POSITIONING IN OPERATING THEATRE BY MURSIDI H.A PATIENT SAFETY.

POSITIONING IN POSITIONING IN OPERATING OPERATING

THEATRETHEATRE

BY MURSIDI H.ABY MURSIDI H.A

PATIENT SAFETY

• To provide knowledge on common surgical position of patient in during surgery

• To identify and develop awareness of potential complication in patient positioning

• To practice measure to avoid injuries and others complication to patient during surgery

• To promote safety and safeguarding patient well-being during intra-operative period

AIM AND OBJECTIVESAIM AND OBJECTIVES

UNDERSTANDING BODILY UNDERSTANDING BODILY SYSTEMSYSTEM

• INTEGUMENTARY SYSTEM– Forces include pressure, shear, friction and Forces include pressure, shear, friction and

macerationmaceration

• VASCULAR SYSTEM– Dilation of peripheral vessels lead to drop in BPDilation of peripheral vessels lead to drop in BP– Venous compression predispose to thrombosisVenous compression predispose to thrombosis

• NERVOUS SYSTEM– CNS depression due to anaesthetic drugsCNS depression due to anaesthetic drugs– Pressure on nerves may lead to temporary or Pressure on nerves may lead to temporary or

permanent damagepermanent damage

NERVOUSNERVOUSSYSTEMSSYSTEMS

• RESPIRATORY SYSTEM– Alteration in diaphragmatic movements and Alteration in diaphragmatic movements and

lung expansionlung expansion– Inadequate tissue oxygenation and perfusionInadequate tissue oxygenation and perfusion

• MUSCULOSKELETAL SYSTEM– Loss control of normal ROMLoss control of normal ROM– May resulted in joint damage, muscle stretch, May resulted in joint damage, muscle stretch,

strain and dislocationstrain and dislocation– Potential of pressure formationPotential of pressure formation

UNDERSTANDING BODILY UNDERSTANDING BODILY SYSTEMSYSTEM

• Occiput• Peri - orbital arch• Zygomatic Arch• Mastoid region• Acromion process• Scapulae• Thoracic vertebrae• Iliac crest• Greater trochanter• Medial or lateral femoral epicondyles• Tibial condyles• Malleolus• Olecranon• Sacrum and coccyx• Patella• Calcaneus

BONY PROMINENCES BONY PROMINENCES

ASSOCIATED RISK PATIENT ASSOCIATED RISK PATIENT FACTORFACTOR

• ADVANCED AGE

• NUTRITIONAL STATUS

• RESPIRATORY DISORDER

• CIRCULATORY DISEASE

• OBESE PATIENT

• CHRONIC IMMOBILITY

• PRESCRIBED MEDICATIONS

• UNDERLYING MEDICAL PROBLEMS

• NATURE OF SURGERY

GOAL OF PATIENT POSITIONINGGOAL OF PATIENT POSITIONING

• PROMOTE PROPER PHYSIOLOGICAL ALIGNMENT

• MINIMAL INTEFERENCE WITH CIRCULATION• PROTECTION OF SKELETAL AND

NEUROMASCULAR STRUCTURES• OPTIMUM EXPOSURE TO OPERATIVE AND

ANAESTHETIST SITE• PROVIDE PATIENT’S COMFORT AND SAFETY• MAINTENANCE OF PATIENT’S DIGNITY• STABILITY AND SECURITY IN POSITION

OPERATIVE NURSING OPERATIVE NURSING ROLESROLES

• Be knowledgeable on table mechanism

• Prepare table attachments and accessories

• Familiar with various patient position for optimum surgery access

• Placement of patient to comfortable position

• Correct position placement when a table break is needed intra-operatively

• Prevent interference with respiration whilst moving

• Ensure patient is fully anaesthetized before positioning

• Never reposition without anaesthetist supervision

• Table fitting must be placed without obstruction to incision site

• All fitting and attachments must be secure completely

• Ergonomic care whilst positioning• Applying diathermy plate

OPERATIVE NURSING OPERATIVE NURSING ROLESROLES

INTRAOPERATIVE NURSING INTRAOPERATIVE NURSING CONSIDERATIONSCONSIDERATIONS

• Maintenance of unimpaired respiratory actionMaintenance of unimpaired respiratory action

• Maintenance of physiological alignment from Maintenance of physiological alignment from pressurepressure

• Maintenance of adequate circulation avoiding Maintenance of adequate circulation avoiding impaired venous returnimpaired venous return

• Maintenance of body temperature by limiting Maintenance of body temperature by limiting exposureexposure

• Avoiding metal contactAvoiding metal contact

• Sufficient staffs and equipments for positioningSufficient staffs and equipments for positioning

• Pressure over the patientPressure over the patient

POSITION DEVICESPOSITION DEVICES• Patient-positioning devices can be Patient-positioning devices can be

divided into two categoriesdivided into two categories

• One which are primarily geared toward One which are primarily geared toward pressure-relief pressure-relief

• Ones which are designed to provide Ones which are designed to provide better access to the surgical site better access to the surgical site

TABLE ACCESSORIES TABLE ACCESSORIES AND ATTACHMENTSAND ATTACHMENTS

TABLE FEATURES AND TABLE FEATURES AND ATTACHMENTSATTACHMENTS

HYDRAULICWHEELED BASE

STAND

DETACHABLEFOOT REST

MANUALLEVER

ARM BOARD

SLIDINGBARS

BREAKABLEHEAD REST

ELEVATEDARM REST LATERAL SUPPORT STIRRUPS

METAL SOCKET

OTHERS – PILLOWS, HEAD RING, SANDBAGS, ROLL SUPPORT, SOFT PADS, MATTRESS

POSITION DURING INDUCTION OF POSITION DURING INDUCTION OF ANAESTHESIAANAESTHESIA

• SUPINE POSITION• HEAD EXTENDED• NECK FLEXED• AIM – to visualized Oral,

Pharyngeal and Tracheal

spaces• POSSIBLE COMPLICATIONS – Trauma to lips

and teeth, Jaw dislocations, laryngeal or vocal cords injury, epistaxis and trauma to pharyngeal wall

SURGICAL POSITIONINGSURGICAL POSITIONING

• The patient lies flat The patient lies flat on his backon his back

• The arms may be The arms may be placed beside the placed beside the body, on an armboard body, on an armboard or supported acrossor supported acrossthe chest by lifting the chest by lifting up the gown which acts as slingup the gown which acts as sling

• Most common Operative position, such as in Most common Operative position, such as in Laparotomy, certain Gynecological and Orthopedic Laparotomy, certain Gynecological and Orthopedic casescases

SUPINE OR DORSAL POSITIONSUPINE OR DORSAL POSITION

SUPINE/DORSAL POSITION

NURSING PRECAUTIONS POTENTIAL COMPLICATIONS

Head not Hyperextended Backache resulted from unsupported lumbosacral curvature

To ensure that arms are not abducted < 90°

Paralysis of arm and hand due to over abduction

Armboard is padded

Hand in prone positionRadial or Ulnar nerve palsy due to arm or elbow hanging or tight strapping

Arms do not overlap or hang over table edge

Patient protected from metal contact

Continuous pressure on the calves may caused venous stasis resulting thrombosis which can

lead to Pulmonary Embolisms

Bony prominences are protected (occiput, scapulae, thoracic vertebrae, olecranaon, sacrum and coccyx, calcaneus)

Potential pressure pointsPotential pressure points

PRONE POSITIONPRONE POSITION

• The patient lying with abdomen on table surface

• Arms are placed above the head

• Pillows are placed under the shoulders, hips and feet

• Access for all surgeries involving posterior back (cervical spine, back, rectal area and dorsal extremities)

PRONE POSITION


Pillow or towel under shoulders and hip facilitate chest expansion, reduce abdominal pressure and venous oozing at operation site

Lower neck and upper back pain resulting from hyperextension of head

Radial and ulnar nerve palsy due to arm restrainer

Hypotension resulted from pressure on inferior vena cava and pooling of blood in lower limbs

Head not hyperextended, placed on side and kept supported

Pressure point are well protected with pad (cheek, ear, acromion process, breast, genitalia, patella, dorsum of feet, toes)

Shoulder dislocation during arm positioning

Brachial plexus injury due to over extension of arm < 90°

Potential Nerve InjuriesPotential Nerve Injuries

Brachial Plexus

• Patient lying in supinePatient lying in supine

position with knees position with knees

over lower break of over lower break of

the tablethe table

• Head tilted down to 15Head tilted down to 15° or according to the surgeon° or according to the surgeon

preferencespreferences

• Arms may placed on the chest or armboardArms may placed on the chest or armboard

• Common position for laparoscopic surgeries in pelvic or Common position for laparoscopic surgeries in pelvic or lower abdominal regionlower abdominal region

• Using of shoulder or knee braces may benefit patient Using of shoulder or knee braces may benefit patient from sliding from sliding

TRENDELENBURG POSITIONTRENDELENBURG POSITION

TRENDELENBURG POSITIONTRENDELENBURG POSITION


Head not hyperextended and arm not abducted beyond 90°

A 30° Trendelenburg position may caused changes in blood pressure, cerebral edema, congestion of face and neck

Hands on padded armboards are supinated

Arms not overlap the table edge or hang over A too steep position may

result in cyanosis due to alteration on diaphragmatic extension and lung expansion

Patient is protected from metal contact

Bony prominences are well protected (occiput, scapulae, thoracic vertebrae, olecranon, sacrum and coccyx and calcaneus)

Shearing of skin may occurred during positioning

Returning leg first to reverse venous stasis

REVERSE TRENDELEBURG REVERSE TRENDELEBURG POSITIONPOSITION

• Patient in supineposition with arms by sides or on armboard

• Table tilted to 5-10° raising the head

• A sand bag may used below the neck and the shoulder blade for extension of neck (RUSS TECHNIQUE)

• The head stabilized by head ring• Position often used for head and neck surgery to reduce

venous congestion• To prevent stomach regurgitation during induction of

anaesthesia

REVERSE REVERSE TRENDELENBURG POSITIONTRENDELENBURG POSITION


Head not hyperextended and arm not abducted beyond 90°

Backache may result from unsupported lumbosacral curvatureHands on padded armboards are

supinated Paralysis may occurred due to over abduction of armArms not overlap the table edge or

hang over Ulnar and radial palsy due to elbow or arm hanging over the table or tight restraint

Patient is protected from metal contact

Bony prominences are well protected (occiput, scapulae, thoracic vertebrae, olecranon, sacrum and coccyx and calcaneus)

Pulmonary embolisms as a result of venous stasis

Cardiovascular overloaded due to quick returnAnti embolic stocking may be used to

prevent blood poolingSkin shearing due to sliding down

Foot bracket may used to prevent sliding

LITHOTOMY POSITIONLITHOTOMY POSITION

• Patient lies in supine position with buttocks at the lower break of the table

• Lithotomy stirrups placed in position level with patient ischial spine

• Arms placed over the chest or on an armboard• Legs are lifted together upwards and outwards and feet

placed in knee crutch or candy cane• Common position for Urology, Gynecology, perineal or

rectal operations

LITHOTOMY POSITIONLITHOTOMY POSITION


Two person required to raised the legs simultaneously by grasping the sole and other hand supporting the calf

Severe backache caused by too high stirrups

Calf holder may resulted peroneal or femoral obturator nerve damageStirrups bars must be checked

and secure before use and it’s height must be similar and not suspend the patient weight

Osteoarthritis or stiff hips due to rough handling

Too quick of lowering the legs may cause hypotensionThe buttock must be even with

the edge of bed to prevent lumbosacral strain Femoral nerve damage due to

acutely flexed thighsAnti embolic stocking may used to promote venous return

Bony prominences protectedHip dislocation or fracture as a result faulty stirrups

Potential Nerve InjuriesPotential Nerve Injuries

TYPES OF STIRRUPS AND IT’S TYPES OF STIRRUPS AND IT’S HAZARDSHAZARDS

• KNEE CRUTCHKNEE CRUTCH– Pressure on peroneal nerve Pressure on peroneal nerve

resulting footdrop and resulting footdrop and neuropathiesneuropathies

• CANDY CANECANDY CANE– Pressure on distalsural and Pressure on distalsural and

plantar nerves which can plantar nerves which can cause neuropathies of the cause neuropathies of the footfoot

– Hyperabduction may Hyperabduction may exaggerated flexion and exaggerated flexion and stretch sciatic nervestretch sciatic nerve

• BOOTH TYPEBOOTH TYPE– May produce support more May produce support more

evenly and reduce localized evenly and reduce localized pressurepressure

KNEE CRUTCH

BOOTH TYPE

CANDY CANE

• Patient lying with one Patient lying with one side facing operative side facing operative side uppermostside uppermost

• The legs flexed to 90The legs flexed to 90° ° and a pillow is placedand a pillow is placedin betweenin between

• Upper arm rested on Upper arm rested on elevated arm rest and the other remains flexed on the table elevated arm rest and the other remains flexed on the table or armboardor armboard

• A roll bags may used below the hip/kidney to increased A roll bags may used below the hip/kidney to increased exposure of iliac regionexposure of iliac region

• Position is maintained by use of sandbags or braces Position is maintained by use of sandbags or braces attached to the side of bedattached to the side of bed

• Head supported on a pillowHead supported on a pillow

LATERAL OR KIDNEY POSITIONLATERAL OR KIDNEY POSITION

LATERAL/KIDNEY POSITIONLATERAL/KIDNEY POSITION


If table break is used, it must If table break is used, it must be correctly level with iliac be correctly level with iliac crest to prevent alteration in crest to prevent alteration in respiration and severe post-respiration and severe post-operative backacheoperative backache

If the kidney rest raised too much, the lungs will not expand adequately which will result in cyanosis and hypotension

Injuries to brachial plexus, median, radial and ulnar nerves can occur if upper arm is not supported

Ensure ear is not trapped Ensure ear is not trapped when supporting the headwhen supporting the head

Arms are supported with Arms are supported with adequate padding to prevent adequate padding to prevent pressure necrosispressure necrosis

If the head is not supported adequately, brachial plexus can get stretched

Perineal nerve damage may resulted from compression on the down knee against hard surface

Bony prominences are fully Bony prominences are fully protected protected (ribs, iliac crest, greater (ribs, iliac crest, greater trochanter, medial and lateral femoral trochanter, medial and lateral femoral epicondyles, Tibial condyles, Malleous)epicondyles, Tibial condyles, Malleous)

NEUROSURGICAL POSITIONNEUROSURGICAL POSITION

• The patient may lying

in a supine position,

prone or lateral• The head is positioned

either on soft ring or a

spiked head rest• The head of the table may be tilted a little to

facilitate venous drainage and to reduce CSF pressure in the brain

NEUROSURGICAL POSITIONNEUROSURGICAL POSITION


Ensure patient is fully anaesthetized before

Similar complications as for prone and supine positionspositioning or insertion or head

spikeDevelopment of skin pressure over the ear, cheek or face if using head ring for several hours (supine)

Eye are well covered and fully protected by pads

Position of spike must not harm patient’s ears and eyes

Face is protected from pressure when in prone position

Sciatic nerve damage may result due to long pressure on the dorsum of the foots

Arms are in good anatomical alignments

Bony prominences is protected whilst in all position

• Patient positioned in

supine with the pelvis

stabilized against well

padded vertical perineal

post• Traction of operative leg is achieved either by boot-

shaped cuff or devices with restraining straps• Un affected leg may be rested on well padded,

elevated leg holder• Common position for ORIF of hip or closed femoral

nailing

FRACTURE TABLE POSITIONFRACTURE TABLE POSITION

FRACTURE TABLE POSITION

ORTHOPAEDIC FRACTURE TABLEORTHOPAEDIC FRACTURE TABLE


Patient usually brought into theatre with hospital bed and traction applied

Pressure due to perineal post may injured genital structure

Ensure patient is anaesthetized before transfer onto OT table

Fecal incontinence and loss of perineal sensation may occurred as a result of pressure injury to perineal and pudendal nerve

Operating table are and attachments are ready according to surgeon preferences or standard manual Tight strap may resulted

peroneal or femoral obturator nerve damage resulting in foot drop

Cautions and extra care regarding shear force injuries, musculoskeletal and nervous system during transfer

Bony prominences protected

• Patient lying intoPatient lying into

prone positionprone position

• Both legs are abductedBoth legs are abducted

and flexed togetherand flexed together

at right anglesat right angles

• Knees flexed and hip Knees flexed and hip

elevatedelevated

• Head, shoulders and chest rest directly on the tableHead, shoulders and chest rest directly on the table

• Arms are placed above the headArms are placed above the head

• Primary position for sigmoidoscopies and laminectomy Primary position for sigmoidoscopies and laminectomy procedureprocedure

KNEE-CHEST POSITIONKNEE-CHEST POSITION

KNEE-CHEST POSITIONKNEE-CHEST POSITION


Legs moved together to prevent back strain

Lower neck and upper back pain due to hyperextended head

Arms gently lift up to prevent dislocation

Ulnar or radial nerve palsies as a result tight arm restrainer

Head is not hyperextended and placed to the side on a pillow

Hypotension due to pressure on inferior vena cava and pooling of blood at lower extremities

Bony prominences are well protected (cheek, ear, forehead, nose, eyes, acromion process, breast [women], genitalia, patella, dorsum of feet, toes)

Shoulder dislocation or brachial plexus injury when placing the arms

Patient may fall from table if bracket are not secure and fail to support patient’s weight

• The patient positioned in

supine with the upper body

part is flexed to 45° or 90°

and the knees slightly

flexed and legs lowered

• Arms may be placed over

the laps or armboard

• A footrest is used to prevent

footdrop and head spike to stabilized head

• Useful position for craniotomies, shoulder or

breast reconstruction and ENTS’

SEMI-FOWLER’S AND FOWLER’S SEMI-FOWLER’S AND FOWLER’S POSITIONPOSITION

SEMI-FOWLER’S AND FOWLER’S POSITION


The cervical, thoracic and lumbar section of spine must be aligned once position established

Orthostatic hypotension due to blood pooling at lower extremities

Risk of venous thrombosis and embolisms as a result of impended venous return

Extra padding are requires over bony prominences (coccyx, ischial tuberosities, calcaneus, elbows, knees and scapulae)

High risk of development of skin pressure over affected bony prominences

The use of anti-embolism stocking may necessary to assist venous return

Alteration on chest movement due to restriction from rested arms or tight straps

Reposition after surgery must be done gently and slowly

JACKNIFE POSITIONJACKNIFE POSITION

• A modification of prone

position

• Patient hips are supported

on a pillow and the table

are flexed at 90° angle,

raising the hips and lowering head and body

• A straps used over the thigh to prevent shearing and sliding

• The head, face, shoulders, chest and feet are supported by soft pads or rolls to prevent bony pressure

• Common position for hemorrhoidectomy or pilonidal sinus procedures

JACKKNIFE POSITION(KRASKE’S)


Pillow or towel under shoulders and hip facilitate chest expansion and reduced abdominal pressure

Lower neck and upper back pain resulting from hyperextension of head

Injury to genitalia due to pressureAnti-embolisms stocking aid

venous return Radial and ulnar nerve palsy due to arm restrainerHead not hyperextended, placed

on side and kept supported Hypotension resulted from pooling of blood in lower limbsPressure point are well protected

with pad (cheek, ear, acromion process, breast, genitalia, patella, dorsum of feet, toes)

Shoulder dislocation during arm positioning

Brachial plexus injury due to over extension of arm < 90°

Patient turn using log-roll technique end of procedure

POSITIONING OF ELDERLY PATIENTPOSITIONING OF ELDERLY PATIENT

• FRAGILE SKIN SURFACES• ARTHRITIC JOINTS• LIMITED RANGE OF MOTION• PARALYSIS• LIFTING RATHER THAN SLIDING OR

DRAGGING• AVOID OF ADHESIVE TAPE FOR

STRAPPING• ADEQUATE PADDING FOR BONY

PROMINENCES• ALLOW PATIENT TO POSITIONING BEFORE

ANAESTHETIZED

POSITIONING OF PAEDIATRIC POSITIONING OF PAEDIATRIC PATIENTPATIENT

• Think of ‘appropriate size’• Right size for bed and attachments• May necessary to use safety strap• Never overextended limbs or keep in one

position for longer periods• Due to small size, children are prone to and

has greater risk of physiologically compromised

• Appropriate positioning and observation are essential

• Liz Sparks an RN in Oklahoma City, concludes, “It’s not all about technique. It’s about knowledge. If you know what causes complications and how to prevent them, you will be more likely to keep patient positioning in mind as something you should routinely monitor.”

THANK YOUTHANK YOU

POSITIONING IN OPERATING THEATRE BY MURSIDI H.A PATIENT SAFETY.

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Transcript of POSITIONING IN OPERATING THEATRE BY MURSIDI H.A PATIENT SAFETY.