Surgical Patient Positioning and Safety Term Paper

Abstract

Positioning surgical patients safely as well as facilitating positive patient outcomes is an expected nursing care professional outcome. This is all intertwined in the intraoperative positioning procedures which comprise the art of securing and moving human anatomy in place to ensure best surgical site exposure that would also ensure a minimal compromise to the patient’s physiological functions such as; gas exchange, airway patency, lung excursion, and circulation ).

The position should also ensure minimal mechanical stress upon the patient’s joins. Potential injuries during surgery include pressure ulcers, nerve injuries, alopecia, or physiologic comprises. The mechanisms of injury include pressure, shear forces, and friction. Surgical patients are prone to pressure against the OR bed due to gravitational force that upon pressing on the muscle, skin, and bone can affect capillary interface pressure.

If this pressure exceeds normal capillary interface pressure of 23 to 32 mm Hg, it may result in an altered tissues perfusion that can result in tissue ischemia. Friction injuries may develop when the patient’s skin rub against rough surfaces such as positioning devices, bed linen, anesthesia equipment, or other surgical equipment. It is thus paramount that the nursing staff and the rest of the surgical team observe the patient’s position and movements during operation.

Introduction

The patient’s position during operation should provide optimum access and exposure to the operative site while at the same time maintaining respiratory and circulation function, body alignment, and skin integrity. The position must also provide easy access to the patient for the intravenous fluids, anesthetics agents, and drugs administration. The position should also be one that will afford comfort to the patient. The nurse should assess the patient for any existing skeletal, respiratory, or neuromuscular limitation as well as the patient’s size before the operation. To determine patients’ position during the operation, the nurse should consult the surgeon’s preference card for the scheduled procedure and or by posting a slip, Reeder, J M. (2002)

Position consideration for all procedures

There are key points to consider before any specific procedure takes place. These include,

1. Do not allow surgical team members to lean on the patient.
2. Do not allow instrument table, mayo stand, or other equipment to rest on or put pressure on the patient.
3. Assure that all equipment/ supplies used are clean and in working order.
4. Maintains patient dignity and body temperature.
5. Assure that the proper side is exposed if the procedure is unilateral.
6. Provide adequate numbers of personnel for the safe movement of the patient.
7. Move the patient only after the anesthesia care team approves; move gently and slowly.
8. Place safety belt 2” above the knees and not so tight as to impeded circulation. This will provide optimum control of patient during induction and emergence from anesthesia.
9. Do not abduct arms to greater than 90°.
10. Assure that legs and/or ankles are not crossed.
11. Assure that patient is not touching any exposed table parts or hanging over sides.
12. Avoid having body surfaces in contact with one another.

There are different patient positions that the nurse should be aware of to handle the patient well in the operating room. These positions include;

Care Supine Position

In this position, the nurse should assure that the patient’s kidney rest on the operating room (OR) bed is at the lowest position. Padding should then be placed under the head and the heels. Arms should be positioned on the arm board or secured underdraw sheet at the patient’s side. Palms should either be turned down or turned towards the patient. The nurse should then pad elbows with a towel or foam. A small pillow under the calves should then be positioned to support the full length of the lower legs. After applying Anti-embolism stockings, the nurse should then place a small sandbag or a blanket roll under the right hip to relieve pressure on the inferior vena cava for those patients who are pregnant, have large abdominal masses, or are obese, Warren A, et al., (2006).

It should be noted that all functions of skytron tables will not operate with kidney rest raised and if foaming is used, the foam should not be removed from the hole as removing the center could diminish circulation. For patients with low back, pain care should be taken not to put pressure on the popliteal space.

For Semi-Fowler’s Position, the nurse should assure that the arm(s) and the hand(s) that have been secured underdraw sheet are free of excess pressure that is created by flexing the operating room table. The patient should be moved into and out of Trendelenburg’s position slowly when handling the patient at Trendelenburg Position, to avoid sudden changes in blood pressure. Trendelenburg’s position should not be used in patients with poorly controlled glaucoma or increased intracranial pressure. In case the Reverse Trendelenburg position is applied, a padded footboard should be used to support the patient, Reeder, J M. (2002).

Lithotomy Position

In this position, the nurse should assure that the patient’s buttocks do not extend over the break in the bed. Legs and knees should be raised simultaneously and very slowly and never abduct the legs without first of all externally rotating the hip. Thighs should be positioned so that they do not exert pressure on the groin or the abdomen. After securing the arms across the abdomen or on arm-boards, the safety belt should be secured and adjusted before and after the lithotomy position. The safety belt needs to be secured over the thighs during anesthesia induction and emergence. If it does not get into the way of the procedure, the safety belt can be used over the abdomen during surgery e.g. gynecological laparoscopy. The nurse should then pad legs at any point where they are in touch with the stirrup. If applicable, safety straps can be used.

Prone position

This is the position where the nurse should provide a laminectomy frame or chest rolls (bath blanket wrapped in egg-crate foam), padding for ear, cheeks, and eyelids, and pillow for under feet. It should be checked that there is no compression of male genitalia or female breasts (if necessary, place laterally). The arms should be positioned at the patient’s side with palms turned upwards, inwards, or over the head on arms boards. If the arms are positioned over the patient’s head, then they should be lowered slowly toward the floor and brought up in an arc while the elbow is flexed. The nurse should securely support the shoulder and elbow during this movement. A safety belt should then be secured above the knees.

Lateral position

In this position, the hips and the shoulders should be turned simultaneously with a minimum of four people assisting in this. If the patient will be flexed, the nurse should assure that the iliac crest is level with the break of the bed. Allowing the upper leg to remain straight, the lower leg should be flexed at the knee and hip. A pillow should then be placed between the knees and the feet and padding or foam placed under bony prominences: knee, ankle, and hip.

The upper arm is then secured with Kerlix roll-on over-bed arm-board (“airplane”) with the elbow slightly flexed and palm up. The lower arm should be secured on the arm board with the elbow slightly flexed and the palm up. The lower shoulder should then be positioned slightly forward with the axillary roll under the axilla. To assure adequate circulation, radial pulses should be checked after positioning is completed. The nurse should stabilize the patient using 3” adhesive tape or safety belt across hips and then secured to the OR table. Male genitalia and the female breasts should be checked to confirm they are free from compression. Without allowing kidney braces (if they were used) to come into direct contact with the patient, the head should be elevated on foam padding and/or folded towels.

Fro-Leg Position

In this position, the nurse should provide 4 to 6 folded blankets to elevate and support the legs and the knees. The feet are secured onto the OR bed with 3” adhesive tape and the feet are protected from adhesive using the folded towel, Warren, A. et al.,(2006).

Conclusion

One of the major concerns of the surgeons, nurses, and a hospital is maintaining patient safety in the operating room. This is important so that preventable complications are avoided. It has been the tradition of the nurses and the anesthesia staff to manage patient safety and positioning in the operating room. The most important aspects of patient safety in the operating room include; patient positioning, proper handling of electrocautery, ocular protection, and airway management. When performed in the right way with attention to the anatomic landmarks, nerve injury and postoperative muscle and joint pain can be prevented by preoperative positioning of the patient, Reeder, J M. (2002).

Thus, great care and caution are required when positioning a surgical patient. Correct positioning will provide the surgeon with easy access to the site, reduce the risk of damage to the nerves, compartments, soft tissues, cardio-pulmonary system and minimize blood loss. Each position has its own risk should be evaluated against its benefits. Whenever possible, extreme positions of the joints should be avoided.

With the plexus brachialis and ulnar nerve having the highest risk in the positioning of the extremities, good anatomical understanding would make it possible to take counter-measures. When positioned with elevated extremities e.g. lithotomy position, or if a tourniquet was applied, there is a high risk to suffer rhabdomyolysis with compartment syndrome or acute ischemia in patients suffering from peripheral vascular disease.

Loss of virus is rare but is usually associated with prone position while air embolism that is unrelated to poisoning may occur during operation of sites above the heart. Since postoperative blindness has occurred in all positions, it is paramount to avoid pressure to the bulbous. Thus it is clear that correct positioning does aid an effective surgery. Slovenly positioning should be rejected as it carries with it a possibility of ill effects that could have permanent damage. Interdisciplinary responsibilities on the surgical positioning must be well defined and documentation of positioning as well as that of positioning control be done very accurately, Ullrich W, et al., (1997).

Reference

Reeder, J M. (2002).Patient Safety, and Competency Assessment Module (Denver: Certification Boards.

Warren A. Ellsworth ,V., Ronald E. and Iverson. (2006). Patient Safety in the Operating Room. Seminars in Plastic Surgery 20: 214-218.

Ullrich W, Biermann E, Kienzle F, and Krier C. (1997). Damage due to patient positioning in anesthesia and surgical medicine.Anasthesiol Intensivmed Notfallmed Schmerzther. 32(1):4-20.

Nursing intervention- Maintaining patient safety in the operating room through proper positioning.

Through proper positioning and maintaining proper body alignment during the procedure.