Patient Positionin OT & AT Class a detailed description

sadad

1. PATIENT POSITIONING FOR VARIOUS SURGERIES Dr. SOUMYAJIT JANA Dept. of General Surgery AIIMS BHUBANESWAR

2. AIMS 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. ASSOCIATED RISK PATIENT FACTOR • ADVANCED AGE • NUTRITIONAL STATUS • RESPIRATORY DISORDER • CIRCULATORY DISEASE • OBESE PATIENT • CHRONIC IMMOBILITY • PRESCRIBED MEDICATIONS • UNDERLYING MEDICAL PROBLEMS • NATURE OF SURGERY

4. GOAL OF PATIENT POSITIONING Promote proper physiological alignment Minimal interference with circulation Protection of skeletal and neuromuscular 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. OPERATIVE NURSING ROLES Be knowledgeable on table mechanism Prepare table attachments and accessories Familiar with various patient position for optimum surgery access Placement of patient to comfortable position Correct position placement when a table break is needed intra-operatively Prevent interference with respiration whilst moving. Ensure patient is fully anaesthetized before positioning Never reposition without anaesthetist supervision Table fitting must be placed without obstruction to incision site All fitting and attachments must be secure completely Ergonomic care whilst positioning Applying diathermy plate

6. INTRAOPERATIVE NURSING CONSIDERATIONS Maintenance of unimpaired respiratory action Maintenance of physiological alignment from pressure Maintenance of adequate circulation avoiding impaired venous return Maintenance of body temperature by limiting exposure Avoiding metal contact Sufficient staffs and equipments for positioning Pressure over the patient

7. POSITION DEVICES Patient-positioning devices can be divided into two categories: One which are primarily geared toward pressure-relief Ones which are designed to provide better access to the surgical site

8. TABLE ACCESSORIES AND A TTACHMENTS

9. TABLE FEATURES AND ATTACHMENTS

10. Guidelines for Patient Positioning Proper execution is needed during patient positioning to prevent injury for both the patient and the nurse. Remember these principles and guidelines when positioning clients: Explain the procedure.  Explain to the client why their position is being changed and how it will be done. Rapport with the patient will make them more likely to maintain the new position. Encourage the client to assist as much as possible.  Determine if the client can fully or partially assist. Clients that can assist will save strain on the nurse. It will also be a form of exercise, increasing the client’s independence and self-esteem. Get adequate help.  When  planning  to move or reposition the client, ask for help from other caregivers. Positioning may not be a one-person task. Use mechanical aids . Bed boards, slide boards, pillows, patient lifts, and slings can facilitate the ease of changing positions. Raise the client’s bed.  Adjust or reposition the client’s bed so that the weight is at the nurse’s center of gravity level. Frequent position changes.  Note that any correct or incorrect position can be detrimental to the patient if maintained for a long time. Repositioning the patient every two hours helps prevent complications like  pressure ulcers  and skin breakdown. Avoid friction and shearing.  When moving patients, lift rather than slide to prevent friction that can abrade the skin making it more prone to skin breakdown. Proper body mechanics. Observe good body mechanics for your and your patient’s safety. Position yourself close to the client. Avoid twisting your back, neck, and pelvis by keeping them aligned. Flex your knees and keep your feet wide apart. Use your arms and legs and not your back. Tighten abdominal muscles and gluteal muscles in preparation for the move. A person with the heaviest load coordinates the efforts of the nurse and initiates the count to 3.

11. Support Devices for Patient Positioning The following are the devices or apparatus that can be used to help position the patient properly . Bed Boards.  Bed boards are plywood boards placed under the mattress’s entire surface area and are useful for increasing back support and body alignment. Foot Boots.  Foot boots are rigid plastic or heavy foam shoes that keep the foot flexed at the proper angle. It is recommended that they should be removed 2 to 3 times a day to assess the  skin integrity  and joint mobility. Hand Rolls.  Hand rolls maintain the fingers in a slightly flexed and functional position and keep the thumb slightly adducted in opposition to the fingers. Hand-Wrist Splints.  These splints are individually molded for the client to maintain proper alignment of the thumb in slight adduction and the wrist in slight dorsiflexion. Pillows.  Pillows provide support, elevate body parts and splint incision areas, and reduce postoperative  pain  during activity, coughing, or deep breathing. They should be of the appropriate size for the body to be positioned .

12. Contd.. Sandbags . Sandbags are soft devices filled with substances that can be used to shape or contour the body’s shape and provide support. They immobilize extremities and maintain specific body alignment. Side Rails.  Side rails are bars along the sides of the length of the bed. They ensure client safety and are useful for increased mobility. They also assist in rolling from side to side or sitting in bed. Check with your agency’s policies regarding the use of side rails as they vary from state to state. Trochanter Rolls.  These rolls prevent the external rotation of the legs when the client is in the supine position. To form a roll, use a cotton bath blanket or a sheet folded lengthwise to a width extending from the greater trochanter of the femur to the lowest border of the popliteal space. Wedge Pillows.  Are triangular pillows made of heavy foam and are used to maintain legs in abduction following total hip replacement surgery .

13. POSITION DURING INDUCTION OF ANAESTHESIA 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

14. Various Surgical Positioning Supine or Dorsal Positioning. Prone Positioning. Trendelenburg Reverse Trendelenburg Lithotomy Lateral or Kidney Positioning Neurosurgical Positioning Fracture Table Positioning (Trauma Surgeries) Knee Chest. Semi Fowler’s & Fowler’s Positioning Jacknife Position.

15. SUPINE OR DORSAL POSITION The patient lies flat on his back The arms may be placed beside the body , on an armboard or supported across the chest by lifting up the gown which acts as sling Most common Operative position, such as in Laparotomy , certain Gynecological and Orthopedic cases

16. Potential pressure points

17. PRONE 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)

18. Potential Nerve Injuries & Potential pressure points

19. TRENDELENBURG POSITION Patient lying in supine position with knees over lower break of the table Head tilted down to 15° or according to the surgeon preferences Arms may placed on the chest or armboard Common position for laparoscopic surgeries in pelvic or lower abdominal region Using of shoulder or knee braces may benefit patient from sliding

20. REVERSE TRENDELEBURG POSITION Patient in supine position with arms by sides or on arm board 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

21. Potential pressure points

22. LITHOTOMY POSITION Patient lies in supine position with buttocks at the lower break of the table Lithotomy stirrups placedin 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

23. Potential Nerve Injuries

24. TYPES OF STIRRUPS AND IT’S HAZARDS • KNEE CRUTCH – Pressure on peroneal nerve resulting footdrop and neuropathies • CANDY CANE – Pressure on distalsural and plantar nerves which can cause neuropathies of the foot – Hyperabduction may exaggerated flexion and stretch sciatic nerve • BOOTH TYPE – May produce support more evenly and reduce localized pressure

25. LATERAL & KIDNEY POSITION In  lateral  or  side-lying position , the patient lies on one side of the body with the top leg in front of the bottom leg and the hip and knee flexed. Flexing the top hip and knee and placing this leg in front of the body creates a wider, triangular base of support and achieves greater stability. An increase in flexion of the top hip and knee provides greater stability and balance. This flexion reduces lordosis and promotes good back alignment. Patient lying with one side facing operative side uppermost The legs flexed to 90° and a pillow is placed in between Upper arm rested on elevated arm rest and the other remains flexed on the table or armboard A roll bags may used below the hip/kidney to increased exposure of iliac region Position is maintained by use of sandbags or braces attached to the side of bed Head supported on a pillow

26. Contd..

27. KIDNEY POSITION n the  kidney  position , the patient assumes a modified lateral position wherein the abdomen is placed over a lift in the operating table that bends the body. The patient is turned on their contralateral side with their back placed on the edge of the table. The contralateral kidney is placed over the break in the table or over the kidney body elevator (if an attachment is available). The uppermost arm is placed in a gutter rest at no more than 90º abduction or flexion . Access to the retroperitoneal area.  The  kidney position  allows access and visualization of the retroperitoneal area. A kidney rest or a small pillow is placed under the patient at the location of the lift. Risk for falls.  The patient may fall off the table at any time until the position is secured. Padding and stabilization support is given. The contralateral arm underneath the body is protected with padding. The contralateral knee is flexed, and the uppermost leg is left straight to improve stability. A large soft pillow is placed in between the legs. A kidney strap and tape are placed over the hip to stabilize the patient.

28. Potential pressure points

29. SIM’s Position Sims’ position  or  semi-prone  position is when the patient assumes a posture halfway between the lateral and the prone positions. The lower arm is positioned behind the client, and the upper arm is flexed at the shoulder and the elbow. The upper leg is more acutely flexed at both the hip and the knee than is the lower one.

30. Contd.. Prevents  aspiration  of fluids.  Sims’ may be used for unconscious clients because it facilitates drainage from the mouth and prevents aspiration of fluids. Reduces lower body pressure.  It is also used for paralyzed clients because it reduces pressure over the sacrum and greater trochanter of the hip. Perineal area visualization and treatment.  It is often used for clients receiving enemas and occasionally for clients undergoing examinations or treatments of the perineal area. Pregnant women comfort.  Pregnant women may find the Sims position comfortable for sleeping. Promote body alignment with pillows.  Support proper body alignment in Sims’ position by placing a pillow underneath the patient’s head and under the upper arm to prevent internal rotation. Place another pillow between the legs.

31. KNEE-CHEST POSITION Patient lying into prone position Both legs are abducted and flexed together at right angles Knees flexed and hip elevated Head , shoulders and chest rest directly on the table Arms are placed above the head Primary position for sigmoidoscopies and laminectomy procedure

32. SEMI-FOWLER’S AND FOWLER’S POSITION Fowler’s position , also known as  semi-sitting position , is a bed position wherein the head of the bed is elevated 45 to 60 degrees. Variations of Fowler’s position include  low Fowler’s  (15 to 30 degrees),  semi-Fowler’s  (30 to 45 degrees), and  high Fowler’s  (nearly vertical ). 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’

33. Potential pressure points

34. JACKNIFE 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 , also known as  Kraske , is wherein the patient’s abdomen lies flat on the bed. The bed is scissored , so the hip is lifted, and the legs and head are low.

35. THANK YOU