MODULE 9 Positioning RPN20231 PDF

MODULE 9: Positioning Suggested Readings Alexander’s Care of the Patient in Surgery (2022) Chapter 6 ORNAC Standards 2023 p. 3-26 – 3-54 Learning Outcomes Compare surgical positions us...

MODULE 9: Positioning Suggested Readings Alexander’s Care of the Patient in Surgery (2022) Chapter 6 ORNAC Standards 2023 p. 3-26 – 3-54 Learning Outcomes Compare surgical positions used in the operating room. Understand the impact on circulatory, respiratory, integumentary systems. Positioning the patient is an essential part in caring for the perioperative patient and is a team approach. The purpose is to maintain physiological and anatomical safety, maintain the airway, allow for access to monitoring devices and intravenous lines and achieve optimal exposure of the surgical area. Incorrect positioning for the surgical patient can result in patient injury from pressure or movement. Prevention is the ultimate goal! The RN will complete a preoperative and postoperative skin assessment. The RPN may be required to assist in positioning the patient in the desired surgical position for the case. Responsibilities of the Healthcare Team All health care members need to preserve the patient's privacy and be aware of the effects of positioning on the neuromuscular, skeletal, circulatory and respiratory. The surgeon determines the optimal position for exposure and patient tolerance. The anesthesiologist indicates when it is safe to move the patient. They monitor and maintain the physiological functions of the patient under anesthesia. The circulating nurse uses the principles of body mechanics, physics, and knowledge of anatomy and physiology to help position the patient and ensures that provides proper equipment, padding. This will ensure protection of vital structures. An ongoing assessment of the patient's position throughout the intraoperative phase is monitored. Preoperative Risk Factors: Patient’s age, height and weight, skin condition, nutritional status, preexisting health conditions, and physical mobility limits (implants, prothesis). Intraoperative Risk Factors: Time and length of surgery, positioning devices, type of anesthetic, blood loss, and hypothermia. Postoperative Risk Factors: Mobility, pain management, respiratory status. Module 9: Positioning  Physiological Effects of Positioning Circulatory System Hypotension from position changes and anesthetic medications Venous pooling in extremities and decreased circulating blood volume Compression of the Vena Cava (mass or pregnancy) causing a decreased cardiac output. In which case, the patient could be positioned with a “bump” or a pillow under the right hip to alleviate compression. Prevention – apply anti-embolic stockings (compression stockings) Arms on armboards should be checked for adequate circulation Lithotomy position – legs should be raised together slowly into the stirrups and same process when they are lowered. This reduces the rush of blood that can cause a sudden drop in blood pressure. Respiratory System Patients with preexisting diseases of the respiratory system are at greater risk of developing pulmonary complications. Some surgical positions and anesthetics may compromise the respiration of the patient i.e. – Prone and Lateral Position Vital lung capacity will be decreased with limited chest movements and lung expansions as a result of the pressure on the chest wall Integumentary System The integumentary system can be injured by physical forces. Skin overlying body prominences is thin with little subcutaneous tissue. When it is compressed, the blood flow is reduced to the surrounding tissue, which can cause pressure sole, ischemia, or necrosis. 1. Pressure- is the force placed on the tissue by the weight of the body as gravity presses downward. The source of pressure can also come from the weight of equipment such as Mayo stands, surgical instruments, or placing weight on the patient. 2. Shearing- caused by blood vessels and tissues that are stretched. This often occurs when patients are “sliding” down the table by the team to the desired position. 3. Friction – caused when the patient is dragged across the linen instead of being lifted. 4. Maceration – occurs when moisture on the skin saturates and weakens the epidermis. For example, lying in a pool of prep, blood, or irrigation fluid. Module 9: Positioning  Nervous System Module 9: Positioning  Position Arms/Legs Comments Supine Arms: *Most common position. - Adducted 90 degrees or - Safety strap secured 2 inches less to prevent above knee hyperextension and compression of brachial plexus. -Improper positioning of the arms - Tucked at sides in a neutral can cause damage to the radial, position, palms facing legs. medial and ulnar nerves. Legs: - Not crossed. - Low back pain = support knees with a pillow - Heels – pad to prevent pressure sore Nerves Pad the patient appropriately to protect the following nerves: Radial Nerve – use elbow pads Common Peroneal Nerve - less pressure in popliteal space will increase blood flow to the legs and reduce injury. Trendelenburg *Head down supine position Follow supine positioning considerations. Reverse *Head up supine position Trendelenburg Lithotomy Arms: 4 Types: Low, Standard, High, - Tucked at sides or Exagerated extended on arm boards. - If tucked, be aware of Risk for venous thrombosis fingers when lowering the because of leg elevation. foot of the bed – risk for Compression stockings may be crush injury! applied. Legs: Lowering the legs slowly will - Must be raised and lowered reduce sudden blood volume with 2 team members changes from the torso to the legs. simultaneously. It will also prevent torsion of the - Legs should be externally ligaments. rotated from the hips - Lowering the legs over 2 Module 9: Positioning  minutes! Nerves Pad the patient appropriately to protect the following nerves: Obturator Nerve: compressed from hip flexion Saphenous Nerve: compressed from medial side of knee brace Femoral Nerve: excessive angulation of the thigh Common Peroneal Nerve: compression on the lateral aspect of the knee Fowler Head of bed is raised 90 Known as the “Sitting Position” degrees and footrest is used. Follow supine positioning Semi-Fowler Head of bed is raised 45 considerations. degrees and legs are slightly lowered Lateral Arms: Side lying right or left. Similar - Should be supported on to the recovery position. arm boards and pillows. Secure patient with safety straps Legs: across legs. - Pillow or padding between knees. - Lower leg will be straight and upper leg will be bent Nerves Pad the patient appropriately to protect the following nerves: Common Peroneal Nerve: Bottom leg compression on OR table Brachial Plexus: Upper arm compression on over-bed arm board Prone Similar positioning *Patient is induced in supine considerations as supine re position and then is turned to the arms. prone position from the stretcher to the OR table. Face: - Ensure eyes are covered, face is padded. Knees and Hips (Iliac Crests) should be padded accordingly. Module 9: Positioning