Principles 2 Fall 2025 > Positioning > Flashcards

Positioning Flashcards

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1
Q

There are _____ AANA standards that CRNAs need to abide by. Standard number ___ deals w/ pt positioning. What does it state? (2)

A

14

8

  1. Collaborate with/ surgical or procedure team to position, assist, monitor proper body alignment
  2. Use protective measures to maintain perfusion & protect pressure points & nerve plexuses
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2
Q

The positioning of the pt should be as ______ as possible. Joints should always be _______ & the pressure points should be ______. What is the exception to this?

A

natural

aligned

padded

The exception to this is if the joints/pressure points are part of the surgical field

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3
Q

T/F: IV ports dont need to be padded as this is an infection risk

A

F

They need to be padded

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4
Q

What is a great way to ensure the pt is comfortable when positioning them?

A

Have them move themselves if they are conscience & able to, this helps to ensure that nothing is stretched or in the wrong position.

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5
Q

How much help do you usually need when positioning a patient? Why?

A

The entire OR team

You never want to move the pt w/o proper help

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6
Q

With positioning, safety belts/straps are used for what areas of the body? (3)

A
  1. Abd
  2. Pelvic
  3. Extremities
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7
Q

________ positioning assessment is imperative. Why?

A

interval

Need to frequently check pt positioning routinely bc nerve damage & other injuries can develop quickly even w/i a few minutes – these injuries may or may not be reversible

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8
Q

The most common surgical position is ______. What are the cardiac affects of this position? (6) Pulmonary? (2)

A

Supine

Cardiac:
1. Transient increase in venous return
2. Transient increase in preload
3. –> increased stroke volume
4. increased cardiac output
5. –> increased BP
6. –> ultimately HR & CO returns to baseline after approximately 10 mins

Pulmonary:
1. Decreased Vt
2. Decreased FRC

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9
Q

The pulmonary changes of _________ (2) with the supine positioning is dt what? What consideration should we have with this?

A
  1. Decreased Vt
  2. Decreased FRC

This is dt the cephalad (upward) displacement of the diaphragm

Once we put them on the ventilator we will have control of Vt

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10
Q

In the supine position, the increase in BP activates the __________ from the aorta via the ________ nerve & the _______ from the _______ nerve. What else does this activate? What does this do?

A

afferent baroreceptors

vagus

carotid sinus

glossopharyngeal

Mechanoreceptors from the atria & ventricles

This decreases SNS outflow to muscle & splanchnis vascular beds –> atrial reflexes regulate renal sympathetic activity, renin, ANP, vasopressin levels –> HR & CO return to baseline w/i 10 mins.

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11
Q

Define abduction

A

Arms away from the body

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12
Q

Define adduction

A

Arms are close to the body

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13
Q

When your arms are ABDUCTED they are ________. They should be ______ degrees to prevent _____ injuries. The arms should be _____, which means that the palms are ____, to prevent ________ compression.

A

Out to the sides (away from body)

<90 degrees

Brachial plexuses

Supine

Up

Ulnar nerve

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14
Q

How should we secure the arms when they are ABDUCTED? (2)

A
  1. Elbows padded
  2. Arms secured w/ velcro strap
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15
Q

When your arms are ADDUCTED they are ________. The hands & forearms should be _____ (2), which means that the palms are ____ (2), to prevent ________ compression.

A

Tucked close to the body

  1. Supine
  2. Neutral

-1. Up (Supine)
2. Towards body (Neutral)

Ulnar nerve

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16
Q

How should we secure the arms when they are ADDUCTED? (2) What is the exception to this?

A
  1. A draw sheet goes under the body and over the arm
  2. Elbow padded

Exception:
May tuck 1 arm & have 1 arm out if surgeon must stand on side of pt so arm board wont be in the way of the surgeon

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17
Q

What will happen if you put the palms/arm of the pt down while the pt is in the supine position?

A

It will put pressure on the ulnar nerve

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18
Q

What are complications of the supine position? (6) What causes some of these complications?

A
  1. Backache
  2. Pressure alopecia
  3. Brachial plexus injury (arms abducted >90 degrees)
  4. Axillary nerve injury (arms abducted >90 degrees)
  5. Ulnar nerve injury (arms pronated = palms down)
  6. Stretch injury of the neck (neck extended & head turned away - brachial plexus)
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19
Q

In the supine position, normal lumbar lordotic curvative is often lost dt ______ in the _________ muscles, which is seen in older pts.

A

laxity

paraspinous

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20
Q

What considerations should we have w/ pts in the supine position w/ kyphosis, scoliosis, or back pain hx? (2) Why?

A
  1. Requires extra padding of the spine
  2. Slight flexion at hip & knee

This is to help keep tension off the back (lower back)

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21
Q

What are the top 2 leading injuries in the supine position in order?

A
  1. Brachial plexus
  2. Ulnar nerve
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22
Q

Trendelenburg is when the head is ______. What is the biggest concern w/ this position? How do we try to prevent this? What considerations should we have regarding this? (2)

A

Head/HOB is DOWN

Biggest concern:
-Sliding downward OR “shifting cephalad” (the head is down so this means shifting downward towards the head)

To prevent this we should use a non-sliding device/pad to prevent sliding

Considerations:
1. Dont use bean bags or shoulder braces –> increase risk of brachial plexus injury

  1. Mark level of pt’s head on the sheet/pad to assess for sliding thru case.
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23
Q

T/F: If the pt shifts even a small amount when in T-burg we need to readjust them

A

F

A small amount of shift is ok

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24
Q

In trendelenburg, CO _____ by approximately ___%. Why does this happen? Does CO stay like this?

A

increases

9%

This is dt an increase in venous return from blood in the lower extremities

No, CO returns to baseline w/i 10 mins

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25
In trendelenburg, ICP & IOP are _______, therefore it is _________ in pts with ________.
Increased Contraindicated IICP
26
In trendelenburg, edema can form in ______(3) with _______(2). What can this cause? How can we minimize this? (2)
Forms: 1. Face 2. Conjunctiva 3. Tongue Increases w/: 1. Increased Sx time 2. Fluid overload This can cause **Postop visual loss** from the edema We can minimize this risk by: 1. Decreasing the tilt of the bed 2. Periodically leveling the pt
27
In trendelenburg, Intra-abd pressure ______ dt _________. What does this cause? What consideration should we have w/ this?
increases upward displacement of the abd Increases risk of aspiration Considerations: **ALWAYS put OG down** to drain stomach
28
What pulmonary changes should we expect in trendelenburg? (2) What causes this? How do we adjust for this? What considerations should we have with this?
1. Decreased FRC 2. Decreased pulmonary compliance This is dt cephalad shift of the diaphragm We adjust by potentially having **higher vent pressures** to maintain Vt Considerations: This position puts the pt at a higher risk for Endobronchial (R mainstem) intubation --> the distance to the carina decreases in this position dt abd contents pushing the carina cephalad
29
Reverse trendelenburg is when the head is ______. What is the biggest concern w/ this position? How do we try to prevent this? (2)
Head/HOB is UP Biggest concern: -Sliding downward towards the feet To prevent this we should use: 1. A non-sliding device/pad to prevent sliding 2. Footrest under feet
30
What are the patho considerations w/ reverse trendelenburg? (2) Why?
1. **Hypotension** dt decreased venous retrurn & pooling in the LE 2. **Decreased perfusion to the brain** dt hypotension
31
In Reverse trendelenburg, you want the BP to be _________. Why? Where should your A-line transducer be zeroed at to get accurate pressure? Why? What other tools are useful in this position to ensure cerebral perfusion?
Normal to slightly elevated This is to help keep the brain perfused Transducer should be zeroed at the **Circle of Willis** to get accuratre arterial measures at the **base of the brain** Cerebral oximetry is another useful tool
32
What positions do we want to zero our A-line transducer at the circle of Willis? (3)
1. Reverse T-burg 2. Sitting 3. Beach chair
33
The _____ the head is positioned ______ the heart the more we should be concerned w/ regarding cerebral perfusion.
higher above
34
In the sitting position, the head MUST be _________. How do we do this? (2)
Stabilized 1. Tapped to headrest 2. Pinned
35
In the sitting position, the hips are flexed _____ degrees & knees are ________. What does this reduces?
<90 degrees slightly flexes This reduces stretching of the sciatic nerve
36
In the sitting position, we need to keep at least _____ distance between the chin & the ______. What does this allow? What other considerations should we have in this position? (2)
2 fingers This allows adequate arterial & venous blood flow Considerations: 1. **Feet need to be supported** to prevent sliding 2. **Compression stockings/wraps** need to be on to maintain venous return
37
_________ position is used frequently in shoulder cases. It is a modified ______ position. How is it different? (2)
Beach chair position Modified sitting position It is different by: 1. Less hip flexion 2. Slight less leg flexion
38
What are the risks of the sitting position? (7)
1. Cerebral hypoperfusion 2. Venous air embolism 3. Pneumocephalus 4. Quadriplegia 5. Spinal cord infarction 6. Cerebral ischemia 7. Peripheral nerve injuries --> Sciatic nerve injury
39
In the sitting position, _________ is a concern in craniotomies. Why?
Venous air embolism The surgical field above the heart & open dural venous sinuses
40
What can causes quadriplegia or spinal cord infarction in the sitting position?
Impaired perfusion dt hyperextension, hyperflexion or excessive rotation of the neck
41
Venous air embolism can cause _______ (4)
1. Arrhythmia 2. O2 desaturation 3. Pulmonary HTN 4. Cardiac arrest
42
What considerations should we have w/ the **sitting position** to prevent cerebral ischemia? (4)
1. Monitor BP at level of the brain (Circle of willis) 2. Avoid hypotension 3. Avoid bradycardia 4. Position head to avoid extreme positions that may compromise perfusion
43
What pathologies are of concern in the sitting position? (3)
1. Hypotension -- decreased MAP 2. Decreased cardiac index 3. Decreased cerebral perfusion pressure
44
In obese pts, ventilation is _______ in the sitting position. Why?
Improved This is dt them being upright & better lung expansion which allows for lower pressures for appropriate Vt
45
In the **prone** position, you are lying face ____ on your ______. Your arms are _______ and either _______, or ______ with elbows ______. How is the head in the prone position? (3)
Face up abdomen Padded Tucked Out (<90 degrees) Flexed. Head is supported using: 1. A prone pillow 2. Horseshoe headrest 3. fixed w/ pins in a neutral position (All avoid putting pressure on eyes, nose, mouth, ears)
46
T/F: Prone tables in the OR are designed to open to avoid compression of the breasts, abd, & gentalia.
T
47
In the prone position, the legs are ____ & slightly flexed at the ____ & _____. What other considerations should we have regarding the legs?
Padded Knees Hips Considerations: We need compression stockings to prevent venous pooling
48
How do we prep/induce the pt when going into prone position?
Induce & intubate SUPINE --> turn PRONE Place EKG leads on the back
49
You need to keep the head ______ when going prone. Why? (2)
Neutral When turning you need to make sure that the head is neutral & the C-spine is stabilized -- this is to: 1. Decrease the risk of jugular occlusion 2. or Carotid occlusion
50
What are the risks with the prone position? (7)
1. Facial edema 2. Airway edema 3. Nerve injury (Ulnar nerve-elbows not padded, brachial plexus-arms abducted >90 degrees) 4. Postop visual loss 5. Eye injury (rt head position) 6. ETT dislodgement 7. Loss of monitors & IV lines
51
What are the biggest risks of the prone position? (2)
1. ETT dislodgement -- make sure that damn tube is TAPED!!!!!!! 2. Loss of lines/monitors -- watch when you moving stuff when turning!!!!!!!!
52
What is the purpose of a cuff leak? When should you do it?
Commonly done when a pt has been in the prone position to check the patency of the pt's airway when there is facial/airway edema. Shows there is not too much swelling so you can extubate the pt safely. You should do a cuff leak test at the start & end of the case.
53
What are pathos r/t the prone position?
1. Facial edema 2. Conjuctiva edema 3. Larynx edema 4. Tongue edema 5. Increased abdominal pressure 6. Decreased venous return 7. Decrease cardiac output
54
In the prone position, venous return is _______ dt compression of the _________
Decreased Inferior vena cava
55
In the prone position, V/Q ratio is ________. Why?
Improved Ventilation & perfusion in the lungs shift to dependent areas
56
What is the lithotomy position? (6)
1. **Supine** --> Tburg or reverse Tburg 2. Legs up in padded or candy cane stirrups 3. Arms tucked or on arm boards 4. Hips flexed approximately 90 degrees 5. Legs abducted 30-45 degrees from midline 6. knees flexed
57
In the lithotomy position, lower extremities must be raised & lowered ___________. Why? Who does this?
In synchrony together This prevents torsion & injury to the lumbar spine Anesthesia does not do this!!!! We are managing airway. 2 other people have to do this.
58
When the foot of the bed is lowered in lithotomy position, what part of the body is most likely to be injury?
The pt's hands/fingers (PROTECT THEIR HANDS/FINGERS)
59
In the lithotomy position, what considerations should we have if the surgery is >2-3 hrs long?
We need to periodically lower the legs
60
What are the risks associated w/ the lithotomy position? (3)
1. Back pain 2. Nerve injuries -brachial plexus - dt arm positioning -ulnar nerve - dt palms being down -common peroneal - lies between fibular head & area compressed from leg support -lateral femoral cutaneous nerve 3. **Compartment syndrome**
61
What are pathos rt lithotomy position? (4)
1. Increase venous return 2. Increase cardiac output 3. Increase ICP 4. Increase in abdominal pressure
62
What pulmonary pathos rt lithotomy position?
1. Decrease lung compliance 2. Decrease title volume
63
Right lateral decubitus =
RIGHT SIDE DOWN
64
Describe the lateral decubitus position (6)
1. Side lying 2. Required anterior & posterior support w/ rolls or bean bag 3. Adequate head support in a neutral position 4. Arms supported IN FRONT of pt 5. Arms abducted <90 degrees 6. Dependent leg slightly flexes
65
Where should there be padding in the lateral decubitus position?
1. An axillary roll should be placed between chest wall & bed -- caudal to axilla (this prevents brachial plexus injury & vascular compression) 2. Padding should be placed between knees
66
The _____ ear should be checked regularly in lateral decubitus position.
Dependent
67
The SpO2 probe should be monitored on the ________ arm in the lateral decubitus position. Why?
For early detection of compression to the axillary neurovascular structures
68
In the lateral decubitus position, if the bed is flexed or kidney rest is used, where does it need to be placed? Why? (2)
Under iliac crest 1. Avoid compression of inferior vena cava 2. Helps allow expansion of dependent lung
69
What nerve injuries can happen in the lateral decubitus position? (2) Why?
1. Ulnar nerve (dt elbows not padded) 2. Brachial plexus (dt arms abducted >90 degrees)
70
In the ___________ (2) positions you need to check ETT tube placement after positioning. Why?
1. lateral decubitus position 2. Prone To ensure it hasnt migrated
71
T/F: Supraglottic airways are a better choice to use in the lateral decubitus position. Why?
F You need to use caution w/ LMAs dt the increased risk of dislodgement or not being in the optimal position.
72
What are the pulmonary patho considerations w/ lateral decubitus position?
**V/Q mismatch** dt inadequate ventilation to dependent lung & reduced perfusion to the nondependent lung
73
In the lateral decubitus position, you should use ________ to prevent venous pooling in the _________
compression stockings/devices lower extremities
74
T/F: The mechanism of peripheral nerve injuries can often be unclear
T
75
Peripheral nerve injuries are the result of _______ (3) and can occur in as little as _______.
1. Stretch 2. Pressure 3. and/or Ischemia 30 minutes
76
Most peripheral nerve injuries are _________ but can be combined of both ______ & _______ and _______ or ________
Sensory Sensory & Motor Temporary or permanent
77
T/F: Nerve injury legal cases can still occur even when optimal positioning is performed
T
78
Nerve injury (Percentage & Recommendations): Ulnar nerve (2)
14% 1. Avoid excess pressure on the postcondylar groove of the humerus 2. Keep the hand & for either supinated or in a neutral position
79
Nerve injury (Percentage & Recommendations): brachial plexus (6)
1. Avoid the use of shoulder braces/beanbags (steep-head down Trendelenburg) 2. Avoid abduction of the arms (steep-head down trendelenburg) 3. Avoid excessive lateral rotation of the head (supine; prone) 4. Limit abduction of the arms to <90 degree (supine) 5. Avoid the placement of high "axillary" roll in the decubitus position -- keep the chest roll out of the zilla to avoid neurovascular compression 6. Use ultrasound to locate the IJ central line placement
80
Nerve injury (Percentage & Recommendations): Spinal cord & lumbosacral nerve root/cord (2)
Spinal cord = 25% Lumbosacral = 18% 1. Avoid severe critical spine flexion or extension when possible 2. Follow current guidelines for regional anesthesia in pts on anticoagulant therapy
81
Nerve injury (Percentage & Recommendations): sciatic & peroneal nerves (4)
7% 1. Minimize the time in lithotomy position 2. Use 2 assistance to coordinate simultaneous movement of both legs to/from lithotomy position 3. Avoid excessive flexion of the hips, extension of knees, torsion of the lumbar spine 4. Avoid excessive pressure on the peroneal nerve at the fibular head
82
T/F: Spinal cord & lumbosacral nerve root/cord injuries are decreasing in number
F They are increasing in number dt increasing use of regional anesthesia
Principles 2 Fall 2025
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