Positioning Pitfalls: Potential Injuries to look for in

Report
POSITIONING PITFALLS: POTENTIAL
INJURIES TO LOOK FOR IN THE POST-OP
PATIENT
DISCLOSURES

Teresa Casio

None

Darin Prescott

Speaker’s Bureau 3M
Healthcare
OBJECTIVES
Match positioning with common surgical and
invasive procedures.
 Describe types of injuries acquired during
invasive and operative procedures.
 Correlate patient reports or other physical
assessment data with potential positioning
injuries.

PRESSURE ULCERS REPORTED IN MN
2012
80
70
60
50
40
2012
30
20
10
0
Jan-Jun
Jul-Dec
http://www.health.state.mn.us/patientsafety/ae
/2013ahereport.pdf
ANATOMY REVIEW

Nerve Injuries
Stretching
 Compression


Pressure Points
When external pressure exceeds capillary pressure
 Boney prominences
 Skin close to bone/implant


Shear injuries

Lateral pressure and compression of skin and
underlying tissue
Position
Pressure Points
Arm (extended Elbow, shoulder
or tucked)
Potential sites for
Neural Injury
Brachial plexus and ulnar nerve
Padding
Elbow; fingers if tucked
heels, elbows, knees, spinal column,
and occiput.
Alignment concerns
Extended to side - <90 angle on
armboard with pad level with table
pad. Palm up. Support entire length of
arm. Extended over head – not
recommended
Tucked at side – Palm facing thigh
and tucked securely to avoid outward
rotation of shoulder.
Supine
occiput, scapulae, thoracic vertebrae,
olecranon process, sacrum/coccyx,
calcaneae,
knees
Brachial plexus, ulna and pudendal
nerves
Prone
head, eyes, nose, chest compression,
breasts, male genitalia, iliac crests,
knees, feet.
optic nerve, brachial plexus, ulnar
nerve
Lateral
axilla, hip, tibial tuberosity, ankle,
other boney prominences on
dependent side.
brachial plexus
neck
axillary role, pillow between legs
(lower leg flexed at hip, upper leg
straight), between knees, ankles, feet,
and tibial tuberosity.
Spinal column, prevent lateral neck
flexion.
Lithotomy
occiput, scapulae, thoracic vertebrae,
olecranon process, sacrum/coccyx, leg
if touching stirrup, heel
Obturator nerves, saphenous nerves,
femoral nerves, common peroneal
nerves, ulnar nerves, lumbar and
sacral pressure
occiput, elbows, lateral or posterior
legs, knees (to protect from stirrups),
heels
Lower back supported; minimal
rotation of hips, keep stirrups at even
height.
Elevate and lower legs slowly and
together when using stirrups
Knee-Chest
head, eyes, nose, breasts, male
genitalia, knees, feet, arms
brachial plexus, optic nerve, ulnar
nerve
head (provide access to airway & avoid
pressure to optic nerve protect
forehead, eyes, and chin), chest block,
knees, feet (to maintain neutral
position with no pressure on toes),
support shoulders and avoid excess
pressure on axilla from positioning
devices.
Head/neck neutral, support shoulders,
arm extended to sides and elbow
flexed <90°, palm down; spine should
be level, knees even, feet neutral.
brachial plexus, optic nerve, ulnar
nerve
head (provide access to airway & avoid
pressure to optic nerve protect
forehead, eyes, and chin), chest block,
hip support, knees in sling with
pillows, protect legs form frame, feet
(to maintain neutral position with no
pressure on toes), support shoulders
and avoid stretch injury.
Head/neck neutral, support shoulders,
arm extended to sides and elbow
flexed <90°, palm down; spine should
be level, knees even, feet neutral.
Jackson Table head, eyes, nose, breasts, iliac crest,
(Prone)
knees, feet, arms
occiput, hips, and legs parallel. Ankles
uncrossed.
Arms see above.
Head/neck neutral.
*Use padded foot-board if steep
reverse trendeleberg
head (provide access to airway & avoid Chest rolls to allow chest movement
pressure to optic nerve protect
and decrease abdominal pressure,
forehead, eyes, and chin); chest rolls,
Head/neck neutral – maintain cervical
iliac crest roll, knees, feet (to maintain neck alignment; arms extended to
neutral position with no pressure on
sides and elbows flexed <90°, palm
toes); support shoulders and avoid
down; Breasts and male genitalia free
from tortion.
excess pressure on axilla from
positioning devices.
SHEAR
RISK FACTORS

Who is at risk?


Everybody!
Diagnosis = Risk for positioning injury related to
the operative or invasive procedure
(Phippen, Ulmer, & Wells, 2009)

Anesthetic drugs

Previous injury

Length of time of surgical procedure
PRE-ASSESSMENT

Braden Scale
Common tool for determining risk for skin
breakdown
 Not useful to OR Nurse
 Eyes on patient; Head to toe assessment



Appropriate for every surgery?
Communication between the admit nurse and OR
nurse
Past medical history
 Physical limitations
 Presence of implants
 Skin integrity concerns

(“Healthcare Risk Control” 2011)
PRE-ASSESSMENT

Example – Patient admitted through Same Day
unit then admitted after surgery
Pre-op skin assessment documented “intact with
small red area top of right 3rd toe”
 5 days post op the patient developed open pressure
ulcer on right foot involving the 3rd toe
 Same Day Admission and OR Nurses’ assessments &
documentation supported this as a pre-existing
condition

JEWELRY

Risk of Jewelry in Surgery
Infection or burn
 Pressure ulcers
 Third spacing


Waivers
COMMON EQUIPMENT
Padding
 Tables
 Positioners
 Stirrups
 Specialty tables
 Other equipment

COMMON POSITIONS & PROCEDURES

Supine:





Lateral




Total Hip Arthroplasty
Thoracoscopy
Nephrectomy
Prone



Laparotomy
Carpal Tunnel Release
Knee Arthroscopy
Eye procedures
Laminectomy
Pilonidal Cyst
Lithotomy


Vaginal Hysterectomy
DaVincci robotic procedures
SUPINE
TRENDELENBERG
LATERAL
http://www.pitt.edu/~position/Lateral/lateral_basic.h
tm
PRONE
http://staanbiomedengg.tradeindia.com/prone-position-for-spine-surgery121222.html
LITHOTOMY
http://www.pitt.edu/~position/Lithotomy/lithotomy1_1.ht
m
POST OP ASSESSMENT

Outcome Indicators





Is the patient able to resume pre-procedure patters of
ambulation?
Does the patient report tingling, numbness,
cramping, pain or ache in the joints?
Does the patient report weakness and stiffness in the
upper or lower extremity?
Can the patient abduct, adduct, flex, and extend the
upper and lower extremities without experiencing
pain or discomfort?
Does the patient show signs of disruption or
breakdown of skin layers, especially over bony
prominences?
(Phippen, Ulmer, & Wells, 2009)
PERIANESTHESIA/PERIOPERATIVE

FOCUS
Munro Pressure Ulcer Risk Assessment Scale
Masters Thesis
 AORN is currently working on validation of tool
 Plan for further research on its application
 Incorporates 3 phases of care

Admission
 Intraoperative
 Recovery


Score is based on cumulative time and patient
position
(Munro, 2010)
REFERENCES
Bouyer-Ferullo, S. (2013). Preventing perioperative peripheral nerve injuries. Association of Peri-Operative
Registered Nurses
Journal, 97(1), 110-124. doi:10.1016/j.aorn.2012.10.013
Healthcare risk control: Patient positioning. (2011). ECRI Institute, 4, 1-9. Retrieved September, 2013 from
https://www.ecri.org/Documents/RM/HRC_TOC/SurgAn6ES.pdf
Fred, C., Ford, S., Wagner, D. & Vanbrackel, L. (2012). . Association of PeriOperative Registered Nurses
Journal, 96(3),
251-260. Retrieved from http://download.journals.elsevierhealth.com/pdfs/journals/00012092/PIIS0001209212006837.pdf
Galvin, P.A. & Curley, M.A. (2012). The braden Q+P: A pediatric perioperative pressure ulcer risk assessment
and intervention tool. Association of PeriOperative Registered Nurses Journal, 96(1), 261-270.
doi:10.1016/j.aorn.2012.05.010
Munro, C.A. (2010). The development of a pressure ulcer risk-assessment scale for perioperative patients.
AORN Journal, 92, 272-287. doi:10.1016/j.aorn.2009.09.035
Phippen, M.L., Ulmer, B.C., & Wells, M.P. (2009). Competency for Safe Patient Care During Operative and
Invasive Procedures. Denver, CO: Competency Credentialing Institute.
Primiano, M., Friend, M., McClure, C., Nardi, S. Fix, L., Schafer, M., Savochko, K. &McNett, M. (2011).
Pressure ulcer risk prevalence and risk factors during prolonged surgical procedures. Association of periOperative Registered Nurses Journal, doi:10
.1016/j.aorn.2011.03.014
Sutton, S., Link, T. & Makik, M.B (2013). A quality improvement project for safe and effective patient
positioning during robot-assisted surgery. Association of Peri-Operative Registered Nurses Journal, 97(4), 448456. doi:10.1016/j.aorn.2013.01.014

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