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Patient positioning in operating theatre -gihs

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Patient positioning in operating theatre -gihs

  1. 1. POSITIONING INPOSITIONING IN OPERATING THEATREOPERATING THEATRE BYBY JEEVA.DJEEVA.D NURSING TUTOR,NURSING TUTOR, GANGA INSTITUTE OFGANGA INSTITUTE OF HEALTHHEALTH SCIENCE,COIMBATORE.SCIENCE,COIMBATORE.
  2. 2. AIM AND OBJECTIVESAIM AND OBJECTIVES • To provide knowledge on common surgical position of patient in during surgery • To identify and develop awareness of potential complication in patient positioning • To practice measure to avoid injuries and others complication to patient during surgery • To promote safety and safeguarding patient well-being during intra-operative period
  3. 3. ASSOCIATED RISK PATIENT FACTORASSOCIATED RISK PATIENT FACTOR • ADVANCED AGE • NUTRITIONAL STATUS • RESPIRATORY DISORDER • CIRCULATORY DISEASE • OBESE PATIENT • CHRONIC IMMOBILITY • PRESCRIBED MEDICATIONS • UNDERLYING MEDICAL PROBLEMS • NATURE OF SURGERY
  4. 4. GOAL OF PATIENT POSITIONINGGOAL OF PATIENT POSITIONING • PROMOTE PROPER PHYSIOLOGICAL ALIGNMENT • MINIMAL INTEFERENCE WITH CIRCULATION • PROTECTION OF SKELETAL AND NEUROMASCULAR STRUCTURES • OPTIMUM EXPOSURE TO OPERATIVE AND ANAESTHETIST SITE • PROVIDE PATIENT’S COMFORT AND SAFETY • MAINTENANCE OF PATIENT’S DIGNITY • STABILITY AND SECURITY IN POSITION
  5. 5. OPERATIVE NURSINGOPERATIVE NURSING ROLESROLES • Be knowledgeable on table mechanism • Prepare table attachments and accessories • Familiar with various patient position for optimum surgery access • Placement of patient to comfortable position • Correct position placement when a table break is needed intra-operatively • Prevent interference with respiration whilst moving
  6. 6. OPERATIVE NURSING ROLESOPERATIVE NURSING ROLES • Ensure patient is fully anaesthetized before positioning • Never reposition without anaesthetist supervision • Table fitting must be placed without obstruction to incision site • All fitting and attachments must be secure completely • Ergonomic care whilst positioning • Applying diathermy plate
  7. 7. INTRAOPERATIVE NURSINGINTRAOPERATIVE NURSING CONSIDERATIONSCONSIDERATIONS • Maintenance of unimpaired respiratory actionMaintenance of unimpaired respiratory action • Maintenance of physiological alignment fromMaintenance of physiological alignment from pressurepressure • Maintenance of adequate circulation avoidingMaintenance of adequate circulation avoiding impaired venous returnimpaired venous return • Maintenance of body temperature by limitingMaintenance of body temperature by limiting exposureexposure • Avoiding metal contactAvoiding metal contact • Sufficient staffs and equipments for positioningSufficient staffs and equipments for positioning • Pressure over the patientPressure over the patient
  8. 8. POSITION DEVICESPOSITION DEVICES • Patient-positioning devices can bePatient-positioning devices can be divided into two categoriesdivided into two categories • One which are primarily geared towardOne which are primarily geared toward pressure-reliefpressure-relief • Ones which are designed to provideOnes which are designed to provide better access to the surgical sitebetter access to the surgical site
  9. 9. TABLE ACCESSORIESTABLE ACCESSORIES AND ATTACHMENTSAND ATTACHMENTS
  10. 10. TABLE FEATURESANDTABLE FEATURESAND ATTACHMENTSATTACHMENTS HYDRAULIC WHEELED BASE STAND DETACHABLE FOOT REST MANUAL LEVER ARM BOARD SLIDING BARS BREAKABLE HEAD REST ELEVATED ARM REST LATERAL SUPPORT STIRRUPS METAL SOCKET OTHERS – PILLOWS, HEAD RING, SANDBAGS, ROLL SUPPORT, SOFT PADS, MATTRESS
  11. 11. POSITION DURING INDUCTION OFPOSITION DURING INDUCTION OF ANAESTHESIAANAESTHESIA • SUPINE POSITION • HEAD EXTENDED • NECK FLEXED • AIM – to visualized Oral, Pharyngeal and Tracheal spaces • POSSIBLE COMPLICATIONS – Trauma to lips and teeth, Jaw dislocations, laryngeal or vocal cords injury, epistaxis and trauma to pharyngeal wall
  12. 12. SURGICAL POSITIONINGSURGICAL POSITIONING
  13. 13. SUPINE OR DORSAL POSITIONSUPINE OR DORSAL POSITION • The patient lies flatThe patient lies flat on his backon his back • The arms may beThe arms may be placed beside theplaced beside the body, on an armboardbody, on an armboard or supported acrossor supported across the chest by liftingthe chest by lifting up the gown which acts as slingup the gown which acts as sling • Most common Operative position, such as inMost common Operative position, such as in Laparotomy, certain Gynecological and OrthopedicLaparotomy, certain Gynecological and Orthopedic casescases SUPINE/DORSAL POSITION
  14. 14. NURSING PRECAUTIONS POTENTIAL COMPLICATIONS Head not Hyperextended Backache resulted from unsupported lumbosacral curvature To ensure that arms are not abducted < 90° Paralysis of arm and hand due to over abduction Armboard is padded Hand in prone position Radial or Ulnar nerve palsy due to arm or elbow hanging or tight strapping Arms do not overlap or hang over table edge Patient protected from metal contact Continuous pressure on the calves may caused venous stasis resulting thrombosis which can lead to Pulmonary Embolisms Bony prominences are protected (occiput, scapulae, thoracic vertebrae, olecranaon, sacrum and coccyx, calcaneus)
  15. 15. Potential pressurepointsPotential pressurepoints
  16. 16. PRONE POSITIONPRONE POSITION • The patient lying with abdomen on table surface • Arms are placed above the head • Pillows are placed under the shoulders, hips and feet • Access for all surgeries involving posterior back (cervical spine, back, rectal area and dorsal extremities) PRONE POSITION
  17. 17. NURSING PRECAUTIONS POTENTIAL COMPLICATIONS Pillow or towel under shoulders and hip facilitate chest expansion, reduce abdominal pressure and venous oozing at operation site Lower neck and upper back pain resulting from hyperextension of head Radial and ulnar nerve palsy due to arm restrainer Hypotension resulted from pressure on inferior vena cava and pooling of blood in lower limbs Head not hyperextended, placed on side and kept supported Pressure point are well protected with pad (cheek, ear, acromion process, breast, genitalia, patella, dorsum of feet, toes) Shoulder dislocation during arm positioning Brachial plexus injury due to over extension of arm < 90°
  18. 18. Potential NerveInjuriesPotential NerveInjuries Brachial Plexus
  19. 19. Potential pressurepointsPotential pressurepoints
  20. 20. TRENDELENBURG POSITIONTRENDELENBURG POSITION • Patient lying in supinePatient lying in supine position with kneesposition with knees over lower break ofover lower break of the tablethe table • Head tilted down to 15Head tilted down to 15° or according to the surgeon° or according to the surgeon preferencespreferences • Arms may placed on the chest or armboardArms may placed on the chest or armboard • Common position for laparoscopic surgeries in pelvic orCommon position for laparoscopic surgeries in pelvic or lower abdominal regionlower abdominal region • Using of shoulder or knee braces may benefit patientUsing of shoulder or knee braces may benefit patient from slidingfrom sliding TRENDELENBURG POSITIONTRENDELENBURG POSITION
  21. 21. NURSING PRECAUTIONS POTENTIAL COMPLICATIONS Head not hyperextended and arm not abducted beyond 90° A 30° Trendelenburg position may caused changes in blood pressure, cerebral edema, congestion of face and neck Hands on padded armboards are supinated Arms not overlap the table edge or hang over A too steep position may result in cyanosis due to alteration on diaphragmatic extension and lung expansion Patient is protected from metal contact Bony prominences are well protected (occiput, scapulae, thoracic vertebrae, olecranon, sacrum and coccyx and calcaneus) Shearing of skin may occurred during positioning Returning leg first to reverse venous stasis
  22. 22. REVERSE TRENDELEBURGREVERSE TRENDELEBURG POSITIONPOSITION • Patient in supine position with arms by sides or on armboard • Table tilted to 5-10° raising the head • A sand bag may used below the neck and the shoulder blade for extension of neck (RUSS TECHNIQUE) • The head stabilized by head ring • Position often used for head and neck surgery to reduce venous congestion • To prevent stomach regurgitation during induction of anaesthesia REVERSEREVERSE TRENDELENBURG POSITIONTRENDELENBURG POSITION
  23. 23. NURSING PRECAUTIONS POTENTIAL COMPLICATIONS Head not hyperextended and arm not abducted beyond 90° Backache may result from unsupported lumbosacral curvatureHands on padded armboards are supinated Paralysis may occurred due to over abduction of armArms not overlap the table edge or hang over Ulnar and radial palsy due to elbow or arm hanging over the table or tight restraint Patient is protected from metal contact Bony prominences are well protected (occiput, scapulae, thoracic vertebrae, olecranon, sacrum and coccyx and calcaneus) Pulmonary embolisms as a result of venous stasis Cardiovascular overloaded due to quick returnAnti embolic stocking may be used to prevent blood pooling Skin shearing due to sliding down Foot bracket may used to prevent sliding
  24. 24. Potential pressurepointsPotential pressurepoints
  25. 25. LITHOTOMY POSITIONLITHOTOMY POSITION • Patient lies in supine position with buttocks at the lower break of the table • Lithotomy stirrups placed in position level with patient ischial spine • Arms placed over the chest or on an armboard • Legs are lifted together upwards and outwards and feet placed in knee crutch or candy cane • Common position for Urology, Gynecology, perineal or rectal operations
  26. 26. NURSING PRECAUTIONS POTENTIAL COMPLICATIONS Two person required to raised the legs simultaneously by grasping the sole and other hand supporting the calf Severe backache caused by too high stirrups Calf holder may resulted peroneal or femoral obturator nerve damageStirrups bars must be checked and secure before use and it’s height must be similar and not suspend the patient weight Osteoarthritis or stiff hips due to rough handling Too quick of lowering the legs may cause hypotensionThe buttock must be even with the edge of bed to prevent lumbosacral strain Femoral nerve damage due to acutely flexed thighs Anti embolic stocking may used to promote venous return Bony prominences protected Hip dislocation or fracture as a result faulty stirrups
  27. 27. Potential NerveInjuriesPotential NerveInjuries
  28. 28. TYPESOF STIRRUPSAND IT’STYPESOF STIRRUPSAND IT’S HAZARDSHAZARDS • KNEE CRUTCHKNEE CRUTCH – Pressure on peroneal nervePressure on peroneal nerve resulting footdrop andresulting footdrop and neuropathiesneuropathies • CANDY CANECANDY CANE – Pressure on distalsural andPressure on distalsural and plantar nerves which canplantar nerves which can cause neuropathies of thecause neuropathies of the footfoot – Hyperabduction mayHyperabduction may exaggerated flexion andexaggerated flexion and stretch sciatic nervestretch sciatic nerve • BOOTH TYPEBOOTH TYPE – May produce support moreMay produce support more evenly and reduce localizedevenly and reduce localized pressurepressure KNEE CRUTCH BOOTH TYPE CANDY CANE
  29. 29. LATERAL OR KIDNEY POSITIONLATERAL OR KIDNEY POSITION • Patient lying with onePatient lying with one side facing operativeside facing operative side uppermostside uppermost • The legs flexed to 90The legs flexed to 90°° and a pillow is placedand a pillow is placed in betweenin between • Upper arm rested onUpper arm rested on elevated arm rest and the other remains flexed on theelevated arm rest and the other remains flexed on the table or armboardtable or armboard • A roll bags may used below the hip/kidney to increasedA roll bags may used below the hip/kidney to increased exposure of iliac regionexposure of iliac region • Position is maintained by use of sandbags or bracesPosition is maintained by use of sandbags or braces attached to the side of bedattached to the side of bed • Head supported on a pillowHead supported on a pillow LATERAL/KIDNEY POSITIONLATERAL/KIDNEY POSITION
  30. 30. NURSING PRECAUTIONS POTENTIAL COMPLICATIONS If table break is used, it mustIf table break is used, it must be correctly level with iliacbe correctly level with iliac crest to prevent alteration increst to prevent alteration in respiration and severe post-respiration and severe post- operative backacheoperative backache If the kidney rest raised too much, the lungs will not expand adequately which will result in cyanosis and hypotension Injuries to brachial plexus, median, radial and ulnar nerves can occur if upper arm is not supported Ensure ear is not trappedEnsure ear is not trapped when supporting the headwhen supporting the head Arms are supported withArms are supported with adequate padding to preventadequate padding to prevent pressure necrosispressure necrosis If the head is not supported adequately, brachial plexus can get stretched Perineal nerve damage may resulted from compression on the down knee against hard surface Bony prominences are fullyBony prominences are fully protectedprotected (ribs, iliac crest, greater(ribs, iliac crest, greater trochanter, medial and lateral femoraltrochanter, medial and lateral femoral epicondyles, Tibial condyles, Malleous)epicondyles, Tibial condyles, Malleous)
  31. 31. Potential pressurepointsPotential pressurepoints
  32. 32. NEUROSURGICAL POSITIONNEUROSURGICAL POSITION • The patient may lying in a supine position, prone or lateral • The head is positioned either on soft ring or a spiked head rest • The head of the table may be tilted a little to facilitate venous drainage and to reduce CSF pressure in the brain NEUROSURGICAL POSITIONNEUROSURGICAL POSITION
  33. 33. NURSING PRECAUTIONS POTENTIAL COMPLICATIONS Ensure patient is fully anaesthetized before Similar complications as for prone and supine positionspositioning or insertion or head spike Development of skin pressure over the ear, cheek or face if using head ring for several hours (supine) Eye are well covered and fully protected by pads Position of spike must not harm patient’s ears and eyes Face is protected from pressure when in prone position Sciatic nerve damage may result due to long pressure on the dorsum of the foots Arms are in good anatomical alignments Bony prominences is protected whilst in all position
  34. 34. FRACTURE TABLE POSITIONFRACTURE TABLE POSITION • Patient positioned in supine with the pelvis stabilized against well padded vertical perineal post • Traction of operative leg is achieved either by boot- shaped cuff or devices with restraining straps • Un affected leg may be rested on well padded, elevated leg holder • Common position for ORIF of hip or closed femoral nailing FRACTURE TABLE POSITION
  35. 35. ORTHOPAEDIC FRACTURE TABLEORTHOPAEDIC FRACTURE TABLE
  36. 36. NURSING PRECAUTIONS POTENTIAL COMPLICATIONS Patient usually brought into theatre with hospital bed and traction applied Pressure due to perineal post may injured genital structure Ensure patient is anaesthetized before transfer onto OT table Fecal incontinence and loss of perineal sensation may occurred as a result of pressure injury to perineal and pudendal nerve Operating table are and attachments are ready according to surgeon preferences or standard manual Tight strap may resulted peroneal or femoral obturator nerve damage resulting in foot drop Cautions and extra care regarding shear force injuries, musculoskeletal and nervous system during transfer Bony prominences protected
  37. 37. KNEE-CHEST POSITIONKNEE-CHEST POSITION • Patient lying intoPatient lying into prone positionprone position • Both legs are abductedBoth legs are abducted and flexed togetherand flexed together at right anglesat right angles • Knees flexed and hipKnees flexed and hip elevatedelevated • Head, shoulders and chest rest directly on the tableHead, shoulders and chest rest directly on the table • Arms are placed above the headArms are placed above the head • Primary position for sigmoidoscopies and laminectomyPrimary position for sigmoidoscopies and laminectomy procedureprocedure KNEE-CHEST POSITIONKNEE-CHEST POSITION
  38. 38. NURSING PRECAUTIONS POTENTIAL COMPLICATIONS Legs moved together to prevent back strain Lower neck and upper back pain due to hyperextended head Arms gently lift up to prevent dislocation Ulnar or radial nerve palsies as a result tight arm restrainer Head is not hyperextended and placed to the side on a pillow Hypotension due to pressure on inferior vena cava and pooling of blood at lower extremities Bony prominences are well protected (cheek, ear, forehead, nose, eyes, acromion process, breast [women], genitalia, patella, dorsum of feet, toes) Shoulder dislocation or brachial plexus injury when placing the arms Patient may fall from table if bracket are not secure and fail to support patient’s weight
  39. 39. Potential pressurepointsPotential pressurepoints
  40. 40. SEMI-FOWLER’SAND FOWLER’SSEMI-FOWLER’SAND FOWLER’S POSITIONPOSITION • The patient positioned in supine with the upper body part is flexed to 45° or 90° and the knees slightly flexed and legs lowered • Arms may be placed over the laps or armboard • A footrest is used to prevent footdrop and head spike to stabilized head • Useful position for craniotomies, shoulder or breast reconstruction and ENTS’ SEMI-FOWLER’S AND FOWLER’S POSITION
  41. 41. NURSING PRECAUTIONS POTENTIAL COMPLICATIONS The cervical, thoracic and lumbar section of spine must be aligned once position established Orthostatic hypotension due to blood pooling at lower extremities Risk of venous thrombosis and embolisms as a result of impended venous return Extra padding are requires over bony prominences (coccyx, ischial tuberosities, calcaneus, elbows, knees and scapulae) High risk of development of skin pressure over affected bony prominences The use of anti-embolism stocking may necessary to assist venous return Alteration on chest movement due to restriction from rested arms or tight straps Reposition after surgery must be done gently and slowly
  42. 42. Potential pressurepointsPotential pressurepoints
  43. 43. JACKNIFE POSITIONJACKNIFE POSITION • A modification of prone position • Patient hips are supported on a pillow and the table are flexed at 90° angle, raising the hips and lowering head and body • A straps used over the thigh to prevent shearing and sliding • The head, face, shoulders, chest and feet are supported by soft pads or rolls to prevent bony pressure • Common position for hemorrhoidectomy or pilonidal sinus procedures JACKKNIFE POSITION (KRASKE’S)
  44. 44. NURSING PRECAUTIONS POTENTIAL COMPLICATIONS Pillow or towel under shoulders and hip facilitate chest expansion and reduced abdominal pressure Lower neck and upper back pain resulting from hyperextension of head Injury to genitalia due to pressureAnti-embolisms stocking aid venous return Radial and ulnar nerve palsy due to arm restrainerHead not hyperextended, placed on side and kept supported Hypotension resulted from pooling of blood in lower limbsPressure point are well protected with pad (cheek, ear, acromion process, breast, genitalia, patella, dorsum of feet, toes) Shoulder dislocation during arm positioning Brachial plexus injury due to over extension of arm < 90° Patient turn using log-roll technique end of procedure
  45. 45. POSITIONING OF ELDERLY PATIENTPOSITIONING OF ELDERLY PATIENT • FRAGILE SKIN SURFACES • ARTHRITIC JOINTS • LIMITED RANGE OF MOTION • PARALYSIS • LIFTING RATHER THAN SLIDING OR DRAGGING • AVOID OF ADHESIVE TAPE FOR STRAPPING • ADEQUATE PADDING FOR BONY PROMINENCES • ALLOW PATIENT TO POSITIONING BEFORE ANAESTHETIZED
  46. 46. POSITIONING OF PAEDIATRICPOSITIONING OF PAEDIATRIC PATIENTPATIENT • Think of ‘appropriate size’ • Right size for bed and attachments • May necessary to use safety strap • Never overextended limbs or keep in one position for longer periods • Due to small size, children are prone to and has greater risk of physiologically compromised • Appropriate positioning and observation are essential
  47. 47. • “It’s not all about technique. It’s about knowledge. If you know what causes complications and how to prevent them, you will be more likely to keep patient positioning in mind as something you should routinely monitor.”
  48. 48. THANK YOUTHANK YOU

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