Safety strap applied 2 in. above knees. Eyes should be protected by using eye patch and ointment. BENJIE SILVA RN,MN LSU-Clinical Instructor Prone Position Surgeries involving posterior surface of the body ( spine, neck, buttocks and lower extremities ) Positioning Techniques Chest rolls or bolster are placed on operating table prior to positioning Foam head rest, head turned to side or facing downward Patient’s arms are rotated to the padded arm boards that face head, bringing them through their normal range of motion. Padding for knees and pillow for lower extremities to prevent toes from touching mattress. Safety strap applied 2 in. above the knees BENJIE SILVA RN,MN LSU-Clinical Instructor  Trendelenburg Position Surgeries involving lower abdomen, pelvic organ when there is a need to tilt abdominal viscera away from the pelvic area. Positioning Techniques Patient is supine with head lower than feet. Shoulder braces should not be used as they may cause damage brachial plexus. When patient is returned to supine position, care must be taken move leg section slowly, then the entire table to level position. Modification of this position can be used for hypovolemic shock. Extremity position and safety strap are the same as for supine. BENJIE SILVA RN,MN LSU-Clinical Instructor  Reverse Trendelenberg Position Upper abdominal, head, neck and facial surgery Positioning Technique Patient is supine with head higher than feet. Small pillow under neck and knees. Well - padded footboard should be used to prevent slippage to foot of the table. Anti embolic hose should be used if position is to be maintained for an extended period of time. Patient should be returned slowly to supine position. BENJIE SILVA RN,MN LSU-Clinical Instructor Lithotomy Perineal, vaginal, rectal surgeries; combined abdominal vaginal procedure Positioning Techniques Patient is placed in supine position with buttocks near lower break in the table ( sacrum are should be well padded ) Feet are placed in stirrups, stirrups height should not be excessively high or low, but even on both sides. Knee brace must not compress vascular structures or nerves in the popliteal space. Pressure from metal stirrups against upper inner aspect of thigh and calf should be avoided. Legs should be raised and lowered slowly and simultaneously ( may require two people ) Modified Fowler ( Sitting Position ) Otorhinology (ear and nose ), neurosurgery Positioning Techniques Patient is supine, positioned over the upper break in the table Backrest is elevated, knees flexed Arms rest on pillow, placed in lap; safety strap 2 in. above the knees. Slow movement in and out of position must be used to prevent drastic changes in blood volume movement. Anti embolic hose should be used to assist venous return. When using special neurologic headrest, eyes must be protected.  Jack Knife Position Rectal procedures, sigmoidoscopy and colonoscopy Positioning Techniques Table is flexed at center break All precautions taken with prone position are taken with Jack knife position. Table strap applied over thighs BENJIE SILVA RN,MN LSU-Clinical Instructor BENJIE SILVA RN,MN LSU-Clinical Instructor Thank You 10 Minutes Break Next Topic Postoperative Phase