intraoperative positioning: risk reduction strategies · intraoperative positioning: risk reduction...

Self -Study Guide

Intraoperative Positioning:Risk Reduction Strategies

Donna S. Watson, MSN, RN, ARNP-BC, CNOR is a Global Manager, Professional Education/Nursing for Covidien Energy-based Devices.

Watson received her associate degree in nursing from the West Virginia Institute of Technology and her bachelor’s and Master of Science in nursing from the University of Evansville. She received her post mas-ter’s certificate in family practice from the University of Washington. She has held a variety of periopera-tive nursing positions, including staff nurse, clinical instructor, clinical educator, and nurse practitioner. During her career she has made numerous professional presentations on various perioperative topics throughout the United States, as well as internationally. She has authored numerous articles, chapters and books. Her publication, Practical Guide to Moderate Sedation/Analgesia, 2nd edition, received the American Journal of Nursing 2005 Book of the Year Award. Perioperative Safety premiered in 2010 with excellent reviews. Watson is a strong advocate for patient safety, and served as the AORN Journal, Patient Safety Column Coordinator from 2009 to 2010. Watson served on the AORN Board of Directors from 1999 to 2003. In 2002-2003 she was the national AORN president.

INTRAOPERATIVE POSITIONING: RISK REDUCTION STRATEGIESSELF-STUDY GUIDE

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2014 Approved for 2 contact hours

Intended Audience: Surgeons, perioperative nurses and other healthcare team members who provide patient care during surgery or invasive procedures.

By

Donna S. Watson, MSN, RN, ARNP-BC, CNOR

Global Manager, Professional Education/Nursing

Covidien Energy-based Devices


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Accreditation Statements

This offering for two (2) contact hours was designed by the staff of Clinical Affairs Professional Education Department, an approved provider of nursing continuingeducation (CE).

Clinical Affairs is a provider approved by the California Board of Registered Nursing, Provider # CEP 12610.

Disclaimer Statement

“Approved” refers to recognition of educational offerings only and does not imply approval or endorsement of any Covidien product.

A certificate of completion pertains only to the participant’s completion of the self-study guide, and does not in any way attest to the clinical competence of any participant.

Verification of Completion

A certificate will be provided to each person who completes the offering. The certificate pertains only to completion of the offering, and is intended for record-keeping purposes.

Commercial Support Statement

Covidien provided an unrestricted educational grant tothe Covidien Energy-based Devices Professional EducationDepartment to develop and disseminate the Intraoperative Positioning: Risk Reduction Strategies Self-Study Guide.

Full Disclosure

It is the policy of Covidien Energy-based Devices Professional Education Department to inform learners/participants of any affiliation or financial interest faculty members have withmanufacturer(s) of any commercial product(s) that may create, or may be perceived as creating, a conflict related to the materials contained in an educational activity. This policy isintended to make you aware of the faculty’s interests, so you may form your own judgments about the materials.

Copyright Statement

© 2014 Covidien All rights reserved. Contents of materials presented or distributed by Covidien may not be reproduced in any form without the written permission of Covidien.

Instructions

Complete the test questions and check the correct responses with the key. A score of 80 percent or better is recommended. Please review the self-study guide portions related to missed questions, if necessary.

Complete the Registration/Evaluation form.

E-Mail the completed Registration/Evaluation form with test question responses to:

MSContinuing.Education.com

Upon receipt of the required documents a certificate of completion for two (2) credit/contact hours will be sent. Please allow 3–4 weeks for the certificate to be e-mailed upon submission of required paperwork. Covidien will maintain a record of your continuing education credit and provide verification if necessary for five (5) years.


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ObjectivesUpon completion of this activity the participant should be able to:

• Review basic principles of safe patient positioning.

• Identify intraoperative risk factors that may contribute to patient injury.

• Discuss etiology of neurological injuries attributed to patient positioning.

• Differentiate tissue characteristics of early stage pressure ulcer from thermal injury.

• Describe perioperative nursing interventions to reduce risk for positioning injury.

• List common pressure point areas associated with general surgical positions.

OverviewThe educational offering provides a detailed discussion of safe practices for patient positioning during a surgical or invasive procedure. The educational offering is intended to review aspects of patient care that include nursing diagnoses, interventions and expected patient outcomes to minimize positioning risk for a patient undergoing surgical or invasive procedure. The study guide is intended to serve as an educational resource and should be used in collaboration with other national recommendations and guidelines such as the Association of periOperative Registered Nurses (AORN).


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OutlineIntroduction

Basic Principles of Patient Positioning

Positioning Injuries

Intraoperative Risk Factors

- Pressure - Shear - Friction - Moisture

Intraoperative Nerve Injuries

Upper Extremity Neuropathies

- Brachial Plexus Injury - Median Nerve Injury - Ulnar Nerve Injury - Radial Nerve Injury

Lower Extremity Neuropathies

- Sciatic Nerve Injury - Femoral Nerve Injury - Peroneal Nerve Injury - Tibial Nerve Injury

Intraoperative Acquired Pressure Ulcers

Pressure Ulcer Staging

- Stage I - Stage II - Stage III - Stage IV - Unstageable - Suspected Deep Tissue Injury - Thermal Injury or Pressure Ulcer - Patient Return Electrode Site Burn Characteristics

Preoperative Nursing Assessment

Vulnerable Surgical Patients

- Age - Nutritional State - Obese - Surgery Length - Hypothermia/Hypotensive - Diabetes

Perioperative Nursing Considerations

- Individualized Plan of Care

Interventions

- Positioning Equipment - Patient Transfers

Surgical Positioning Considerations and Techniques

- Supine or Dorsal Recumbent - Trendelenburg/Reverse Trendelenburg - Prone - Sitting - Lithotomy - Lateral or Lateral Decubitus

Positioning Challenges

- Obese Patient - Robotic Surgery

Risk Reduction Strategies

Documentation

Evaluation

Competency Check List

Conclusion

References

Positiong Post Test

Test Key

Registration/Evaluation Form


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IntroductIon

Advancements in medicine, nursing and healthcare technology continue to expand the range of surgical interventions offered for the patient. The clinical need to properly position the patient during a surgical or invasive procedure remains a critical aspect of the perioperative team member responsibilities. Every member of the perioperative team must participate in the common goal of an optimal outcome for the patient who is free from injury attributed to positioning.

During surgery the patient may be positioned in a manner that varies from normal anatomical position and can result in movement and stretching beyond a patient’s normal range of motion. If positioned incorrectly, the body’s normal physiological mechanisms which compensate and protect the joints, tissue and cardiovascular system may be compromised. The perioperative team members should have knowledge of anatomy and physiology, demonstrate proficient assessment skills to recognize the potential for an untoward patient outcome, and plan appropriate individualized interventions when positioning the surgical patient. Effective positioning promotes tissue safety, optimal air exchange, minimal cardiovascular compromise while allowing for adequate surgical site exposure (AORN, 2010).

Patient positioning should be planned preoperatively to meet specific needs of the patient and the surgical team. Correct positioning of a surgical patient demands consideration of the safety aspects and desired patient outcomes to minimize untoward effects on the respiratory, cardiovascular, neurological, integumentary and musculoskeletal systems (AORN, 2010). In addition to preoperative planning, the perioperative team should be prepared to anticipate any patient needs specific to positioning throughout the entire surgical or invasive procedure. This includes having the anticipated positioning equipment immediately available and easily accessible. The perioperative team must participate in the management of risk reduction strategies to minimize the potential for patient injury secondary to patient positioning.

BasIc PrIncIPles of PatIent PosItIonIng

General principles common across different types of surgical positioning that may be encountered by the perioperative team include, but are not limited to: (AORN, 2010)

• Maintaining patient dignity and privacy at all times

• Knowledge of anatomy and physiology by perioperative team members to avoid patient injury

• Provision of optimal exposure at the surgery site during the procedure

• Knowledge of appropriate use and application of positioning devices and aids by perioperative members

• Ability to implement various positioning techniques that avoid untoward effects on the patient’s respiratory, circulatory, neuromuscular and integumentary systems that may be attributed to improper positioning techniques

• Position patient to avoid direct contact with metal or hard surfaces

• Position patient in a manner that will support all body parts

• Provide padding to target pressure points and bony prominences associated with positioning injury

PosItIonIng InjurIes

Facilitation of safe patient positioning requires perioperative team members to be knowledgeable of the different types of injuries that may occur as a result of improper positioning. Perioperative team members should have an understanding of contributing factors that may lead to an untoward patient outcome. Potential patient positioning injuries may include, but are not limited to:

• Pressure ulcers (Fawcett, 2011)

• Occipital alopecia (Khalaf, et al, 2004)

• Nerve injuries (Fawcett, 2011; Winfree & Kline, 2005)

• Physiological compromise (AORN, 2010)

• Vascular complications (Fawcett, 2011)

• Impairment of skin integrity (AORN, 2010)

• Ocular injuries (Berg, et al, 2010)

IntraoPeratIve rIsk factors

Patient injury related to patient positioning is generally attributed to multiple risk factors involving direct pressure, friction to the skin, shear forces, moisture or a combination of each.


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Pressure

Surgical patients may have compromised mobility and sensory deficits attributed to the use of specific types of anesthesia care that include general, regional, monitored anesthesia care, and moderate sedation/analgesia. The administration of sedative medications results in levels of sedation that range from consciousness to unconsciousness (Odom & Watson, 2005). As a surgical patient advances on the sedation continuum toward the level of general anesthesia, there are a loss of protective mechanisms that include decreased pain sensation, loss of mobility and consciousness. Positioning injuries occur if perioperative team members fail to implement risk reduction strategies to avoid direct pressure, friction, and/or shear forces to a dependent body part.

The understanding of pressure is essential for the prevention of a patient positioning injury during surgery. Pressure occurs when the skin is compressed between a bony prominence and a hard surface such as the procedure bed. When external pressure exceeds normal capillary pressure of 32 mm Hg, the patient is placed at an increase risk for impaired tissue perfusion. (Walton-Geer, 2009; AORN,2010). It is the effect of direct pressure exceeding capillary pressure of 32 mm Hg that may cause restriction of adequate circulation, resulting in ischemia of the underlying tissue.

Pressure combined with friction and shear that occurs on body areas with bony prominences create an opportunity for tissue damage. It is this type of tissue damage that may progress to a pressure ulcer attributed to improper positioning. The perioperative team members should protect the patient and have an understanding of common pressure sites for the surgical patient. Knowledge of the common pressure sites allow the perioperative team members to select appropriate positioning devices and apply positioning techniques that will limit exposure to capillary pressure greater than 32 mm Hg on tissue where possible (Figure 1).

Pressure may also result from a surgical instrument or equipment that rest directly on the patient (e.g., drill, mayo stand, bed attachments, posts) (Heizenroth, 2007). A perioperative team member leaning directly on a patient may apply unnecessary pressure that results in patient injury. Pressure may occur when prominent pressure points are placed

directly over or onto a hard surface (e.g., metal leg holders or metal table with no padding) without adequate padding. It is essential to select and apply positioning equipment designed to redistribute pressure and minimize risk for patient injury (AORN, 2010).

Shear

Shear and friction are often incorrectly used interchangeably. Shear is “a mechanical pressure that is parallel rather than perpendicular to an area” (Maklenbust & Siegreen, 2001, p. 24). Shearing forces during surgery occur when a body part is moved, however the skin will remain fixed. This may occur when a patient is placed in a lithotomy position, and repositioned to the edge of the surgical table without lifting and moving the entire body. As the body is pulled down to the edge of the table, the skin is stationary resulting in stretching and folding of the skin. The end result is tissue damage and ischemia to the coccyx area which may progress to a pressure ulcer (Figure 2).

Figure 1: Common sites for pressure points

Figure 2: Shearing force demonstrating stretching and folding of the skin


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Friction

Friction will “oppose the movement of one surface against another.” (Grey, et al, 2006, p. 472). Friction may result from the skin rubbing across the surgical bed linen or positioning device during transfer with an insufficient number of staff for a safe transfer (Figure 3). When friction is created the outcome may result in damage to the outer protective skin layer. The initial appearance may include an open skin lesion, or blister. If severe this may progress to a pressure ulcer.

Moisture

Moisture on the skin may intensify the effects of pressure, shear and friction (Heizenroth, 2007). Skin exposed to moisture for a prolonged period of time results in maceration and skin break down. Factors during surgery that contribute to increased risk of pressure ulcer development include moisture and irrigation (Park, et al, 2005). During surgery the patient may be exposure to excessive moisture from pooling of prep solution, irrigation solution, and body fluids. Care should be taken to prevent unnecessary moisture exposure for the patient.

IntraoPeratIve nerve InjurIes

Bundinger in1894 was the first to report brachial palsy attributed to positioning during surgery (Sayer, et al, 2001). Neurological injuries are not common in the surgical setting, in part of which may be attributed to the diligence with positioning placed by the perioperative team. However, when nerve injuries do occur, most often these nerve injuries affect the sensory and motor ability of the peripheral extremities. Symptomatology may range from paresthesia, dysesthesia, to paralysis. The actual incidence of nerve injuries during anesthesia is difficult to account for. An iatrogenic nerve injury results from a “combination of stretch, ischemia, and /or compression” during surgery (Winfree, et al, 2005, p. 1).

Table 1 summarizes untoward peripheral neuropathies that

Figure 3: Example of friction force when a patient is moved without adequate number of people and the heels are dragged across the bed surface

Upper Extremity

Median Nerve Numbness of the surface area of thumb, index finger and middle finger. Weakness or inability to abduction of the thumb.

Test sensation/mobility of the thumb, index finger and middle finger.

Ulnar Nerve Numbness of the little finger. Inability or weakness during abduction and/or adduction the of the fingers.

Test sensation of the plantar surface of the fifth fin-ger. Test mobility to include extension, flexion, ab-duction, and adduction of the fingers to the thumb.

Radial Nerve Numbness or weakness of the triceps, posterior forearm and hand.

Test movement and sensation of the distal thumb.

Brachial Plexus Numbness or weakness of the arm and shoulder. May result from injury to the median, ulnar, radial, musculocutaneous, and circumflex nerve.

Test sensation and gross motor function of the shoulder, arm, wrist and fingers.

Lower ExtremityFemoral Nerve Numbness and weakness over the thigh, knee or leg. Inability

for flexion of the hip. Test ability to flex the thigh.

Obturator Nerve Numbness of thigh and difficult gait. Weakness of adduction of the thigh.

Test ability to adduct the leg.

Sciatic Nerve Numbness or weakness of the lower back with radiation down back of leg to foot. May exhibit foot drop.

Test ability to flex the thigh.

Common Peroneal Nerve

Numbness, weakness or decreased ability to dorsiflexion the ankle, toes and/or foot drop.

Test ability to dorsiflex the great toe.

Tibial Nerve Numbness or weakness of the ankle and/or foot. Difficulty with gait.

Test plantar flexion of the foot.

Table 1: Peripheral Neuropathies

Sources: Fawcett, 2011; Heizenroth, 2007; Sawyer, et al, 2000


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occur due to improper positioning during surgery, patient symptomatology, and initial screening to determine injury and indication for further assessment to confirm a diagnosis.

Upper Extremity Neuropathies

Neuropathies of the upper extremity may present immediately following surgery or days afterward. Providers assessing

the patient may not link the clinical symptoms to surgical positioning. Neuropathies can result in significant disability for the patient and may lead to litigation. Early identification of an iatrogenic nerve injury is important for appropriate care and follow-up. Initial assessment should focus on clinical symptoms and identification of affected nerves.

Parameters to evaluate sensory and motor pathways may include, but are not limited to assessment of the median, ulnar and radial nerves (Figure 4). A normal sensation following a pinprick to the palmar surface of the

index finger indicates an intact median nerve. A normal sensation

following a pinprick to the palmar surface of the fifth finger indicates an intact ulnar nerve. The ability for the patient to actively flex and extend the thumb indicates an intact radial nerve. Injuries involving the brachial plexus include injury to ulnar, medial and radial nerves. The patient with a brachial plexus injury may present postoperatively with limited range of motion, inability to flex the arm, and pain involving the affected arm and shoulder. It is important that the preoperative assessment reflect any pre-existing motor or sensory deficits. The surgeon should be informed of any concerning clinical symptoms.

Brachial Plexus Injury

The brachial plexus is composed of the median, radial, and ulnar nerve cords that run through the shoulder and upper extremity (Figure 5). Injury may result if the upper extremity is abducted or anteriorly flexed greater than a 90-degree angle. In lateral position, an improperly positioned axillary roll may result in compression of the brachial plexus. In Trendelenburg

position, placement of a shoulder brace incorrectly, medially or laterally, may result in injury from direct tissue compression over the clavicle. Excessive extension, rotation, and lateral flexion of the head may result in stretching of the brachial plexus at the cervical site. Injury to the brachial plexus nerve may cause motor and/or sensory dysfunction to the muscles and skin of the shoulder, and arm (Winfree & Kline, 2005).

Median Nerve Injury

The median nerve runs along the path of the upper extremity in close proximity with the brachial artery. Injury can occur to the medial nerve when prolonged pressure is applied directly to the brachial artery. The medial nerve can be accessed at the antecubital space of the arm and the hand at the palmar surface of the carpal tunnel. Injury to the median nerve may result in motor and sensory dysfunction of the hand, thumb and/or two adjacent fingers (Fawcett, 2011).

Ulnar Nerve Injury

The ulnar nerve runs in close proximity to the ulnar bone. The nerve courses from the axilla, through the ulnar groove, located between the olecranon and the medial epicondyle of the humerus. The ulnar nerve is located just beneath the skin along the medial epicondyle and vulnerable to compression type of injury. To minimize risk associated with ulnar nerve injury the perioperative team should position the upper extremity in a manner to avoid direct compression, excessive extension, or pronation. Apply padding at the elbow to minimize risk for an ulnar nerve injury. Injury to the ulnar nerve may result in motor and sensory dysfunction of the loss and weakness on the medial forearm, third, fourth and fifth fingers (Heizenroth, 2007).

Figure 5: Brachial Plexus

Figure 4: Upper Extremity Nerves


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Radial Nerve Injury

The largest terminal branch of the brachial plexus is the radial nerve (Russell, 2006). The radial nerve supplies innervations to the muscles of the upper extremity and forearm. The radial nerve is located on the posterior side of the humerus, transversing down through the antecubital space to the digits. Compression of the radial nerve on a hard surface such as an operating room table may result in motor or sensory dysfunction. Injury to the radial nerve results in weakened grip with the inability to use the hand. Severe damage can cause wrist drop. Radial nerve damage should be suspected when there is an inability to oppose the little finger and thumb (Heizenroth, 2007).

Lower Extremity Neuropathies

Assess movement and sensation of the lower extremity and foot to determine any untoward outcomes related to possible nerve injury that may involve the peroneal, tibial and sciatic nerves following surgery (Figure 6). If the patient has the inability to dorsiflex the foot, this may indicate injury to the peroneal nerve. Inability to plantar flex the great toes may indicate tibial nerve damage. Assess the ability to abduct and adduct the lower extremity. Document and immediately report to the surgeon any

complaints of numbness, painsensory motor deficits of the lower extremity following surgery.

Sciatic Nerve Injury

The sciatic nerve is located in the buttock muscle and runs close to the ischial tuberosities as it enters the thigh area. The sciatic nerve is recognized as the largest nerve in the body. A patient positioned in a sitting position for prolonged periods of time without application of appropriate padding is at an increase risk for sciatic nerve injury. Any position that can result in overstretching of the sciatic nerve may result in injury. The perioperative team should avoid hyperflexation and external rotation of the lower extremity. Patient complaints of sensory or motor deficits consistent with sciatica, back or thigh

pain with radiation to digits, paralysis, or foot drop should be immediately reported and documented.

Femoral Nerve Injury

The femoral nerve begins at the spinal nerve roots and courses through the medial thigh. Nerve injuries attributed to improper patient positioning (e.g., overstretching of the femoral nerve in the lithotomy position), incorrect placement of retractors (e.g., self-retaining or fixed), or direct pressure to the nerve (Irvin, et al, 2004). Patient complaints of sensory or motor deficits that include the inability to flex the hip, inability to extend the knee, or numbness over the superior thigh and calf should be immediately reported and documented.

Peroneal Nerve Injury

The peroneal nerve is a branch of the sciatic nerve. The nerve is located along the lateral side of the popliteal fossa and courses around the fibula head. Injuries may occur as a result from prolonged direct pressure to the area of the popliteal fossa or compression of the fibular head. Compression of the fibular head may occur if there is inadequate padding of the lower extremity and the nerve becomes compressed due to pressure between the bone and a hard surface such as a metal stirrup. The nerve runs to the ankle and may be compressed and result in injury from prolonged crossing of the ankles. Patient complaints of sensory or motor deficits that include inability to dorsiflex the ankle, toes, or evert the foot should be immediately reported to the surgeon and documented.

Tibial Nerve Injury

The tibial nerve is a branch of the sciatic nerve, located in area of the popliteal fossa coursing to the ankle. Care must be taken to avoid any direct pressure with a hard object. The perioperative team should confirm adequate padding is in place and the padding is not excessive or causing unnecessary bulk to the popliteal fossa area. Patient injury may result to the tibial nerve if exposed to direct pressure by crossing the ankle or plantar flexation of the feet during surgery. Patient complaints of sensory or motor deficits that include the loss of motor control of the calf muscles, and weakness of plantar flexion of the ankle and digits should be reported and documented.

IntraoPeratIve acquIred Pressure ulcers

The prevalence of pressure ulcers in the United States continues

Figure 4: Lower Extremity Nerves


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to increase with an estimated 2.5 million patients treated annually (Institute for Healthcare Improvement [IHI], 2007). The incidence in the United States varies by clinical setting with estimates for acute care ranging from 0.4 percent to 38 percent (Ayello & Sibbald, 2008). Cost for treatment of pressure ulcers annually in the United States is estimated conservatively around $11 billion (Reddy, et al, 2006). Organizations such as the National Quality Forum and Centers (2010), Centers for Medicare and Medicaid Services (2010) and the Joint Commission (2010) are calling for increased awareness and efforts toward pressure ulcer prevention.

The Centers for Medicare and Medicaid Services (2010) in 2008 announced a new system that no longer reimburse facilities for the development of a pressure ulcer that occurs as a result of care received during the patient’s hospitalization. To receive coverage for the condition, it must be documented in the medical record as an existing preadmission finding. The intent of this new rule is that funding is to be spent on prevention and not treatment following an occurrence that could have been prevented with appropriate interventions. The new system places the financial burden for patient care of a pressure ulcer secondary to hospitalization on the facility. Facilities are carefully evaluating current practices against best practices and implementing changes as appropriate to promote safe patient care. This applies to the surgical services areas that include assessment of policies related to pressure ulcer prevention during surgery, procedures, protocols and use of appropriate positioning devices and padding with implementation of risk reduction strategies.

Pressure Ulcer Staging

Intraoperative acquired pressure ulcers may occur as a result from incorrect positioning, inadequate or improper use of protective devices and padding, and direct pressure on bony prominences causing excessive pressure for prolonged periods of time (Fawcett, 2011). Pressure ulcers can be diagnosed incorrectly as thermal or burn injuries (Stewart & Magnano, 2007). It has been cited that half of intraoperative lesions labeled as electrosurgical burns are not burns, instead these injuries are pressure ulcers (Stewart & Magnano, 2007). The perioperative team and staff who manage the patient should be familiar with a pressure ulcer classification and have the ability to differentiate a pressure ulcer from a thermal injury. Increased awareness and use of a pressure ulcer classification system will assist healthcare providers and team members to differentiate from a thermal injury and to correctly identify an

intraoperative pressure ulcer should one occur.

The International National Pressure Ulcer Advisory Panel (NPUAP) and the European Pressure Ulcer Advisory Panel (EPUAP) have developed a comprehensive clinical practice guideline based on existing research that is intended for use globally for the prevention and treatment of pressure ulcers (European Pressure Ulcer Advisory Panel [EPUAP] & National Pressure Ulcer Advisory Panel [NPUAP], 2009). The NPUAP and EPUAP define a pressure ulcer as “localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear” (NPUAP & EPUAP, 2009).

The perioperative team and health care providers caring for the patient throughout the postoperative period should be able to identify and classify an ulcer should findings from physical examination suggest an area of concern on the skin or underlying surface. The following six-stage classification developed by the NPUAP and EPUAP (2009) may be used to document physical assessment findings that describe the various stages of pressure ulcers.

Stage I:

Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area (Figure 7).

Further description:

The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Stage I may be difficult to detect in individuals with dark skin tones. May indicate “at risk” persons (a heralding sign of risk).

Figure 7: Stage I Pressure Ulcer


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Stage II:

Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister (Figure 8).

Figure 8: Stage II Ulcer


Presents as a shiny or dry shallow ulcer without slough or bruising.* This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation.

*Bruising indicates suspected deep tissue injury

Stage III:

Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling (See Figure 9).

Figure 9: Stage III Ulcer Further description: The depth of a stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and stage III ulcers can be

shallow. In contrast, areas of significant adiposity can develop extremely deep stage III pressure ulcers. Bone/tendon is not visible or directly palpable.

Stage IV:

Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling ( Figure 10).


The depth of a stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable.

Unstageable:

Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed ( Figure 11).

Figure 11: Unstageable Ulcer

Figure 10: Stage IV Ulcer


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Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as “the body’s natural (biological) cover” and should not be removed.

Suspected Deep Tissue Injury:

Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue (Figure 12).

Figure 12: Suspected Deep Tissue Injury


Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment.

Thermal Injury or Pressure Ulcer

Thermal injuries may occur during surgery as a result from inappropriate use of thermal, electrical, chemical, mechanical, and radiological sources (Stewart & Magnano, 2007; Rosenfield & Pitlyk, 1999; ECRI, 1993). It has been estimated that approximately one half of all reported electrosurgical burns are not burns, instead pressure ulcers (Stewart & Magnano, 2007). Due to the issue of misdiagnosed thermal injuries attributed to electrosurgery it is important to have an understanding of the mechanisms of injury for a lesion

located at a patient return electrode site.

Electrosurgery delivers a concentrated radiofrequency current for the effect of tissue cutting or coagulation. To achieve the desired tissue effect, the current must be concentrated at the tip of an active electrode. The delivery of the high current concentration results in the desired tissue effect of cutting or coagulation. When the current is delivered into the tissue, the current must safely return back to the electrosurgical unit without causing patient injury. This occurs as the high current concentration is delivered into patient tissue, the current passes through muscles and surrounding tissue and is dispersed at the site of a patient return electrode. The result is the current dispersal from a higher concentration to a lower current concentration, allowing for the current to return back to the electrosurgery unit without resulting in unintended tissue injury.

In the past electrosurgical patient return electrode site thermal injuries have been attributed to (Fickling & Loeffler, 2000):

• Incorrect placement of a patient return electrode over bony prominences, excessive hair and/or oily skin

• Patient return electrode displacement related to movement and repositioning following application

• Poor adherence of patient return electrode to the skin

• Patient return electrode displacement related to excessive tension on the cord

In 1981, the major innovation of contact quality monitoring systems was introduced and significantly reduced patient burns at patient return electrode site. This innovative technology assesses the quality of contact between the patient return electrode and the patient’s skin. If there is an area of compromise, the contact quality monitoring system will alarm and inactivate the system until safe patient parameters are initiated.

Patient Return Electrode Site Burn Characteristics

A thermal injury resulting from electrosurgery is dependent upon the length of exposure and current density. Unlike pressure ulcers, thermal burns are generally immediately diagnosed at the time of removal of the patient return electrode. Tissue characteristics consistent with a patient return electrode site pad burn include the following (Fickling & Loeffler, 2000).

• First Degree Burn: Tissue effect includes mild erythema,


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heat and pain without blistering

• Second Degree Burn: Tissue effect on the dermis includes erythema, blistering and hyperemia involving the tissue under the thermal burn

• Third Degree Burn: Involves thermal tissue damage of the entire dermis and may involve deeper levels of tissue

• Fourth Degree Burn: Involves thermal tissue damage of the dermis and deeper underlying tissue that may include the fascia, tendon, and muscles

A distinguishing factor for a thermal injury related to a patient return electrode is the time that the injury is diagnosed. An electrosurgical thermal injury is obvious at the time of removal of the patient return pad or within the first hour following (Pearce, et al, 1983). If the tissue damage occurs later in the postoperative period, the tissue damage should not be attributed or diagnosed as an electrosurgical burn. An electrosurgical burn initially may appear as deep non-uniform tissue damage affecting an area that is the circumference is generally not greater than 33.2mm (Fickling & Loeffler, 2000).

Pressure ulcers and electrosurgical burns are difficult to differentiate. Pressure ulcers have frequently been incorrectly diagnosed as electrosurgery burns (Stewart & Magnano, 2007). Unfortunately, this has resulted in incorrect risk reduction measures and wound care in the postoperative phase. The perioperative team members should be aware of any new skin lesion occurring following a surgical procedure greater than two hours. The skin lesion should be investigated for pressure necrosis (Stewart & Magnano, 2007). A thorough investigation will assist in identifying contributing factors to avoid future patient untoward outcomes. Recognition and understanding of the contributing factors allow the perioperative team members to implement risk reduction strategies to minimize future risk for occurrence (e.g., applying appropriate padding to redistribute pressure during surgery).

PreoPeratIve nursIng assessment

The preoperative patient assessment related to patient positioning includes information obtained from the patient’s medical record. This information will provide important data for the perioperative team to determine the appropriate positioning devices and aids necessary to appropriately position the patient for the duration of the surgical intervention. Review of the patient’s medical record should include: current medical

problem, surgical consent, past medical history, past surgical history, medications, allergies, laboratory data, diagnostic studies and social history.

Patients identified to be at an increased risk for the development of a pressure ulcer related to positioning include any patient over the age of 70; any scheduled vascular procedure; any procedure scheduled for a duration of 4 hours or longer; patients with poor nutritional status, small stature, diabetes and/or vascular disease (AORN, 2010).

Patient assessment parameters pertinent to patient positioning include, but are not limited to (AORN, 2010):

• Age

• Weight

• Height

• Body Mass Index

• Skin condition (e.g., erythema, ecchymosis, abrasion, edema, lesion, trauma)

• Range of motion deficit

• Nutritional status

• Prosthetic device

Vulnerable Surgical Patients

Additional risk factors that place a patient at an increased risk for an untoward patient outcome related to positioning include, but are not limited to age, surgery duration, nutritional state, obesity, hypothermic/hypovolemic statsus and diabetes.

Age

Any patient with minimal subcutaneous tissue is at an increased risk for an untoward outcome specific to positioning. A patient with minimal subcutaneous tissue has less tissue to provide protection at prominent pressure points, placing the patient at an increased risk during surgical positioning. Patients that may fall into this category include the very young (i.e., infant or child) and the geriatric. The geriatric patient may have compromised cardiovascular, pulmonary, and musculoskeletal systems that contribute to positioning risk. For example, a geriatric patient presenting with limited range of motion of joints related to osteoarthritis may present unique positioning challenges.


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Nutritional State

A patient with inadequate nutritional intake will present as underweight and malnourished. The malnourished patient may have significant compromise of the integumentary and musculoskeletal systems with direct implications related to surgical positioning. Clinical features of a malnourished state include poor skin turgor, thin, friable skin and decreased tissue mass over bony prominences. Additionally, the malnourished patient is at an increased risk for pressure ulcers, the development of infections, and for prolonged healing process (Stechmiller, 2010). All of these factors may result in an extended recovery period following surgery. In order to minimize patient risk, the perioperative team must carefully position the patient to avoid direct pressure to bony prominence pressure points and take measures to avoid any unnecessary delays during surgery.

Obesity

The morbidly obese patient is defined as having a body mass index [BMI = weight (kg)/height (m2)] of greater than 40 or over 100 pounds of the recommended weight (AORN, 2010). The morbidly obese patient may present with existing comorbidities that increase risk during surgery which include (Dybec, 2004):

• Diabetes

• Hypertension

• Hyperlipidemia

• Cardiovascular disease

• Sleep apnea

• Osteoarthritis

• Gastroesophageal reflux disease

• Depression

• Stress incontinence

• Menstrual irregularity

General considerations for the significantly obese patient include patient transport and transfer to an appropriate size operating room table that is wide enough and will support the patient’s weight. Adequate staff to safety transfer the patient is critical. Use of appropriate positioning devices and padding that will maintain a capillary interface pressure of 32 mm Hg or less (AORN, 2010).

Surgery Duration

The surgical patient is in a compromised state that usually includes the loss of mobility, sensory function, motor function, and ability to communication due to anesthesia. The patient must be safely positioned to minimize tissue injury by using appropriate positioning devices and padding to avoid excessive pressure to the tissue. The amount of pressure that the tissue can tolerate is based on many factors and is patient dependent. Patient risk for the development of pressure ulcers increase for surgical procedures exceeding two and one-half hours (Walton-Geer, 2009; AORN, 2010; Schultz, 2005). Use of appropriate padding to the pressure areas will more evenly distribute tissue pressure to avoid direct pressure that will contribute to tissue ischemia and injury.

Hypothermic/Hypotensive

Other risk factors identified to increase risk for the development of pressure ulcers include hypotensive episodes and a low core body temperature during surgery (EPUAP & NPUAP, 2009). Hypothermia occurs when the core body temperature falls below 36.0O C or 96.8O F. Hypothermia may result in thermal discomfort, abnormal platelet function, cardiac ischemia, alteration in drug metabolism, slow immune response, elevated infection risk and prolonged recovery (Wagner, 2011). Appropriate measures should be taken to maintain a normothermia state during surgery. Hypothermia and hypovolemia cause decreased tissue perfusion that may contribute to prolonged wound healing.

Figures 7 through 12, Illustrations are used with the permission of the National Pressure Ulcer Advisory Panel, March 2011


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PerIoPeratIve nursIng consIderatIons

Individualized Plan of Care

During the preoperative phase of care the perioperative nurse should assess and collect pertinent data to formulate an individualized plan of care. Assessment parameters should include identification of specific positioning needs for the surgical patient that will prevent injury during surgery. The information should be documented in the patient record. Any unusual findings should be communicated to the surgeon. Table 2 identifies patient diagnosis, interventions and outcomes related to positioning of the surgical patient.

taBle 2:

outcome o.80 Patient is free from signs and symptoms of injury related to positioning.

outcome defInItIon: Patient is free from signs and symptoms of positioning injury.

InterPretIve statement: Prevention of positioning injury requires application of the principles of body mechanics, ongoing assessment throughout the perioperative period, and coordination with the entire health care team. Preexisting conditions (e.g., poor nutritional status, extremes of age, vascular insufficiency, diabetes, impaired nerve function) may increase the patient’s risk of injury. Other factors, independent of nursing care (e.g., type and length of procedure, type of anesthesia) can contribute to the risk of positioning injury.

OUTCOME INDICATORS: • Skin condition (general): smooth, intact, and free from ecchymosis, cuts abrasions, shear injury, rash, or blistering. • Cardiovascular status: heart rate and blood pressure within expected ranges; peripheral pulses present and equal bilaterally;

skin warm to touch; free from cyanosis or pallor; capillary refill less than 3 seconds. • Neuromuscular status: flexes and extends extremities without assistance; denies numbness or tingling of extremities.

EXAMPLES OF INTERIM OUTCOME STATEMENTS: • The patient’s pressure points demonstrate hyperemia for less than 30 minutes. • The patient has full return of movement of extremities at time of discharge from the OR or procedure room. • The patient is unable to move lower extremities secondary to spinal anesthesia at time of transfer to postanesthesia care unit

(PACU). • The patient’s peripheral tissue perfusion is consistent with preoperative status at discharge from the OR or procedure room. • The patient is free from pain or numbness associated with surgical positioning.

PotentIallY aPPlIcaBle nursIng dIagnoses: • Risk for impaired skin integrity (00047): At risk for skin being adversely altered • Impaired skin integrity (00046): Altered epidermis and/or dermis • Risk for perioperative positioning injury (00087): At risk for inadvertent anatomical and physical changes as a result of

posture or equipment used during an invasive/surgical procedure• Impaired physical mobility (00085): Limitation in independent, purposeful physical movement of the body or of one of

more extremities • Ineffective protection (00043): Decrease in the ability to guard self from internal or external threats such as illness or injury • Ineffective peripheral tissue perfusion (00204): Decrease in blood circulation to the periphery that may compromise health

nursIng InterventIons and actIvItIes: Assesses baseline skin condition (A.240) Assesses skin condition for integrity (e.g., rash, breaks, ecchymosis) in consideration of the planned procedure.

• Examines patient skin condition, solicits patient’s perception of pain, and evaluates peripheral pulses, and identifies mobility impairments while patient is awake.


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• Assesses patient’s skin condition, including: • color (e.g., pallor, cyanosis, jaundice, pigmentation changes); • drainage; • edema; • evidence of previous surgery sites (e.g., fragile tissue such as scars, keloid formation); • fragile tissue (e.g., scars, keloid formations, dehiscence); • moisture (e.g., dry, sweaty); • presence of lesions, ulcers, or wounds; • temperature (e.g., warm, hot, cool); • texture (e.g., rough, smooth); • thickness (e.g., paper thin, thick); • turgor (e.g., decreased due to dehydration); and • vascularity (e.g., bleeding, bruising, ulcers).

• Interviews patient for history of skin disorders. • Reviews medical record for history of skin disorders and previous history of radiation exposure. • Assesses patient’s risk for skin injury related to thermal sources. • Assesses patient’s risk for skin injury related to mechanical hazards. • Assesses skin for injury from invasive devices (e.g., tubes, drains, indwelling catheters, cables). • Identifies the nursing diagnoses that describe the patient’s degree of risk for skin injury related to mechanical positioning

hazards.

Identifies baseline cardiac status (A.220) Assesses blood pressure, heart rate and rhythm, SAO2 , and other parameters as appropriate.

• Performs or reviews assessment of patient’s cardiac status and identifies deviations by: • assessing the patient’s vital signs; • auscultating for quality and regularity of heart rhythm; • evaluating the patient’s electrocardiogram [ECG] for cardiac dysrhythmias or other changes; • identifying presence of peripheral edema; • evaluating hemodynamic parameters, if available, such as: • central venous pressure (CVP),

- mean arterial pressure (MAP), - pulmonary artery pressure (PAP), and - pulmonary capillary wedge pressure (PCWP).

• Assesses cognition to include level of consciousness (LOC); orientation to person, place and time; and presence of restlessness or agitation.

• Reports variances from norms to appropriate members of health care team.

Identifies baseline tissue perfusion (A.220.2) Assesses tissue perfusion and identifies any impairments or risk factors prior to an operative or invasive procedure.

• Validates nursing assessment completed preoperatively. • Verifies anticipated procedure length. • Recognizes and anticipates fluid loss. • Follows facility policies, procedures, guidelines, or protocols for skin assessment preoperatively. • Interviews patient for history of vascular problems and surgical or invasive procedures. • Reviews medical record for vascular or cardiac history and surgical or invasive procedures. • Assesses risk for venous thromboembolism.

• assessing the patient’s extremities to include, but not limited to: - equality (e.g., quality, equal bilaterally), volume, and rate of peripheral pulse;


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- presence or absence of deep vein thrombosis; - color, size, and shape of extremities; and - warmth, dryness, and capillary refill, and

• identifying deviations to include, but not limited to: - blood pressure; - cardiac output; and - Doppler readings.

• Verifies patient’s preoperative hydration status, height, weight, skin turgor, and pulses. • Identifies and reports variances from norm (e.g., edema, ascites, adventitious breath sounds, elevated central venous pressure

[CVP]) to appropriate members of the health care team.

Identifies baseline musculoskeletal status (A.280)Assesses functional status of the musculature and skeletal system with regard to range of motion, mobility, deformity, and strength.

• Interviews patient and reviews chart for musculoskeletal medical history (e.g., scoliosis, lordosis, joint pain, osteoarthritis, osteoporosis).

• Interviews patient and reviews chart for surgical history. • Identifies history of falls and determines fall risk. • Assesses functional limitations while patient is awake and responsive, such as

• bone fractures; • gait; • mobility; • muscle strength; • paralysis (e.g., body part, spinal level); • presence of amputations; • presence of contractures; and • range of motion.

• Assesses sensory limitations, such as • tingling, • numbness, or • pain.

• Identifies the use of assistive mobility device, such as • wheelchair; • walker; • crutches; • cane; or • prosthesis, including type.

Identifies physical alterations that require additional precautions for procedure-specific positioning (A.280.1) Identifies those at risk for positioning injury and implements appropriate precautions.

• Reviews chart for information on patient’s weight, preexisting medical conditions, previous surgeries, laboratory results and nutritional habits.

• Identifies individuals at risk, for positioning injury (e.g., those with implanted devices or amputations, elderly adults, infants, the morbidly obese, those who have limited mobility, those who are incontinent).

• Assesses external devices (e.g., drains, catheters, orthopedic immobilizers). • Interviews patient for history of implanted devices. • Examines patient skin condition, evaluates patient’s level of consciousness, elicits patient’s perception of pain, evaluates

presence of peripheral pulses, and identifies mobility impairments. • Applies antiembolism stockings in a manner to minimize friction injuries.


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• Implements measures to prevent inadvertent hypothermia. • Maintains safe environment through use of elevated bed rails, application of safety straps, securing additional devices (e.g.,

oxygen tanks, IV poles, indwelling urinary catheter, chest tube). • Supervises placement of equipment and surgical instruments on patient. • Monitors patient for external pressures applied by members of health care team.

Verifies presence of prosthetics or corrective devices (A.40) Identifies presence of or use of prosthetics or corrective devices and modifies nursing care as indicated for planned procedure.

• Interviews patient for history of implanted devices and determines presence of metal and synthetic prostheses and implants, pacemakers, implanted electronic devices (IED), hearing augmentation devices, intraocular lenses, or plastic or fluid implants (e.g., penile implants, testicular implants, breast implants) and notifies appropriate members of health care team.

• Individualizes plan of care to accommodate prosthetic or corrective devices.

Positions the patient (Im.40) Determines the need for, prepares, applies, and removes devices designed to enhance operative exposure, prevent neuromuscular injury, maintain skin and tissue integrity, and maintain body alignment and optimal physiological functioning.

• Positions patient on stretcher with side rails up and wheels locked • while awaiting admission to the OR or • when procedure is completed on the stretcher.

• Modifies OR bed as necessary before attaching positioning devices. • Adapts positioning plan to accommodate patient’s limitations. • Supervises placement of equipment and surgical instruments on patient. • Maintains patient’s body alignment. • Maintains proper alignment of legs (e.g., uncrossed) during the surgical or invasive procedure.

Implements protective measures to prevent skin/tissue injury due to mechanical sources (Im.120) Prevents skin and tissue trauma secondary to mechanical sources including the use of devices such as positioning equipment, tourniquets, sequential compression devices, razors, clippers, tape, and the OR bed.

• Determines that devices are readily available, clean, free of sharp edges, padded as appropriate, and in working order before placing patient on the OR bed.

• Selects positioning devices based on patient’s identified needs and the planned operative or invasive procedure. • Monitors patient for external pressures applied by members of health care team. • Uses positioning devices to protect, support, and maintain the patient’s position. • Applies antiembolism stockings in a manner to minimize friction injuries.

Applies safety devices (Im.80) Prepares, applies, attaches, uses, and removes devices (e.g., restraints, padding, support devices) and takes action to minimize risks.

• Examines the surgical environment for equipment or conditions that pose a safety risk and takes corrective action. • Selects safety devices based on patient’s needs and the planned operative or invasive procedure. • Ensures that safety devices are readily available, clean, free of sharp edges, padded as appropriate, and in working order

prior use. • Applies safety devices to patient according to the plan of care, applicable practice guidelines, facility policies, and

manufacturers’ documented instructions. • Attaches padded arm boards to bed at less than 90-degree angle. • Places patient’s arms on arm boards with palms up and fingers extended or secures arms at patient’s side in neutral position. • Places fingers in position clear of table breaks or other hazards. • Prevents limbs from dropping below bed level to prevent compression of peripheral nerves. • Applies safety belt loosely so blood flow is not compromised.


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• Protects body parts from contact with metal portions of OR bed. • Protects patency of tubes, drains, and catheters. • Rechecks body alignment, extremities, safety strap, and all padding if repositioning occurs. • Removes positioning devices cautiously after surgery while maintaining body alignment and homeostatic status.

Evaluates tissue perfusion (E.270) Assesses tissue perfusion in perioperative phase of care

• Examines patient to assess peripheral pulses and/or neuromuscular impairments.

Evaluates musculoskeletal status (E.290) Observes and monitors musculoskeletal status throughout the perioperative phase of care.

• Evaluates functional limitations • Evaluates mobility impairments • Evaluates range of motion • Assesses tissue perfusion and identifies changes in extremities (e.g., pulses, skin color, temperature, turgor, capillary refill,

arterial oxygen concentration [SAO2] as appropriate). • Examines patient to assess neuromuscular impairments. • Examines sites related to positional devices for signs and symptoms of skin or tissue injury.

Evaluates for signs and symptoms of physical injury to skin and tissue (E.10) Observes for signs and symptoms of physical injury to skin and tissue acquired from extraneous objects.

• Compare postoperative status with preoperative nursing assessment and review of medical record. • Inspects and evaluates the patient’s skin, bony prominences, pressure sites, prepped area, and adjacent tissue for signs of

irritation or injury (e.g., discoloration, rash, abrasions, blisters, raised areas). • Solicits for complaints of pain or discomfort in areas other than the surgical incision. • Solicits for complaints of numbness or tingling (e.g., thermoregulation site, site of positioning aids). • Solicits for complaints of vision difficulty. • Evaluates circulation, sensation, and motion of extremities by

• inspecting color, size, and shape of extremities; • palpating for warmth, dryness, and capillary refill; • palpating for quality and volume of pulses.

• Reports unexpected variances to appropriate members of the health care team.

SOURCE:

AORN. Perioperative Nursing Data Set, 3rd Edition. Denver, CO: AORN; 2011.


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Diabetes

Diabetes is a risk factor for the development of pressure ulcers following surgery due to impaired tissue perfusion (Walton-Geer, 2009). Other symptomatology associated with diabetes include peripheral neuropathies, small vessel disease, atherosclerosis, and delayed healing.

InterventIons

Positioning Equipment

The perioperative team members must maintain the patient’s dignity and privacy throughout all phases of perioperative care. The surgeon’s procedure preference card should be reviewed. All requested positioning equipment and devices should be immediately available. Equipment should be clean and in appropriate working condition prior to transporting the patient into the operating room.

The perioperative team should be familiar with the application and correct use of all positioning equipment to avoid inadvertent patient injury. Any concerns or issues regarding patient positioning should be discussed with the surgeon and anesthesia provider.

Patient Transfer

The circulator nurse must confirm that the operating room and transfer stretcher are locked before patient transfer. There should be adequate number of persons immediately available for safe transfer of the patient from the stretcher to the operating room bed if assistance is indicated. Self transfer is appropriate for an awake patient, who is able to complete the task without issue.

The anesthesia provider is responsible for the management of the patient’s head and neck during patient transfer. This is important when positioning a patient into the prone or lateral position following intubation. The surgeon is responsible to supervise patient positioning. The surgeon will direct any specific positioning requirements related to specialized equipment or placement of the patient in a compromised position indicated for the scheduled procedure. Patient extremities and body alignment are supported during transfer and positioning. Special care is taken to prevent accidental removal of indwelling catheters, tubes, and cannulas. Following correct positioning of the patient, the circulator nurse should assess the patient for body alignment and confirm all pressure

points and high risk areas are adequately padded. The surgeon is responsible for the final inspection and confirmation of appropriate patient position (Bishop, 2009). The safety strap is confirmed to be applied and correctly positioned. All extremities are secured and appropriate padded to prevent injury.

surgIcal PosItIonIng consIderatIons and technIques Supine or Dorsal Recumbent Position

The supine position is one of the most frequently used positions during surgery. The supine position allows for the body to rest face up in a natural position. Modification of the supine position may include patient placement into positions such as Trendlenburg; reverse Trendlenburg, and a variety of sitting positions. Pressure point areas in the supine position include the occiput, scapula, olecranon, sacrum, ischial tuberosities and calcaneus (Figure 13).

In supine position, the patient’s arms should be placed and secured on a padded arm board or tucked to the side. The circulator nurse should assess the patient to determine that the spine is in correct alignment with the chest, and lower extremities. All pressure points should be assessed and application of appropriate padding to high risk areas to redistribute pressure during surgery to minimize risk for potential patient injury.

The head should be in a neutral position that is appropriately aligned with the chest, hips and lower extremities (AORN, 2010). Assessment of the head and neck will determine the need for additional padding and support. Use of a padded head positioner will assist in maintaining normal head alignment and redistribute pressure to minimize risk of postoperative occipital alopecia. Use caution when turning the head, as this may result in compromise of blood flow to the brain or spinal cord. The

Figure 13: Supine Position


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perioperative team should never use products that are not intended for the specific use of positioning during a procedure, due to potential to cause patient injury (Denholm, 2010).

The arms are placed on padded arm boards that are level with the body. Use of self locking arm boards is recommended due to the safety feature to prevent unintended movement of the arm board during the procedure. Scrubbed personnel should avoid leaning directly on the arm or arm board due to the potential for patient injury from excessive pressure. Injury may occur from direct pressure or hyperextension of the arm and shoulder. The hand should be positioned palm up to minimize injury to the ulnar nerve. Extension of the patient’s arm beyond a 90-degree angle may result in injury due to excessive stretching and compression to the brachial plexus nerves. Following correct positioning, each arm should be secured with a safety strap to maintain position of the arm on the arm board and to avoid excessive extension of the wrist.

The surgical procedure may require the patient’s arms and hands to be positioned along the side of the body in a neutral position. The arms are tucked to the patient’s side with the palms facing inward (AORN, 2010). Arms may be tucked to the side and secured with a lift sheet or padded sled. When tucking the arm with a lift sheet, the arm can be secured by placing a smooth lift sheet at least 2 inches above the elbow prior to tucking (Fawcett, 2011). There is a tendency, if not well tucked, for the arm to slide off at the elbow area, thereby potentially compressing the ulnar nerve against the metal railings of the OR bed. Padding should be applied at the elbow for protection of the ulnar nerve. If monopolar electrosurgery is used and the arms are tucked to the side, the hands should be secured with padding to prevent any possibility for skin to skin contact to minimize the potential risk for a thermal injury.

The circulator nurse should confirm that all IV tubing and monitoring cables are away from the ulnar nerve. Scrubbed personnel should assess for direct pressure on the patient from equipment anytime the operating room bed is raised or lowered. The scrub personnel should run their hand between the mayo stand and the sterile drape to ensure no direct patient contact has occurred. Additionally, assessment of the patient should occur following any positioning changes or changes involving positioning equipment.

The safety strap should be applied over the upper thighs and serves as a safety measure for both the local patient and the anesthetized patient. The safety strap is placed at least two

inches above the knees and applied loosely over the upper thighs to avoid impairment of circulation. Avoid placing the safety strap over bony areas that may result in excessive pressure. To decrease patient anxiety always communicate the intended use of the safety strap prior to applying.

A patient who is pregnant will benefit from being tilted to the left side with placement of a wedge pad directly beneath the right side. This will allow for the abdominal contents to be shifted to the left and avoid undue pressure to the vena cava and aorta (AORN, 2010).

Trendelenburg and Reverse Trendelenburg Position

A modification of the supine position is the Trendenlenburg and reverse Trendelenburg positions The Trendelenburg position involves a head-down tilt, feet up position. When positioned in Trendlenburg position, the abdominal viscera is tilted in a direction away from the pelvic area to provide the surgeon with optimal visualization. The reverse Trendelenburg position involves a head-up, feet down position. Pressure point areas in the Trendelenburg and reverse Trendelenburg position include the occiput, scapula, olecranon, sacrum, ischial tuberosities and calcaneus (Figure 14 and Figure 15).

Figure 14: Trendelenburg Position

Figure 15: Reverse Trendelenburg Position


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The Trendelenburg position allows for improved visualization during a surgical procedure and decreased blood flow to the operative site secondary to the gravitational blood flow (AORN, 2010). The position may also decrease lower extremity venous stasis due to the redistribution of blood. The patient is at an increased risk for a brachial plexus injury due to the increased pressure placed on the clavicle (AORN, 2010). The patient should be positioned slowly to avoid sudden changes in circulatory response such as hypotension. When positioned into the Trendelenburg or reverse Trendelenburg position there are increased risks for shear injuries.

To minimize the potential for injury to the brachial plexus, shoulder braces should be avoided when placing a patient in the Trendelenburg or reverse Trendelenburg position (AORN, 2010). The patient should be positioned in a face up position with the popliteal space directly over the lower operating room bed break. This will avoid any compression to the lower extremities if the position requires the feet to be lowered during the case. For reverse Trendelenberg position place a padded footboard at the end of the operating room bed to minimize injury to the feet and to support the weight of the patient (AORN, 2010).

The application of anti-embolism stockings and sequential pneumatic compression will help to minimize lower extremity venous status during the procedure. Assess the lower extremities to confirm there is no direct contact with equipment or the Mayo stand following placement into Trendelenberg or reverse Trendelenberg position. The hands should be safely positioned on an arm board or secured at the side of the body to avoid any type of crushing injuries to the hand and fingers with positioning.

Prone Position

The prone position may include a variety of modifications such as the knee-chest, kneeling, jackknife, or Kraske. In the prone position, the patient is positioned face down. Pressure point areas include the eyes, ears, cheeks, acromion process, iliac crest, breast, genitalia, patella, and toes (Figure 16).

There are a variety of positioning devices used to position the patient prone in a flexed position at the hip. If possible the arms should be positioned and tucked to the patient’s side (AORN, 2010). If placed over head, the arms are positioned on padded arm boards along the side of the patient’s head, extended in an outward position with a less than 90- degree angle. The palms should be placed in a pronated position on

the padded arm board with the elbows flexed (AORN, 2010). If positioned incorrectly in the prone position, the diaphragm movement may be severely restricted resulting in a limitation of expansion and air exchange. Unnecessary pressure of the anterior chest wall and the abdomen will result in increased respiratory effort with decreased respiratory effort and function (AORN, 2010).

The prone position may result in excessive pressure on the femoral veins. The excessive pressure to the femoral veins may compromise venous return to the heart and decrease cardiovascular output. Additionally, unnecessary pressure on the inferior vena cava in the prone position may result in hypotension and excessive venous pooling of the lower extremities.

Extreme caution should always be implemented when the patient is placed in the prone surgery position due to the potential for visual impairment and ocular occlusion. It is critical to place the patient in a position that will avoid any direct pressure on the area of the eye orbit and the position of the head should be at a level higher than heart level if the surgical procedure will permit (American Society of Anesthesiologist [ASA], 2006).

Positioning devices for the prone position may include a padded headrest, shoulder, and iliac crest supports, and padding aids for pressure points such as knees, ankles, toes, elbows, eyes, and clavicles. Pressure points will vary when in the prone position due to the various devices applied that may include but are not limited to the Wilson frame, four-post device, special laminectomy table, or kneeling frames.

Following the induction of general anesthesia on a transport stretcher, the patient is positioned onto the operating bed to an appropriate prone positioning device. Spinal alignment is maintained during positioning and assessed before and

Figure 16: Prone Position


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following to assure there is no torsion of the spinal column. The circulator nurse assures that there are a sufficient number of persons to move and position the patient safely. The patient is positioned to avoid compromise of the respiratory system. The patient is assessed to determine appropriate spinal alignment and ensure that the airway is not compromised.

The arms are positioned carefully by placing onto locked armboards place along the side of the patient’s head. The arms are placed in a downward position and brought upward to rest on padded armboards. Care is taken to avoid excessive range of motion on the shoulder with this maneuver. The elbows are flexed and the hands placed in a pronated position. Padding is placed at the elbow to minimize injury to the ulnar nerve.

Avoid placing pressure to breast or male genitalia. Padding should be placed beneath the feet and the pedal digits should be assessed to confirm free from pressure. The application of anti-embolism stockings and sequential pneumatic compression may be applied to facilitate venous return. A safety strap should be applied to avoid any direct compression and placed at least two inches above the popliteal space. Assess and confirm no direct pressure to the ears, eye globe, eyelids, nose, and cheeks. The scrub personnel should not lean on the patient as significant injury may occur.

Sitting Position

A Fowler’s (sitting), modified Fowler’s, and beach chair position involves placing the patient in a sitting position on the operating room table. Pressure point areas in the sitting position include the occiput, scapula, olecranon, sacrum, ischial tuberosities and calcaneus with special emphasis to the arms and shoulders (Figure 17).

In the sitting position, stabilization of the head, neck, shoulders and trunk must be safely maintained throughout the procedure to avoid extension or hyperflexion of the spinal

column. Depending on the procedure the patient may be placed in special head holding device (e.g., neurosurgical three-point headrest device). Assess for pressure points with the use of any head holding device.

The arms are positioned across the across the abdomen or on a padded mayo. The elbows should be padded to provide protection to the ulnar nerve. In addition to the pressure point areas listed above, assess the axilla and brachial plexus to determine if padding is indicated based on position and surgery. Padding of the axilla and brachial plexus may be necessary to avoid direct pressure of the upper extremities and shoulders to hard surfaces and minimize risk for nerve injury. The upper extremities should be secured to avoid inadvertent arm injury.

To minimize nerve injury to the sciatic nerve due to compression at the ischial tuberosities the knees should be slightly flexed with padding to the buttocks and lower extremities. Heel protectors should be applied to prevent pressure injury to the calcaneus. The application of compression stockings will help to minimize lower extremity venous status during the procedure. Following correct positioning, reassess that the safety strap is securely positioned.

Lithotomy Position

The lithotomy position involves a modification of the supine position. The patient’s lower extremities are elevated, abducted, and placed into leg holders or stirrups. The position devices may be modified depending on the procedure to accommodate a low, standard, high or exaggerated position. Pressure point areas in the lithotomy position include the occiput, scapula, olecranon, sacrum, ischial tuberosities and calcaneus (Figure 18).

Figure 17: Sitting Position

Figure 18: Lithotomy Position


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The patient may require compression stockings and/or sequential pneumatic compression pump prior to the procedure to decrease venous stasis and increase venous return. Due to the position, the lumbosacral area is at an increase risk for positioning injury due to excessive pressure. The buttocks should be positioned at the break of the bed and never over the edge. Postoperatively the patient may present with new onset lumbosacral pain related to incorrect positioning. Should there be a need to reposition the patient further down on the table, it is important to lift the patient and avoid dragging the patient to the edge due to shear forces and possible injury. Arms are positioned on padded armboards at a less than 90-degree angle to prevent injury to the brachial plexus or tucked to the side. Always assess hand position prior to lowering and raising the lower portion of the bed to avoid a crushing injury.

Stirrup selection is dependent upon the surgeon preference and patient condition. The perioperative team should be aware of the type of stirrup used and potential complications. The lower extremities should be assessed for pressure points, followed with application of padding to minimize potential for patient injury if indicated. Avoid applying too much padding as this can be dangerous and result in patient injury. Stirrup placement should be level. Positioning the patient into stirrups require two individuals to slowly raise and lower the legs simultaneously.

Scrubbed personnel should avoid leaning on the patient’s lower legs. This may result in direct pressure to the thigh resulting in external rotation and injury to the hip. Assess for pressure of the lower extremity against the stirrup to minimize injury to the peroneal nerve. Special care should be taken when utilizing candy cane stirrups as hyperextension of the knee may occur and result in significant patient injury. A safety strap may be difficult to place for a patient in the lithotomy positon (AORN, 2010). If possible carefully place the safety strap to allow for adequate surgery site access and avoid impeding diaphragmatic movement.

Lateral or Lateral Decubitus Position

The lateral position involves positioning the patient on the unaffected surgery side to provide access to the chest, kidney, or hip area. Pressure points in the lateral position include the ear, acromion process, iliac crest, greater trochanter, lateral knee and malleolus (Figure 19).

There are a variety of positioning devices used to stabilize the patient in the lateral position (e.g., beanbag). Following induction while in the supine position, the patient is moved

and safety positioned. Arms are placed on padded armboards positioned on one side of the patient. Padding is applied to the elbows to minimize ulnar nerve injury.

Figure 19: Lateral Position

The body is maintained in normal spinal alignment. The head is supported with a padded head positioner to maintain correct spinal alignment. Assess and pad the ear to minimize injury from direct pressure. The lower shoulder should be positioned slightly forward with a pressure-distributing axillary roll (Fawcett, 2011). Avoid direct pressure on the brachial plexus. Use only manufacturer approved positioning devices intended to redistribute pressure. Never use a rolled sheet, towel or intravenous bag as an axillary roll (Denholm, 2010). These may result in harming the patient unnecessarily. The lower leg is flexed at the knee and the remaining extremity is straight with padding between the legs. Apply additional padding to the lower leg at the knee, ankle and heel due to increase risk for pressure injury. Secure the patient on the bed with a safety strap, tape, beanbags or other positioning devices.

PosItIonIng challenges

Obese Patient

It is important the perioperative team recognize that an obese patient is different from being just a large patient and special precautions will need to be taken (Association of Anaesthetists of Great Britain and Ireland, 2007). It is estimated that nearly two-thirds of adult Americans are overweight with a body mass index [BMI = weight (kg)/height(m2)] > 25 kg/m2 (Brodsky & Margarson, 2010). Obesity is defined as a BMI > 30 kg/m2 and morbid obesity is defined as a BMI > 40 kg/m2 (Brodsky & Margarson, 2010). The patient with morbid obesity


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usually has several comorbidities that may include hypertension, diabetes mellitus, osteoarthritis and obstructive sleep apnea (Brodsky & Margarson, 2010). Transfer and positioning present unique challenges for the obese patient due to the patient size, extra weight and the increased risk for the untoward patient complications of pressure ulcers and neural injuries (Brodsky, 2002). These patients present an increased risk for skin breakdown and pressure ulcer development.

The perioperative nurse should perform an assessment to determine the specific positioning needs for the obese patient (Figure 20). Communication should be open ended between the surgeon, anesthesiologist and the perioperative team to promote patient safety and positive patient outcomes. This should include the development of a collaborative individualized plan of care that will address the specific positioning needs related to the desired position, positioning equipment and availability of sufficient padding.

Figure 20: Obese Patient

Unique considerations include, but are not limited to the following:

• Safely transfer the obese patient. The transfer of an obese or morbidly obese patient to the various areas within the operating room suite can be challenging and safety is of optimal concern. The obese patient ideally is transferred on a bed and not a hospital gurney or stretcher. Gurneys or stretches are small, uncomfortable, and may not accommodate the weight capacity of the obese patient.

• The decision to rent or purchase a bariatric bed is based on safety features and not price. Malfunction of bariatric hospital beds has resulted in fires, poor functioning of the side rails, and contributed to

patient falls and entrapment (Kramer-Jackman & Kramer, 2010). Considerations for bariatric bed selection include, but are not limited to International Electrotechnical Commission (IEC) 60601-2-38 National Recognized Testing Laboratory certified label, bed width, bed height, side rails and entrapment, mattresses and entrapment, bed system testing, required safety features (e.g., emergency CPR release, ability to place in Trendelenburg, bed adjustment, temperature storage features), and other desired features (e.g., trapeze for transfer) (Kramer- Jackman & Kramer, 2010).

• The perioperative team members should know the maximum patient weight of the bed for safe transfer, as it may be different from the patient weight for the bed (Kramer-Jackman & Kramer, 2010). It should be noted that some bed manufacturers have instructions for use that specify their bariatric bed should not be used for patient transfer or repositioning when the bed is occupied (Karmer- Jackman & Kramer, 2010). In the operating room, this is important information because the obese patient is usually transferred from a bariatric bed to the procedure bed due to safety precautions.

• The safety of the procedure bed is equally important. The procedure bed must be able to safely accommodate the desired surgical position, all of the necessary surgical equipment and accessories, and handle the maximum patient weight and height. There are procedural beds available that can accommodate a maximum patient weight ranging from 800 to 1000 pounds (AORN, 2010).

• The perioperative team should understand appropriate body mechanics and use appropriate staffing and available devices to transfer the obese patient. Awareness of appropriate body mechanics is important for perioperative team members to minimize risk to staff and the patient. Nursing is in the top ten professions to have work related back injuries (DeKastle, 2011). When positioning the obese patient it is important to have an adequate number of staff. Ideally, staff should consist of lift team members who have special training in safe aspects of lifting and positioning the obese surgical


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patient (DeKastle, 2011). Additionally, the use of appropriate lifting equipment and devices will aid with the transfer of the obese patient and reduce risk of injury to the staff and patient. It is important to consider specific positioning needs during the preoperative planning to determine the safest method for patient transfer and ensure that appropriate equipment and padding is working and immediately available.

• Position the patient to avoid potential injuries of pressure ulcers and neuromuscular injury. The obese patient is at an increase risk for the development of pressure ulcers and iatrogenic nerve injury (Brodsky, 2002). The patient should be positioned with positioning equipment and padding that will redistribute pressure in pressure point areas such as bony prominences (AORN, 2010). The perioperative team should have available an adequate number of positioning products with varying sizes. The positioning devices, pads and products should be appropriate for use for the obese patient to provide protection to promote intact skin integrity. It is important to use appropriate sized pads with extra width in order to redistribute the patient’s weight and promote circulation. The products should be flame retardant and latex free.

• Minimize risk for deep venous thrombosis and pulmonary embolism. The obese patient is at an increased risk to develop deep venous thrombosis and pulmonary embolism (Bonanomi, et al, 2007; Geerts, et al, 2004). The application of anti-embolism stockings and sequential pneumatic compression should be considered to facilitate venous return in the obese patient.

Robotic Surgery

Common patient positions during robotic surgery include the supine, Trendelenburg, and lithotomy positions. Pressure point areas in these positions may include but are not limited to the occiput, scapula, olecranon, sacrum, ischial tuberosities and calcaneus.

The equipment used for robotic surgery includes the surgeon console, the patient cart and the vision cart. Positioning for robotic surgery involves similarities with the standard positions, however there are some differences that the

perioperative team will need to be aware of to implement additional safety measures. Positioning is based on surgeon preference and the surgical procedure. Some physician’s prefer to position the patient and operating room bed directly under the surgical arms, other physician’s require different positioning. It is important to understand that once the robotic system is docked, there can be no repositioning of the patient (Cestari, etal, 2010). If repositioning of the patient is necessary, the robotic system must be undocked to allow for any repositioning.

Position the patient to avoid potential injuries of pressure ulcers and neuromuscular injury.

• Assess all pressure point areas and apply appropriate padding to high risk areas to redistribute pressure during surgery to minimize risk for potential patient injury. The surgical procedure may require the patient’s arms and hands to be positioned along the side of the body in a neutral position. The arms should be tucked to the patient’s side with the palms facing the thighs (AORN, 2010). Arms may be tucked to the side and secured with a lift sheet or padded sled. When tucking the arm with a lift sheet, the arm can be secured by placing a smooth lift sheet at least 2 inches above the elbow prior to tucking (Fawcett, 2011). Positioning of the arms should include application of padding at the elbow to provide protection of the ulnar nerve.

• Apply foam padding to head. The use of foam padding will assist in maintaining head alignment throughout the procedure. Due to the use of instruments and equipment in close proximity to the face, extreme care must be taken to provide adequate facial protection. This may include the use of foam padding to the face for protection and placement of a mayo stand over the patient’s face following draping (Shveiky, et al, 2010; Francis, 2006). Additional head support is applied to minimize risk for postoperative alopecia (Shveiky, et al, 2010).

Stablize patient to prevent sliding when placed into steep Trendenlenburg.

• The patient may be placed in steep Trendlenburg during surgery and the shoulders must be securely positioned to avoid sliding. Shoulder braces should not be used due to potential injury to the patient (AORN, 2010).


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One technique involves the use of cross-chest straps. Two straps of foam padding are placed on the chest over the acromino-clavicular joint and contralateral breast (Shveiky, et al, 2010). Each foam strap is secured with wide tape. There should be no direct pressure on the shoulder area.

Reassess patient positioning throughout the surgical procedure.

• It is important to reassess the patient’s position throughout the procedure. When placed in steep Trendlenberg for prolonged periods of time, the team may consider undocking the robot and placing the patient briefly in supine position (Shveiky, et al, 2010). Reassess all pressure point and make adjustments if indicated.

rIsk reductIon strategIes for PreventIon of PosItIonIng InjurIes

Standards of care for the surgical patient recommend the patient should maintain tissue integrity and should not incur injury from their surgical procedure. The potential for patient injury and subsequent legal suits can be diminished through the concerted efforts of the perioperative team members.

The following section outlines other actions and interventions recommended by the AORN that will assist to minimize patient risk related to positioning during a surgical or invasive procedure (AORN, 2010).

• Awareness and implementation of the AORN “Recommended Practices for Positioning the Patient in the Perioperative Setting.” The AORN is the leading authority for setting standards, guidelines and position statements regarding patient safety for the surgical patient. The recommendations are developed and based on available evidence based practice and provide recommendations that are applicable across a wide range of practice settings.

• Preoperative planning is essential as it relates to availability of positioning equipment and devices necessary for safe patient positioning. Communication should start at the time the surgery or invasive procedure is scheduled. Information may include, but is not limited to: age, height, weight, physical/mobility limitations and any request for positioning equipment and devices.

• Confirm the availability of requested and anticipated positioning equipment and devices. All equipment should

be inspected, confirmed to be in appropriate working condition and immediately available for use on all surgical procedures.

• Perform a thorough skin assessment and document any skin blemishes, rashes, brusies, open womb and/or ulcers and their location

• Inspect all positioning equipment and devices prior to use. Perioperative team members must ensure that equipment is in appropriate condition for use prior to patient application. This should be done prior to patient arrival into the operating room.

• Confirm with perioperative members availability of equipment during the time out period. Discuss availability of equipment and make any modifications to the plan of care as may be determined based on patient need.

• The Registered Nurse must conduct an appropriate assessment on the patient to determine risk and develop a plan to minimize risk to the patient based on assessment findings. It is important to identify factors that place the patient at an increased risk and to implement corrective actions and interventions to minimize the potential for an untoward patient outcome.

• Assure adequate number of individual are available to safely position the patient.

• Supine-to-supine position:

52 pounds (lbs) or less, two persons

52 lbs – 104 lbs, three persons

104 lbs – 157 lbs, four persons

157 lbs, three persons or more and mechanical lift devices

• Supine-to-prone position:

48.5 lbs or less, three persons

48.5 lbs – 72.7 lbs, four persons

>73 lbs, three or more persons and mechanical assistance devices

• Lithotomy position: two or more persons

• Lateral position:

76 lbs or less, three persons

76 lbs-115 lbs, four persons


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>115 lbs, four persons or more plus lateral positioning device

• Reassess the patient after positioning. The patient should be reassessed related to need specific to positioning following any positioning or repositioning that may occur before or during the surgical procedure.

• Use only appropriate positioning equipment. Use manufacturer approved positioning equipment and devices intended to redistribute pressure. Use of inappropriate equipment and items place the patient at an increased risk for positioning injury.

• Apply principles of positioning specific to the equipment used and the specific procedure. Apply specific nursing actions detailed earlier in the study guide to minimize risk when the patient is placed in a specific position.

• Following procedure conduct assessment to determine any potential concerns related to position and untoward patient outcomes and include hand off communication to the receiving staff. Assess the patient for any potential untoward patient outcomes related to positioning and communication to the receiving staff patient information to include but is not limited to: name, age, height, weight, procedure, surgery length, position, estimated blood loss, intraoperative medications, and skin condition following surgery.

documentatIon

The perioperative nurse is responsible for documenting assessment parameters collected during the preoperative, intraoperative, and postoperative phases of care. Documentation specific to patient positioning should include pertinent assessment data, devices utilized, intraoperative position and risk reduction strategies implemented by the perioperative team. Examples of risk reduction strategies may include, but not limited to placement and the type of padding applied, application of safety straps and any reassessment following repositioning of the patient. Following the procedure the periperative nurse should assess and document skin integrity for signs of erythema, blanching, edema, induration or skin breakdown. In addition to documentation, inform the surgeon and post anesthesia recovery area staff of any abnormal findings.

EvaluationEven with the most judicious positioning care, a patient may exhibit signs indicating an inadvertent intraoperative positioning injury. The patient may complain of pain and discomfort related to the body position required for the specific surgery. Soft tissue damage may result from placing the patient in a compromised position that extends beyond their normal range of motion. Injury may result from stretched muscles, tendons, ligaments and nerves. Any patient complaint of sensory and/or motor deficit such as burning, numbness, inability to move or decreased range of motion should be immediately reported to the surgeon with further evaluation to determine the etiology and appropriate treatment for the specific symptomatology.

comPetencY check lIst Perioperative team members should be able to demonstrate the following patient positioning competencies:

• Selects appropriate equipment and supplies based on patient assessment

• Positions surgical bed

• Positions the patient in center of bed

• Maintains appropriate body alignment

• Positions arms on arm boards

• Positions the patient to avoid direct contact with metal or hard surfaces

• Support all body parts

• Pads prominent bony prominences

• Pads high risk areas to avoid nerve compression

• Coordinates the move of an anesthetized patient

• Positions extremities with monitoring lines for easy access

• Maintains patient privacy

• Demonstrates appropriate use of safety straps

• Correctly positions the patient in various surgical positions to include:

Supine Position

Trendelenburg Position

Reverse Trendelenburg

Prone


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Sitting

Lithotomy

Lateral or Lateral Decubitus

conclusIon

Safe patient positioning is an essential element in achieving optimal patient outcomes during surgery. An incorrectly positioned patient may result in unexpected surgical delay, increase exposure to general anesthesia, and an untoward patient outcome. Unintended positioning patient outcomes include the development of postoperative pressure ulcers, musculoskeletal complaints, vascular compromise, and nerve damage. Each unexpected outcome may prolong a patient’s recovery, add additional financial cost for the patient and facility, and result in significant patient disability.

Positioning the patient during surgery involves participation of the surgeon, anesthesia provider and perioperative staff. Patient positioning is a collaborative team effort. To safely deliver patient care related to positioning each team member should have demonstrated competency to include knowledge and understanding of anatomy and physiology; the ability to identify high risk patients; skill and knowledge to select and use appropriate positioning equipment and devices;

and understanding of risk reductions strategies to minimize patient injury.

Understanding the unique attributes of positioning equipment and devices is important. Positioning equipment and devices should be selected based on the ability to redistribute pressure at high risk pressure point areas to minimize risk and injury. The selection should be based on safety features and not economics. Use of products not intended for positioning should be avoided due to the increased potential for patient injury.

Every perioperative team member plays an important role in promoting safe positioning practices. Continued vigilance of every perioperative team member will promote positive patient outcomes for the surgical patient.


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references

American Society of Anesthesiologist. Practice advisory of perioperative visual loss associated with spine surgery. Anesthesiology. 2006; 104(6):1319-1328.

Association of Anaesthetists of Great Britian and Ireland. Perioperative management of the morbidly obese patient. London: Association of Anaestehtists of Great Britian and Ireland; 2007.

Association of periOperative Registered Nurses. Recommended practices for positioning the patient in the perioperative practice setting. In: Blanchard J, Burlingame B, Chard R, Denholm B, Giarrizzo-Wilson S, Maxwell-Downing D, Mitchell S, Ogg M, Petersen M, eds. Perioperative Standards and Recommended Practices. 2010 Edition. Denver, CO: AORN; 2010: 327-350.

Association of periOperative Registered Nurses. Perioperative Nursing Data Set, 3rd Edition. Denver, CO: AORN; 2011, 96-97.

Ayello EA, Sibbald G. Nursing standard of practice protocol: pressure ulcer prevention & skin tear prevention. January, 2008. Hartford Insititute for Geriatric Nursing Web site. Available at: http://consultgerirn.org/topics/pressure_ulcers_and_skin_tears/want_to_know_more. Accessed October 1, 2010.

Berg KT, Harrison AR, Lee MS. Perioperative visual loss in ocular and nonocular surgery. Clinical Ophthalmology. 2010; 4:531-546.

Bishop P. Position the patient. In Phippen M, Ulmer B, Wells MP, eds. Competency for Safe Patient Care During Operative and Invasive Procedures. Denver, Co: Competency & Credentialing Institute; 2009:177-213.

Bonanomi G, Hamad G, Bontempo FA. Venous thrombosis and pulmonary embolism. In: Schauer PR, Schirmer BD, Brethauer S, eds. Minimally Invasive Bariatric Surgery. New York, NY: Springer; 2007:407-412.

Brodsky JB, Margarson, M. Weighing in on surgical safety. AHRQ WebM&M; http://webmm.ahrq.gov/case.aspx?caseID=221. August 2010. Accessed October 19, 2010.

Brodsky JB. Positioning the morbidly obese patient for anesthesia. Obesity Surgery. 2002; 12(6): 751-758.

Cestari A, Buffi N, Scapaticci E, Lughezzani G, Salonia A, Briganti A, Rigatti P, Montorsi F, Guazzoni G. Simplifying

Patient Positioning and Port Placement During Robotic-Assisted Laparoscopic Prostatectomy. Europeon Urology. 2010; 57(2010): 530-533.

Centers for Medicare and Medicaid Services. Hospital-acquired conditions (present on admission indicator). The Centers for Medicare and Medicaid Services. Available at: https://www.cms.gov/HospitalAcqCond/01_Overview.asp#TopOfPage. Accessed October 1, 2010.

Denholm B. Clinical issues: using IV bags to position patients. AORN Journal. 2010;92(1):106-107.

DeKastle RJ. Prevention back injuries. In: Watson DS, ed. Perioperative Safety. St. Louis, MO: Mosby Elsevier; 2011:252-272.

Dybec, RB. Intraoperative positioning and care of the obese patient. Plastic Surgical Nursing. 2004;24(3):118-122.

ECRI. Investigating device-related “burns.” Guidance [Health Devices]. 1993;22(7):334-52.

European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Washington DC: National Pressure Ulcer Advisory Panel; 2009.

Fawcett D. Prevention of positioning injuries. In: Watson DS, ed. Perioperative Safety. St. Louis, MO: Mosby Elsevier; 2011:167-178.

Fickling J, Loeffler C. Patient return electrode lesions. Valleylab Hotline News. 2000;5(3):1-4.

Francis, P. Evolution of robotics in surgery and implementing a perioperative robotics nurse specialist role. AORN Journal. 2006;83(3): 630-650.

Geerts WH, Pineo GF, Heit JA, Berggvist D, Lassen MR, Colwell CW, Ray JG. Prevention of venous thromboembolism: the seventh ACCP conference on antithrombotic and thrombolytic therapy. Chest. 2004;126(3 Suppl): 338S-400S.


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Grey JE, Harding KG, Enoch S. ABC of wound healing: pressure ulcers. BMJ. 2006;332(7539): 472-475.

Heizenroth PA. Positioning the patient for surgery. In: Rothrock JC, ed. Alexander’s Care of the Patient in Surgery. 13th ed. St. Louis, MO: Mosby Elsevier; 2007:130-157.

Institute for Healthcare Improvement. Relieve the pressure and reduce harm. May 21, 2007. Available at: http://www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/ImprovementStories/FSRelievethePressureandReduceHarm.html. Accessed October 2, 2010.

Irvin W, Andersen W, Taylor R, Rice L. Minimizing the risk of neurological injury in gynecologic surgery. Obstet Gynecol. 2004;103(2):372-383.

Khalaf H, Negmi H, Hassan G, Al-Sebayel M. Postoperative alopecia areata: Is pressure-induced ischemia the only cause to blame? Transplantation proceedings. 2004;36(7):2158-2159.

Kramer-Jackman K, Kramer D. Bariatric hospital bed safety and selection. Bariatric Nursing and Surgical Patient Care. 2010;5(1):1-12.

Maklebust J, Sieggreen M. Pressure Ulcers: Guidelines for Prevention and Management. 3rd ed. Ambler, Penn: Springhouse; 2001.

National Quality Forum. National voluntary consensus standards for developing a framework for measuring quality for prevention and management of pressure ulcers. Available at: http://www.qualityforum.org/Projects/Pressure_Ulcers.aspx. Accessed October 1, 2010.

Odom-Forren J, Watson DS. History of moderate sedation. In: Odom-Forren J, Watson DS, eds. Practical Guide to Moderate Sedation/Analgesia. 2nd ed. St. Louis, MO: Mosby Elsevier; 2005:1-19.

Park HS, Park KY, Yu SM. Factors influencing the development of pressure ulcers in surgical patients. Taekan Kanho Hakho Chi. 2005;35(1):125-34.

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Reddy M, Gill SS, Rochon PA. Preventing pressure ulcers: A systemic review. JAMA. 2006; 296(8):974-984.

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Sawyer RJ, Richmond MN, Hickey JD, Jarratt JA. Peripheral nerve injuries associated with anaesthesia. Anaesthesia. 2000; 55(10):980-991.

Schultz A. Predicting and preventing pressure ulcers in surgical patients. AORN Journal. 2005; 81(5):986-1006.

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Stechmiller, JK. Understanding the role of nutrition and wound healing. Nutr Clin Prac. 2010; 25(1):61-68.

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Wagner, VD. Normothermia management prevention of harm from perioperative hypothermia. In: Watson DS, ed. Perioperative Safety. St. Louis, MO: Mosby Elsevier; 2010: 179-194.

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POSITIONING POST TEST

1. Basic principles of patient positioning include: A. Providing optimal exposure at the surgery site B. Maintaining patient dignity and privacy C. Use of appropriate positioning devices and aids D. All of the above

2. Impaired tissue perfusion may occur when external normal capillary pressure exceeds: A. 32 mm HG B. 50 mm HG C. 65 mm HG D. 93 mm HG

3. ________ occurs when a body part is moved without lifting and the skin remains fixed. A. Nerve compression B. Moisture C. Shearing D. Friction

4. During surgery the patient may be exposed to excessive moisture from which of the following: A. Prepping solution B. Irrigation solution C. Body fluids D. All of the above

5. Nerve injuries that may result from improper positioning include: A. Tibial, peroneal, femoral nerves B. Brachial plexus C. Median, ulnar, radial nerves D. All of the above

6. Contact quality monitoring is a system that: A. Constantly monitors the quality of the pad/patient interface B. Constantly monitors the quality of the generator/pad interface C. Monitors changes in skin temperature D. Monitors skin moisture level

7. A distinguishing factor used to differential an electrosurgery thermal injury from an intraoperative pressure ulcer includes which of the following:

A. Presence of erythema and blistering B. Time of occurrence C. Lesion appearance D. Tissue depth


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8. Vulnerable surgical patients at an increased risk for positioning complications include all of the following except: A. Malnourished Patient B Healthy Patient C. Diabetic Patient D. Obese Patient

9. Several studies indicate the risk for development pressure ulcer increase for a surgical procedure duration greater than: A. 30 minutes B. 1 – 2 hours C. 2 1/2 – 4 hours D. 5-6 hours

10. Identify the correct positioning device used to redistribute pressure and minimize patient injury: A Intravenous bag B. Rolled towel C. Manufacture approved positioning device D. Rolled lift sheet

11. Identify the most frequently used position during surgery: A. Supine B. Prone C. Lithotomy D. Lateral

12. Extension of a patient’s arm greater than a __ angle may result in injury related to excessive nerve stretching and compression. A. 45 degree B. 60 degree C. 90 degree D. 120 degree

13. The obese patient is at an increased risk for the development of a postoperative pressure ulcer and nerve injury. A. True B. False

14. The number of persons recommended to safely transfer a patient weighing 124 pounds from a supine-to-supine position: A. Two persons B. Three persons C. Four persons D. Four persons and a mechanical lift device


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1. D2. A3. C4. D5. D6. A7. B8. B9. C10. C11. A12. C13. A14. C

TEST KEY


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regIstratIon/evaluatIon form

This form may be duplicated or copied

To receive continuing education credit, E-mail this form to: MSContinuing.Education.com

All sections of this form must be completed in order to receive acertificate of completion and to comply with the record-keepingrequirements of an approved provider.

Please type or print legibly

Name RNq LPN/LVNq Otherq

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evaluatIon

We appreciate your comments and evaluation of this offering which will assist us in planning future educational programs. Yes No1. Did the activity meet the stated objectives? • Review basic principles of safe patient q q positioning. • Identify intraoperative risk factors that may q q contribute to patient injury. • Discuss etiology of neurological injuries q q attributed to patient positioning. • Differentiate tissue characteristics of early q q stage pressure ulcer from thermal injury.

Yes No

• Describe perioperative nursing interventions qq to reduce risk for positioning injury. • List common pressure point areas associated qq positioning. 2. Did the activity meet your personal learning qq objectives?

3. Do you plan on changing any aspect of your qq practice as a result of this activity? If yes, what?

Scoring Key: 5=Excellent 4=Good 3=Average 2=Fair 1=Poor

Organization of content 5 4 3 2 1 Effectiveness of this learning method 5 4 3 2 1Relevance of content to practice 5 4 3 2 1Relevance of test questions to content 5 4 3 2 1Overall quality 5 4 3 2 1

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Offering accredited for two contact hours of continuingeducation for nurses.*Mandatory for CE

TesT QuesTion Responses

Please circle the correct response.1. a b c d 6. a b c d 11. a b c d2. a b c d 7. a b c d 12. a b c d3. a b c d 8. a b c d 13. a b c d4. a b c d 9. a b c d 14. a b c d5. a b c d 10. a b c d


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NOTES:


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NOTES:

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