Midterm Week 5 (Positioning)

Question 1

The overall goals of surgical positioning are to

• Maintain a physiologically and anatomically ____ _____
• Provide optimum _____ during the operative procedure
• Maintain the patient’s _____
• Allow access to (2)

Answer 1

• safe environment
• exposure
• airway
• monitoring devices, intravenous lines

Question 2

Why is positioning important?

• Patient cannot do what?
• Enables IV lines and catheters to ->
• Enables monitors ->
• Facilitates the surgeon’s ->
• Patient safety (1)

Answer 2

• make clinician aware of compromising positions
• remain patent
• to function properly
• technical approach
• Don’t let them fall off table

Question 3

Preop Assessment =

Risk Factors (5)

Answer 3

= Info about patient’s medical history and condition, and possible risk factors, needed to plan the necessary precautions and prevent positioning-related injuries

• Pre-existing DM
• PVD
• Renal Failure
• Neuropathy
• Obesity

Question 4

Implementation

• Assessing the patient’s _____
• Developing a ___ _ ____
• ______ the necessary positioning devices
• The actual ->
• Reevaluating (2) intraoperatively
• Evaluating _____ _____ with respect to _____ related complications

Answer 4

• needs
• plan of care
• assembling
• positioning of patient
• body alignment and tissue integrity
• patient outcomes, position

Question 5

Developing a plan of care

• After the preoperative assessment, next step is to develop a plan of care. Review the type of ______ to be administered, the planned surgical _____ the surgical _____ required, the _____ _____, the estimated ____ of the procedure and the patient’s ____ and ____ status
• Ensure that (2) are available to position the patient on the table

Answer 5

• anesthesia, procedure, position, surgeon’s preferences, length, physical/mental status
• appropriate positioning devices, adequate # of personnel

Question 6

Positioning Devices

1) Procedure Tables (3)
2) Attachable equipment (6)
3) Pads to ->
4) Support devices for head, arms, chest

Answer 6

1) Urology, Orthopedic, Spinal Surgery tables
2) headrests/holders, overhead arm supports, stirrups, footboards, leg holders, shoulder supports, skull clamps, armboards, additional UE support, lateral positioning bars
3) to protect pressure points
4) Securing devices (e.g., safety belts, tapes, vacuum beanbags)

Question 7

Urology Tables =

Answer 7

= are shorter than general surgery tables, with emphasis on leg elevation, perineal fluid drainage and compatibility with radiography

Question 8

Orthopedic tables

Answer 8

= come with a wide variety of standard orthopedic accessories, such as removable leg supports, collapsible arm extension devices, foot traction units, a transfer board for moving the patient, a nailing support or hip rest and traction extensions.

Question 9

Spinal Surgery Tables

Answer 9

= designed to facilitate imaging and placement of the patient in the kneeling position.

Question 10

Table Attachments

1) Leg Attachments =
2) Shoulder Supports =
3) Skull Clamps =
4) Armboards =
5) Additional UE support =
6) Lateral positioning bars

Answer 10

1) which include hanging straps that suspend the ankles and padded foot and calf supports
2) may be necessary to secure patients in a steep head-down tilt position (trendelenburg)
3) provide maximum stability of the positioned head
4) which may be contoured to cradle the patient’s arm and protect the biceps, elbows and forearms
5) designed to support the upper arm, forearm, wrist and/or hand

Question 11

Pads and Positioning Devices

• Any direct contact between pt and surface of table/positioning device has potential to?
• These devices help distribute pressure ->

Answer 11

• cause injury

- wider area

Question 12

Pads and Positioning Devices (5)

Answer 12

1) Arm pads
2) Donuts
3) Rolls,
4) Heel cups
5) Egg-crate foam
6) Vacuum beanbags
7) Pillows and blankets
8) Table pads

Question 13

1) Arm Pads =
2) Donuts =
3) Rolls =

Answer 13

1) Arm pads redistribute pressure from pressure points to a larger surface area. They include ulnar nerve protectors and a variety of larger pads that cushion the whole arm.
2) Donut-shaped head pads are designed to protect and cradle the patient’s head. Smaller donuts may be used to cradle other parts of the anatomy.
3) Full and half-round positioning devices are used to lift certain areas of the body off the mattress, restoring more physiological alignment and relieving down-side pressure points.

Question 14

4) Heel Cups
5) Egg-crate foam
6) Vacuum beanbags

Answer 14

4) appropriate for any procedure that is lengthy and involves pressure at the patient’s heel area. Slit in back of the cup secures the patient’s Achilles tendon. Heel cups can be used in multiples to provide quick, easy protection of any bony prominence or potential high-pressure area
5) convoluted foam mattress overlay (egg-crate foam) is effective in reducing pressure only if it is made of thick, dense foam that resists compression.
6) contain tiny plastic pellets. They are molded to the shape of the positioned patient and then the contained air is evacuated, stiffening the bag to help hold the patient in place. A cloth covering placed over the bag prevents direct contact between the plastic surface of the bag and the skin.

Question 15

7) Pillows and Blankets

8) Table Pads

Answer 15

7) produce only a minimum of pressure reduction. Towels and sheet rolls do not reduce pressure and may contribute to friction injuries.
8) Soft, segmented table pads that adhere to metal surfaces are standard parts of all procedure tables. A full-length table pad offers maximum protection and comfort for the patient.

Question 16

Shearing =

Answer 16

= patient’s skin remaining stationary while underlying tissues shift or move, when pulled or dragged without support to the skeletal system or when a draw sheet is used

Question 17

Friction =

Answer 17

= when skin rubs over a rough stationary surface. Maintaining the patient’s correct body alignment and supporting extremities and joints decreases the potential for injury during transfer and positioning

Question 18

Physiological Compromises (4)

Answer 18

• Respiratory compromise
• Circulatory compromise
• Nerve and muscle trauma
• Intraoperative skin injury

Question 19

Respiratory Compromise =

Often in what positions (3)

Answer 19

= decreased respiratory function by mechanical restriction of rib cage

• Prone, Lateral, Lithotomy

Question 20

Circulatory Compromise =

Answer 20

= increased in positions such as lithotomy or head down that cause redistribution and congestion of blood supply

Question 21

Nerve and Muscle Trauma, when are pts at greatest risk? (3)

Answer 21

• UPPER EXTREMITIES ARE ABDUCTED AT > 90 degrees to the body
• Hips placed in excessive rotation
• Head and Neck is hyperflexed or extended

Question 22

Intraoperative Skin Injury =

Answer 22

= function of the intensity of pressure and the duration of that pressure. High pressure for short durations and low pressure for longer durations may be equally damaging to tissue

Question 23

Intensity of Pressure ->

Duration of Pressure ->

Answer 23

• can lead to tissue ischemia and breakdown

- risk increases as length of procedure increases

Question 24

Responsibilities of the Periop Nurse

• Safe ____ using adequate ____
• Use of adequate _____ and _____ aids
• Provide an ongoing _____

Answer 24

• transfer, personnel
• padding/positioning
• assessment

Question 25

Responsibilities of Periop Nurse (Implementation) - Use safe ____ _____ during transfers and positioning ensure adequate____ is used - Maintain stretcher/bed in a ____ position prior to patient transfers and positioning - Verify ____ ____ on OR table to be used - Ensure that the patient is adequately ____ to the OR table - One strap placed across the patient’s ____ and the second across the ____ ____ - Extra care must be taken to ensure that ____ skin is _____ (ie lithotomy position)

Answer 25

- body mechanics, assistance - locked - weight limit - secured - thighs, lower legs - loose, protected

Question 26

Basic Surgical Positions (8)

Answer 26

- Supine - Prone - Lateral - Lithotomy - Sitting/Lawnchair/Semi-Fowlers - Jackknife - Trendelenburg - Reverse Trendelenburg

Question 27

Supine = - Most ____ used position - _____ in alignment with ____ - Arms (2) - Check orientation of arm -> - Make sure arm is _____ (palms up) - Most common nerve damage = *

Answer 27

= on back - common - Spinal column, legs, hips, head - alongside trunk or abducted on arm boards - ARM < 90 NOT TOUCHING METAL OR CONSTRICTED - SUPINATED - BRACHIAL PLEXUS* dt positioning arm > 90

Question 28

Supine Pressure Points (8)

Answer 28

- Occiput - Scapulae - Spinous processes of thoracic vertebrae - Elbows - Sacrum - Coccyx - Calves - Heels

Question 29

Prone = - Pt is anesthetized ___ then repositioned - Arm placement (2) - Check NECK _____* and ARM _____* to avoid what injury? - Pad ____, ___ roll support, ____ support

Answer 29

= Face down, on stomach - supine - tucked or abducted - ROTATION, EXTENSION* , brachial plexus - elbows, chest, iliac

Question 30

Prone position is used for what type of surgeries? (2)

Answer 30

Posterior craniotomies and for spine-related procedures - such as spinal fusions, resections of masses (e.g., lipomas) and repair of dermal defects

Question 31

Prone Pressure Points (8)

Answer 31

- eyes - ears - cheeks - shoulder - breasts - iliac crests - male genitalia - patellae and toes

Question 32

Prone Concerns - Most common nerve damage = (4) - Vulnerable vessels = (4) - Susceptible to =

Answer 32

- Brachial, radial, median, ulnar - Carotid, Aorta, Vena Cava, Saphenous - hyperextension of joints

Question 33

Lateral Position = - Most important consideration* = - Always place on ____ roll - Place padding between -> (2) - Position arms -> - Check _____!

Answer 33

= on the side (left lateral position with right side up) - Maintain BODY ALIGNMENT, NECK IN NEUTRAL POSITION - axilla - knees, below lateral dependent leg (prevent nerve damage) - parallel to one another - Pulses

Question 34

Lateral Position Pressure Points (7)

Answer 34

- downside of the ear - Shoulder - elbows - ribs - iliac crest - Hip - medial and lateral ankles.

Question 35

Lateral Concerns = - Most common nerve damage (4) - Vulnerable Vessels (6)

Answer 35

= Respiratory, Circulatory, and Pressure points - Brachial, radial, median, ulnar - Carotid, axillary, brachial, aorta, vena cava, saphenous

Question 36

Lithotomy =

Answer 36

= the patient lies on the back, with the legs separated from the midline into 30° to 45° or unforced abduction and elevated in leg holders

Question 37

Lithotomy Position Types of Stirrups (3) Degrees of Lithotomy (2) How should you move the legs when positioning patient in and out of lithotomy?

Answer 37

- Candy Cane, Allen stirrups, Knee cradles - Low, High - Move both legs at same time

Question 38

Lithotomy Position Pressure Points* (7)

Answer 38

- occiput (back of head) - scapulae - spinous processes of the thoracic vertebrae - elbows - sacrum - knee - medial and lateral ankle and heel

Question 39

Candy Cane =

Answer 39

= “candy cane” shaped pole either suspends the ankle and instep by a strap or suspends the foot in a cloth boot.

Question 40

Knee crutch =

Answer 40

= supports the popliteal space, but permits the foot and much of the lower leg to hang unsupported.

Question 41

Allen stirrups =

Answer 41

= A “calf rest” supports only the dorsal lower leg.

Question 42

Lithotomy Concerns - Particular attention needs to be given to the _____ space behind the knee where the legs rest in the stirrups - Elevate lower legs slowly and ____ from stirrups Keep arms _____ from chest facilitate respiration - Place stirrups at _____ height

Answer 42

- Popliteal - simultaneously - away - even

Question 43

Trendelenburg = - Arms in a ____ position either at ___ or bilateral arm ____ - What is used to assure table padding is fixed to the table to prevent pad slippage?

Answer 43

= head down, feet up (head-down tilt of 35 to 45 degrees ) - comfortable, side, boards - Surgical tape

Question 44

What type of surgeries might the Trendelenburg position be used?

Answer 44

Procedures for lower abdomen/pelvis -> to move viscera away from pelvic area for better exposure

Question 45

Trendelenburg Concerns - _____ ____ is decreased - Pressure of organs ->

Answer 45

- Lung volume | - pressure against diaphragm mechanically compresses the heart

Question 46

Reverse Trendelenburg = - used for ___ and ___ procedures - facilitates ____, aids in ____ and decreases ____ supply to the area - What is used to prevent patient from sliding down

Answer 46

= feet down, head up - head, neck - exposure, breathing, blood - footboards

Question 47

What position is safest for the obese patient?

Answer 47

Reverse Trendelenburg

Question 48

Semi Fowler's Position/Sitting/Lawnchair/Becahchair - most frequently used ____-___ position - almost exclusively for what types of surgeries (2) - _____ padding, ___ holder, feet rest up against ____ ___ - Arms _____ loosely over ____ and ___ or placed on ___ - Pillow under _____

Answer 48

- head elevated - posterior craniotomies, upper cervical spine /also used for shoulder/breast reconstruction - subgluteal, head, padded boards - crossed, abdomen, taped, lap - knees

Question 49

Jack Knife = - ____ are over center break of OR bed - Chest -> - Arms -> - Pillow placed under ____ - Used in what types of surgeries? (2)

Answer 49

= modification of prone - prone + V position - Hips - chest rolls to raise the chest - extended on angled arm boards with elbows flexed and palms down - ankles to free feet and toes from pressure - ass and asshole surgeries

Question 50

Positioning the Morbidly Obese Pt - OR must be capable of? - ___ devices to transfer - 1-2 ____ ___ must be long enough to secure patient

Answer 50

- supporting weight and wide enough - lifting - safety straps

Question 51

Arm Boards should be at level of?

Answer 51

Table pads