PATIENTS AT RISK
THE ART & SCIENCE OF PATIENT POSITIONING™
A Patient Positioning injury is any dysfunction, discomfort, or injury not related
to the surgical site, they are for the most part PREVENTABLE
Presented by: Clare Tager, BSE, MFA, claretager@gmail.com
Designed by: Candi Forney, candiforney@charter.net
O.R. Nurses frequently do not hear....
• “Peripheral nerve injuries are a significant source of anesthesiarelated liability claims….The signs of denervation resulting from
acute injury appear 18 to 21 days after the event and are limited to a
specific nerve distribution. Recovery from peripheral nerve injury is
often slow, taking 3 to 12 months and during this time the patient may
experience pain and disability.” ~Basics of Anesthesia
“Freedom from injury related to positioning is
one of a number of expected outcomes of the
surgical experience.” ~ AORN Standards and Practices
“The perioperative nurse should view positioning as a
specialized piece of knowledge that when applied can
make a distinct difference in patient outcomes. The
practice of patient positioning is rational and logical.
Positioning is grounded in basic knowledge of anatomy
and physiology. The perioperative nurse approaches
positioning with a sense of urgency and intense
thought.” -~Alexander’s Care of the Patient in Surgery
The sequelae of improper positioning may be
temporarily discomforting, permanently disabling, or
may terminate in the death of the patient.
Operative position has been the direct cause of injuries to
delicate nerves, skeletal and supporting structures and other
organs and tissues; the sporadic reporting of such accidents
in the medical literature makes one suspect that many more
accidents occur, but fail to be reported. There are no reliable
statistical data to reveal the incidence of complications
related to body position during surgery.
~Dr. John Lincoln, Director of Anesthesia, Maine Medical Center,
Complications related to Body Positions During Surgery
Factors Leading to Injury
• Faulty Positioning of the Patient
• Undue Haste
• Failure to insist on an adequate number of
personnel before a position change
• Equal=potential for injury to patient (and staff!!)
• Post Op Backache one of the most common
complications!
Back Pain
Nerves at Risk
Brachial Plexus
Ulnar Nerve
Femoral Nerve
• Example: Hyper-flexion
can damage this nerve, i.e.
High lithotomy, when hips
are flexed too far back or
low lithotomy when leg is
stretched lower than the
plane the abdomen.
Saphenous Nerve
• Saphenous Nerve is a
branch of the femoral that
supplies cutaneous
branches to the inner
aspect of the leg and foot
• (Also distal, sural and
plantar nerves)
• Ankle straps of candy
canes can put pressure on
these which could result in
neuropathies of the foot.
Obturator Nerve
• Injury can occur as a result
of over-abduction of legs in
lithotomy.
• Patient loses sensation on
inner aspect of thigh (can’t
bring thighs together – gait
and balance affected.
• Leg has to swing out before
making contact with surface.
Sciatic Nerve
• Runs behind the length of the
leg down into the foot.
• Exaggerated flexion can
stretch it. So hyper abduction
or hyperextension can
damage this nerve.
• Think of a licorice stick –
stretch it. Now try and get it
back to it’s original size and
configuration. With enough
alternating hot and cold,
perhaps over time…but very
painful.
• Severe Pain, Foot drop, loss
of Knee flexion can result.
Flexing legs less than 45
degrees from abdomen is a
problem
Peroneal Nerve
• Branch of the Sciatic Nerve
• Comes out of the outer
aspect of the knee and affects
motor properties in the
anterior and lower leg
• The sensation of our legs
going to sleep is the result of
pressure placed on our
peroneal nerve
• It is one of the most
frequently damaged by being
compressed against stirrup
bar and can cause foot drop,
loss of dorsal extension of the
toes, inability to evert the foot
and loss of sensation below
the knee
PRESSURE/ ORAPU
O.R. ACQUIRED PRESSURE ULCERS
• “Documented incidents for ORAPU - between 8.5% and 66%”
• “Surgical positioning affects the risk and location of skin breakdown... adding surface
layers, i.e. cloth, warming blanket on top of a pressure reducing surface negates the
the effect of the pressure reduction surface and produces a higher pressure reading
than would be expected... Hence negativity.”
~Sharon Aronovitch, Phd., APRN,BC, CWOCN, Intraoperatively Acquired Pressure Ulcers,
1998
AORN STANDARDS &
PRACTICES 2008
• Capillary closure Point is 32mmhg, yet research studies found foam
overlays or replacement pads ( most OR bed mattresses) do not have
effective pressure reduction capabilities
•
Standard OR Table pads (even new ones) may not reduce capillary
interface pressure for all body types
•
Pressure readings as high as 150mmhg noted during prolonged
unrelieved pressure without position change
• Studies show viscoelastic overlays are effective for preventing skin
changes and pressure sore formation, offering most benefit for older
patient population, patients with chronic health problems, vascular
disease or surgical procedures over 2 hours
“Pressure ulcers slow patients recovery and
prolong their hospital stays, Worse, nearly 60,000
US hospital patients are estimated to die each year
from complications due to hospital acquired
pressure ulcers, The total annual cost for treating
pressure ulcers in the US is estimated at $11
billion”
~IHI 5 Million Lives Campaign, How to Guide: Prevent Pressure Ulcers
Medicare Regulations
• Effective October 2008, Medicare no longer
reimburses for a number of hospital-acquired
complications, including pressure sores.
• Aronovitch study: “Treatment of a single ulcer has
been estimated to cost up to $40,000.”
RESOURCES
•
SUZY SCOTT-WILLIAMS, RN, MSN,
CWOCN
•
susie.scott-williams@va.gov
•
Soozeq77@aol.com
•
(901) 523-8990 ext 7136, VA Medical
Center Memphis, TN
1. Sacrum
Anatomic Locations of Pressure Ulcers
2. Heel
36.9%
30.3%
Occiput
3. Ischium (sit bone)
8.0%
Scapula
4. Elbow
6.9%
Elbow
5. Malleolus (ankle bone)
6.1%
Trochanter
Sacrum
6. Trochanter (hip bone)
5.1%
7. Knee
3.0%
Ischium
Knee
8. Scapula (shoulder blade) 2.4%
Malleolus
9. Occiput (back of head)
1.3%
Amlung SR, Miller WL, Bosley LM, Adv Skin Wound Care. 2001 Nov/Dec;14(6):297-301.
10.
Amlung SR, Miller WL, Bosley LM, Adv Skin Wound Care. 2001 Nov/Dec;14(6):297301.
Heel
30.3%
Heels
Perioperative Pressure Ulcer (PPrU)
Defined
A Perioperative pressure
ulcer is any pressure related
tissue injury that presents i.e.
non-blanchable erythema,
purple discoloration or
blistering within 48-72 hrs
post-operatively and is
associated with the surgical
position. ~Scott Williams (2005)
Perioperative Pressure Ulcer
Prevention Program (PPUP)
•
Assessment
•
Perioperative Nursing Care Plan
•
Universal Pressure Precautions
•
Product Specification
•
Staff Education & Awareness
•
Evidence-based Best Practices
•
Nursing Specialty Collaboration
•
Quality Improvement
Scott Triggers™
• Assess pre-op for ALL
• Four Triggers
• Age over 62
• Albumin < 3.5
• ASA Score 3 or greater
• Surgery > 3 hours (time in/out of OR)
• Consider cardiac, vascular, trauma,
transplants, and bariatric procedures
• 2 or more triggers=HIGH RISK
SURGICAL PT
AGE
ALB
ASA
& TIME
Risks Involving Morbidly Obese and Bariatric
Patients
“Patients who are 100% over normal weight can have as
much as a 40-50% increase in the mechanical work of
breathing.” ~Alexander’s Care of the Patient in Surgery
Morbidly Obese Patients Positioning Concerns
• AORN Standards and Practices
• Bed must articulate and support 800 to 1000 pounds
• Mattresses should not ' bottom out"
• Width of legs determines whether lower legs remain on
•
•
•
bed or require stirrups. Check stirrup weight limit.
Consider table width extenders
Padded Sleds may be used to contain patients arms at
side of body as long as no excessive pressure on arms
Extra wide extra long safety straps ( Sheets not a good
substitute) One safety strap across thighs, one over
lower legs
In Supine, a roll or wedge under right flank to relieve
compression of vena cava
Morbidly Obese Patients Positioning Concerns
• AORN Standards and Practices
• In Prone, support for the upper chest and pelvis reduces
pressure on diaphragm and inferior vena cava
• Trendelenburg should be avoided, as added weight of
abdominal contents press against diaphragm, respiratory
compromise, increased blood flow from lower extremities
causes vascular congestion
• Lithotomy should be avoided if possible due to weight of
patients thighs pressing on abdomen and raising intraabdominal pressure, risk of circulatory complications
• Lateral position may be preferred instead of prone but
nursing awareness that shifts in weight can in itself
increase risk of falling
Lithotomy
The Time Factor
“A recent study showed that patients in the
lithotomy position sustained few injuries during the
first hour of surgery, but each additional hour
posed a 100-fold increase in the risk for
neuropathy.” ~Dr. Mark Warner, Mayo Clinic, Department
Anesthesia
Lithotomy
•
"Hyperextension can
sometimes occur
intraoperatively when the
patient is draped and you
cannot see the leg. The
resulting injury is foot drop
as well as loss of knee
flexion.“ ~Dr. John Martin,
Introduction to Positioning
Lithotomy Risks
• Hyperflexion = < 45 degrees from the
abdomen
• Hyperextension = No flexion in knee or leg
lower than the plane of the abdomen in low
lithotomy
•
“If arms are to be tucked, the sheet
needs to be under the patient and
not underneath the mattress. When
sheet is underneath the mattress,
arms can more easily drop over the
edge of the bed and become
compressed against metal sidebars
or mattress. Obese patients are at
risk here if patient is too large for
the OR bed. Such compression
could injure ulnar, radial, or
medial nerves”.
~Alexander’s Care of the Patient in Surgery
Stirrups
The first consideration in patient positioning is to...
FIT THE EQUIPMENT TO THE PATIENT, NOT
THE PATIENT TO THE EQUIPMENT
~Dr. John Martin, Positioning in Anesthesia and Surgery
Crutch Stirrup
• If stationary knee-padded
stirrups are used, excessive
pressure may be placed on the
popliteal space.
~Alexander's Care of the Patient in Surgery
Boot Stirrup
1. Place sockets at hips
2. Extend the legs if going into high lithotomy
3. Avoid over-flexion less than 45 degrees from
the abdomen
4. Avoid frog-legging
5. Line up toe, knee, opposite shoulder
Caution! Incorrect Positioning
Candy Canes
“What you do in the few minutes you have to
position a patient for surgery can have
lasting consequences. Candy Cane leg
holders that wrap around the head of the
fibula can compress the leg’s peroneal
nerve. Excessively abducted hips increase
the strain on the obturator nerve and can
cause pain and adductor muscle
dysfunction. Hip flexion increases pressure
on the femoral and lateral femoral cutaneous
nerves and can cause painful paresthesias.”
~Outpatient Surgery, 6 Patient Positioning
Pointers, Nathan Hall, Editor, April 2008
Placement of Patients Buttocks on Edge of OR Table
•“The Patients Buttocks
should not extend over the
break of the bed to prevent
pressure areas and to
decrease lower back strain”
~AORN Positioning Module
•Note also, Peroneal Nerve
area being compressed
against the post. ~Dr. John
Martin
Uncontrolled Abduction
• “Uncontrolled abduction of the
thigh can manifest in postoperative back-ache and
stretching in the groin area can
manifest as an Obturator nerve
injury.”
~AORN Positioning Module
Address at ACOG 2003
•
“Avoid candy cane stirrups! I know plenty of people still
use these things, but many of us are getting away from this
practice. They basically just hang your leg dangling there
which is not ideal for making sure the patient’s leg is safe.”
He encouraged his audience of fellow Gynecologists to use
boot stirrups and to do the positioning themselves adding,
“make sure you feel comfortable with the positioning because
you’re the one who’s going to be in court if there is a
problem.” ~Dr. William Hurd, Professor of Gynecology, Wright State
University, Dayton, Ohio, ACOG
AORN Standards 2009 Lithotomy
•
Stirrups placed at even height
•
Patients buttocks should be even with the lower break of
the procedure bed and positioned in a manner that
securely supports the sacrum on the bed surface
•
Legs moved slowly and simultaneously into holders to prevent
lumbosacral strain
•
To maintain hemodynamic status, legs slowly returned to bed
•
Arms extended less than 90 degree
AORN Standards 2009 Lithotomy
•
Arms tucked only if surgically necessary with elbows padded
and palms facing in toward body
•
Support should be provided over the largest surface area
of the leg positioner
•
Legs should not rest against stirrup posts
•
Scrubbed personnel should not lean against patients thighs
•
Patient should be in the lithotomy position for the
shortest time possible
1885 TRENDELENBURG
Staff Seeking Solutions
" It is definitely an uncomfortable position as the blood
pools in your head. Even the surgeon commented
‘We do this to our patients?’ If you have never been
positioned Trendelenburg, I suggest you try it. In our
peri-op classes we included many positions for our
new staff members to practice and to experience but
not Trendelenburg; now it will be on the list."
~Claudia Campese RN CNOR Nurse Educator, New Hanover Regional Medical Center,
Wilmington NC
Trendelenburg Risks
• Excessive pressure on clavicle =
compression on B-Plexus
• Morrell Closed Claims: B-Plexus injury
results from shoulder braces and
Trendelenburg
• Patients with history of heart failure
especially at risk
• Gravitational blood flow away from surgical
field masks blood loss.
• “Any variation of
Trendelenburg’s
position should be
maintained only as
long as necessary” Alexander’s Care of the Patient in Surgery
• Cerebral blood flow may fall as pressure
rises
• Trendelenburg can equal visual loss related
to decrease venous return from head
~ AORN Standards & Practices 2009
Alexander’s Trendelenburg
•
CONSIDERATIONS
•
Sliding in Trendelenburg:
Issues
•
Steeper degrees of
Trendelenburg with new OR
tables
•
Robotics
Deep Venous Thrombosis
•
“Steep Trendelenburg
position with acute flexion
of the knees may cause
kinking of a diseased
popliteal artery, with
damage resulting in
thrombosis, gangrene, and
requiring amputation.” ~Dr.
John Lincoln
Alexander’s Prone
Spinal Frame
Spinal Frame Positioning Issues
Morbidly Obese/Bariatric Patients
Spine Frame Positioning
Issues
•
Imaging
•
Visual Access
•
Decompressed Abdomen
•
Pressure Management
• Skin Sheer & Maceration
•
Face
•
Large Patients
•
Pediatrics
•
Brachial Plexus
• Breasts
The Prone Positioning of Patients on Operating Room Equipment:
Intraoperative Complications
~Helen Manson, Professor of Anesthesia, UK
•
Cardiopulmonary: Pressure on abdomen compresses inferior vena cava and
femoral veins,…. Support surfaces that minimize intraabdominal pressure are
essential
•
Respiratory: High airway pressures and large tidal volumes need to ventilate
a patient improperly positioned can have severe side effects. The patient who
is supported with the abdomen FREE FROM PRESSURE will have improved
ventilation and oxygenation
•
Neurological: Careful positioning of the neck and head support in a neutral
postion are ESSENTIAL to prevent neurological injury while prone. Use of
Chest Rolls led to increased venous pressure which .. decreased the perfusion
pressure in the spinal cord, causing Ischemia. CASE: Pt had fatal ischemic
stroke after being positioned prone with head rotated during spine surgery
•
Case: Postoperative Paraplegia due to cervical spine injury attributed to neck
positioning during prone spine surgery
The Prone Positioning of Patients on Operating Room Equipment:
Intraoperative Complications
~Helen Manson, Professor of Anesthesia, UK
• Patient support devices that minimize abdominal compression and maintain
neck and body in NEUTRAL position can help prevent these neurological
complications
• Nerve: Peripheral nerve injury one of the most frequent causes of morbidity
Compression of lateral femoral cutaneous nerve a common complication.
Support devices that minimize pressure are key
• Skin: Prone patients at high risk for pressure ulcer development Iliac bony
prominences common area for pressure ulcers . The prolonged nature of these
spinal procedures increase likelihood of shearing and pressure injury
• Pressure: Prone positioning may inadvertently damage breast tissue, resulting in
chest wall pain, breast tenderness or bleeding of nipples Longitudinal
positioning frames or rolls can damage breast tissue by direct compression,
Rupturing of implants also noted
• Ocular: Compared with Supine and lateral positioning, there is a ten fold
increase in eye injury associated with surgery while prone. In addition to Corneal
abrasions, POVL Postoperative visual loss is associated with spinal surgery.
67% of all cases of POVL registered on ASA Registry occurred after spine
surgery. ASA has a task force set up on post operative blindness due to prone
positioining
Nerve damage from Coronary Artery Bypass Surgery
can Affect Arm Functioning
~Dr. Joseph Episcopio, Senior Attending Physician in Internal Medicine, Lehigh Valley, PA
One seldom discussed complication is injury to the brachial plexus nerve
which should be considered when the patient complains of acute onset of
shoulder pain, weakness and/or paralysis following the surgical procedure.
•Brachial plexus injury
• Patient experience intense pain and discomfort
• Delay in return to employment(uncompensated)
• Possible permanent disability.
•Emergence of Emotional involvement
• Depression
• Anxiety
Mr. Thompson, 62 year retired pharmacist was
admitted to Methodist Medical in Memphis,
Tennessee in 1982 for a coronary bypass.....
• Pain
• Discomfort
• Emotional Involvment
• Depression
• Anxiety
• This gentleman was my
Dad...
Patient Advocacy…
You are the voice for the
voiceless