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9/7/2013
1
Laura Faires Krioukov BSN RN
Legacy Emanuel Medical Center
Operating Room staff nurse
Portland, Oregon
Incorporating SCIP
protocols into the
complex care of
patients undergoing
Head and Neck
Surgery
� KNOWLEDGE OF SAFE POSITIONING
PRINCIPLES
�UNDERSTANDING OF PHYSIOLOGICAL
CONSQUENCES OF POSITIONING
�UTILIZATION OF APPROPRIATE
MATERIALS TO PROTECT PATIENT FROM
PRESSURE SORES, BURNS OR SHEARS.
� INSPECTION OF PATIENT IMMEDIATELY
POST OPERATIVE TO ASSESS
EFFECTIVENESS OF POSITIONING
� DOCUMENTATION OF POSITIONING AND
RESULTS
� DOCUMENTATION CONSIDERATIONS
� PRELOADED POSITIONING DEVICES AND
POSITIONS IN COMPUTERIZED CHARTING
� HARD STOP IN COMPUTER FOR POSITIONING
� IF DESIGNING COMPUTER CHARTING, ALWAYS
LEAVE COMMENT SECTION FOR FREE TEXT
� COMMENTS ON ADDITIONAL AIDS USED
� MOVE TO DOCUMENT PREOP SKIN
CONDITION FOR EARLY SKIN BREAKDOWN
DETECTION
� UTILIZE UNIVERSAL SKIN INTEGRITY GUIDELINES
OR SPECIFIC HOSPITAL GUIDELINES
� DOCUMENT Q 4 HOURS FOR LENGTHY
PROCEDURES
� OPPORTUNITY TO IMPROVE TECHNIQUES BY
STUDYING RESULTS OF CASES
�use
padding
and
positionin
g
equipmen
t to help
with: alignment
pressure points,
preventing shifting during
procedure
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�Length of surgery
�Multiple sites
�Change of position
during surgical
procedure
�Checking position
q4h and charting
�Evaluating
effectiveness
�Developing more
effective methods
Positioning
the patient
for a surgical
procedure is
the shared
responsibilit
y of the
entire OR
team. But
someone has
to LEAD this
team.
�A patient under
anesthesia loses some
or all of his protective
reflexes .
�Proper positioning of
the patient is a simple
and effective method
to help prevent
intraoperative neural
injury.
�There are many
devices on the
market to aid in
safely
positioning
patient
Pillows and
headrests are
cruciaI.
If the patient is
supine or in
Trendelenberg
position, use
"donuts" or
cushioning to
protect the back of
head.
In many procedures,
the buttocks remain
in contact with the
table surface. In
longer procedures,
this can be the
beginning of
pressure sores.
Place padding
underneath the
buttocks to prevent
this.
9/7/2013
3
Reminder to evaluate
skin condition
PRIOR to
positioning (using
some universal
guidelines on skin
condition or
breakdown)
Document pre-op
AND post op
condition (computer
can ask for
comment)
�After positioning
patients about to
undergo a
procedure, be sure
to take time to
evaluate body
alignment and
tissue integrity.
�Check tubes and
lines at the outset
and at regular
DOCUMENTED
intervals
throughout the
procedure.
Treat or pretreat
sacral or newly
identified skin
breakdown before
leaving the OR or
before beginning
procedure, if
possible or
applicable.
�Remember that
older, more frail,
sicker patients will
be at greater risk for
pressure sores and
positioning/pressure
injuries than less
debilitated patients.
�have a working knowledge of what's
available.
�materials used for positioning, especially
padding, should be able to absorb
compressive force, redistribute pressure,
prevent excessive stretching, and provide
support for optimum stability
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� Studies suggest that
positioning devices
should maintain
normal capillary
interface pressure of
32 mm Hg or less
�Incidence of pressure
ulcers between 12%
and 35% in surgical
patient
�Pay attention to
eyes, ears, nose
even for short
procedures.
�Ears can suffer
pressure injuries
when patients are
lateral
�Noses from NG or
nasal intubation
and traction from
positioning
�Brachial plexus
injuries_LATERA
L
�Pillows and
headrests are
crucial.
�place padding for
other surfaces
that will remain
in contact with
the bed surface.
9/7/2013
5
� Studies are
incomplete regarding
efficacy of foam, gel or
standard OR bed pad
and outcomes are
different for different
body surfaces and
positions.
�This BEGS for further
study by OR nurses!
�In many procedures, the
buttocks can remain in
contact with the table
surface. But in longer
procedures, this can
cause pressure sores and
other complications, so
place padding
underneath the buttocks
to prevent this.6
�PLACEMENT OF SEQUENTIAL
COMPRESSION DEVICES ON
PATIENTS ESPECIALLY HIGH RISK
PATIENTS
�IDEALLY STARTED BEFORE THE
SURGICAL CASE
�USING
ALTERNATIVE
SITES
� Some studies have
shown that using
SCDs on arms can
decrease LEG DVT.
� Should be a
consideration in
patients with
previous DVT history
� FOLLOW SCIP PROTOCOLS FOR TIMING,
SELECTIONAND DURATIONOF
ANTIBIOTICS.
� TIMING
� 30-60 MINUTES PRIOR TO INCISION
� (PART OF TIME OUT)
� GIVEN BY ANESTHESIOLOGIST (NOT ON CALL),
NOT IN HOLDING AREA
SELECTION
� Cefazolin, Cefuroxime, or
� Vancomycin or Clindamycin if allergic to first choice
DURATION
� REDOSE FOR LONG PROCEDURES
� DISCONTINUE AFTER 24 HOURS (up to half of all
patients receive antibiotics prophylactically longer
than this)
� Prevent heat loss through exposure
� Use warm blankets as temporary
measure
� Utilization of warmed-air blankets
during prolonged surgery—Goal for
patient to be at 36 degrees by transfer to
post-anesthesia unit.
� Warm IV and irrigation fluids
� Utilize temperature monitoring devices
� Temperature foley
� Esophageal probe
9/7/2013
6
Turning room
temperature up
is not effective
as a warming
intervention, as
it is rarely
turned to body
temperature .
It will merely
slow heat loss.
�Prewarming is essential for patients
undergoing long surgical procedures.
�Prep time for lengthy procedures often
exposes patients to long periods in a cool
operating room.
�Patients can lose up to 1.6 degrees C in
the preincision period.
� Warming should CONTINUE when the
patient is transferred to the operating bed
�Warm early
and
continuously
�Monitor
temperature
throughout
case
�Use warming devices creatively
� Upper body sideways for fibular flaps
�Utilize more than one device if
necessary
� Start with underbody, switch to other shapes
�Alternate sites
� As site changes
�Cost vs outcomes approach to patient
care
� Two forced air blankets are much less
expensive than a post operative infection
�Preventing positioning injuries and DVTS and
maintaining normothermia in complex surgical
procedures is challenging.
�Preop planning,
preparing protocols for
team members is helpful
in providing consistent
intraoperative care