HOLY TRINITY COLLEGE Puerto Princesa City

In Partial Fulfilment of the Requirements in

Related Learning Experience

at theOperating Roomat theOperating Room(11th day to 15th day of May 2009)

Submitted by:

Eduardo L. AlcantaraEduardo L. AlcantaraBSN Second Year N1

Submitted to:

Ma’am Rhodora May C. Libiran,Ma’am Rhodora May C. Libiran, R.N. R.N.

Clinical Instructor

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Why is positioning important?o Patient cannot make clinician aware of compromising positionso Enables IV lines and catheters to remain patento Enables monitors to function properly o Facilitates the surgeon’s technical approacho Patient safety (aka Don’t Let The Patient Fall Off The Table)

THE POSITIONS:

Supine (a.k.a. Dorsal Recumbent) o A position in which the client is lying flat on the back.o Arms on arm boards

o Check orientation of arm (arms < 90 degrees)

o Place additional padding under elbow if ableo Arms tucked

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o Check fingerso Check IV lines and SaO2 probe

Uses: This is the usual position for administering general anesthesia and for doing most surgery of the abdomen such as laparotomy, herniorrhaphy, and appendectomy. With slight modifications, it is also used for other types of surgery, such as surgery on the arms or legs.

Procedure:1. Start with the bed flat and the patient lying on the back. The patient's head should be about two to three inches from the head of the bed. 2. Place a pillow under the patient's head. It should extend about two inches below the patient's shoulders, with the head in the middle of the pillow.3. Place a trochanter roll along the affected hip or along the both hips if the patient has little control over the legs. A trochanter roll is devised by rolling a bath blanket into a shape about 12-14 inches in length. The roll should be just long enough to reach from above the hip to above the knee. The trochanter roll prevents external rotation of the hip. 4. Place pillows under the legs to reach from above the back of the knee to the ankle so that the ankles and heels do not rub on the sheets. 5. If care plan so indicates, position the footboard or place a folded pillow to support the patient's feet. The ankles should be at 90° angles. 6. Extend the patient's arms and place small pillows to reach from the elbow to below the wrist. The hand should be in alignment with the wrist.

Variation: SEMI-SUPINE POSITION

Start with the patient in supine position. Roll the patient's trunk and shoulder away from you so that there is a 45° angle between the patient's back and the bed.

1. Place a pillow behind the patient's back for support. 2. Bring the patient's left shoulder forward. Flex the elbow of the left arm and place the lower left arm, palm up, on a pillow. 3. Flex the elbow of the right arm and bring the forearm across the chest with palm down. 4. Extend both legs. Place right leg a little behind left leg. Support right leg with two pillows folded in half that extend from groin to ankle.

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Prone

A position in which the client is lying on the abdomen with the head turned to one side.

Face down HEAD PLACEMENT

Head straight forward ET tube placement and patency

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Check bilateral eyes/ears for pressure points Head turned

Check dependent eye/ear ETT placement Be aware of potential vascular occlusion

Arm placement Tucked – similar concerns to supine Abducted

Check neck rotation and arm extension to avoid possible brachial plexus injury

Make sure elbows are padded Chest Rolls

Often up to surgeon as to what type of rolls are used Ileac support

Make sure some sort of padding is placed under iliac crests

Procedure:Start with the bed flat and the patient lying on the abdomen with head turned to either side, spine straight and legs extended. 1. Place a small pillow under the head so that it extends to the patient's shoulders and five to six inches beyond the face. 2. Place a small pillow under the abdomen. This relieves pressure on the back and reduces pressure against a female patient's breasts. An alternate method is to roll a towel and place it under the shoulders.

3. Place a pillow under the arms to reach from the elbow to below the wrists. The shoulders and elbows may be flexed or extended, whichever is more comfortable for the patient.

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4. Place a pillow under the lower legs to prevent pressure on the toes. The patient may be moved down in the bed before starting the procedure, so that the feet extend over the end of the mattress. This allows the foot to assume a normal standing position.

Uses: The prone position is used for surgical procedures- major or minor-that are performed on the back, shoulders, neck, or back of the head. Placement of the patient in the prone position for minor surgery, using local anesthesia, differs in some respects with placement for general anesthesia.

Variation: SEMI-PRONE POSITION

This position relieves pressure on the hips. Breathing is easier in this position than in the full prone position. Directions given here are for the patient lying on the left side. These can be easily adapted for the right side.

1. Extend the patient's left arm and tuck it slightly beneath the patient's body. 2. Place a pillow in front of and at right angles to the patient's chest. 3. Flex the patient's right knee and hip. Support with pillows that are parallel to the leg. 4. Grasp the patient's left arm from the back of the patient. Turn the patient onto his chest facing away from you. Gently pull his left arm toward you and push on his hip. 5. Extend the right arm upward and toward the head of the bed. Place it on the head pillow with the fingers and palm against the bed. 6. Flex the upper arm on a pillow. 7. Lift up the sheepskin and place a foam block under the sheepskin above the iliac crest (hip bone).

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8. Place another foam block under the sheepskin just below the iliac crest. You should be able to slide your hand between the hip and the bed.

Lateral

Patient on side (lateral decubitus position). i.e. left lateral decubitus position means right side up

Most important to maintain body alignment Keep neck in neutral position Always place axillary roll Place padding between knees Try and place padding below lateral aspect of dependent leg

(prevent peroneal nerve damage) Position arms to parallel to one another

Place padding between arms or place non-dependent are on padded surface

Check pulses

Variations:A. LATERAL KIDNEY POSITIONUses: The lateral kidney position is used for surgery on the kidney or the proximal third of the ureter.

B. LATERAL CHEST POSITIONUses: The lateral chest position is used for thoracoplasty, pneumonectomy, & lobectomy.

C. RIGHT LATERAL POSITION

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Procedure: 1. Start with the bed flat and the patient turned to the left side, with spine straight. Remember before turning to move the patient to the right side of the bed. 2. Place a pillow under the head so it extends five to six inches beyond the patient's face and down to the shoulders. 3. Position patient's right arm so shoulder and elbow are flexed and palm of hand is facing up. 4. Place patient's left arm so it is extended or only slightly flexed and rest it on patient's hip or bring it forward and place it on a pillow. The patient's shoulder, elbow, and wrist should be at approximately the same height. 5. Place a pillow between the patient's legs so that it extends from above the knee to below the ankle. The patient's hip, knee, and ankle should be at approximately the same height. 6. A pillow may be placed behind the patient to help maintain the position.

Lithotomy

The position is used for procedures ranging from simple pelvic exams to surgeries and procedures involving, but not limited to reproductive organs, urology, and gastrointestinal systems.

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Various types of stirrups

Candy cane Allen stirrups Knee cradles

Various degrees of lithotomy Low High

Move legs at same time when positioning patient in and out of lithotomy

Uses: The Lithotomy position is used for surgery in the perineal area, such as drainage of rectal abscesses and perineal prostatectomy, and for gynecological surgery such as vaginal hysterectomy.

Stirrups

Sitting Position

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Position used in neurosurgery procedure to facilitate access to posterior fossa.

Potential complications from sitting position Venous air emboli

Need to take measures to detect and extract VAE Hypotension Brainstem manipulations resulting in hemodynamic changes Risk of airway obstruction

Uses:Included in surgery for which the patient sits upright are various operations on the nose and throat, as well as some plastic surgical procedures. The sitting position is described using the operating table as a chair.

Procedure: Patients should be positioned in a comfortable, well-constructed chair, so that the head and the spine are erect. The back and buttocks should be up against the chair back. The feet should be flat on the floor.

1. Pillows or postural supports may be needed to maintain the position. 2. A small pillow may be folded and placed at the small of the back to add comfort and support. 3. Do not permit the back of the patient's knees to rest against the chair.

Jack-Knife (a.k.a. Kraske position)

It is an anatomic position in which the patient is placed on the stomach with the hips flexed and the knees bent at a 90-degree angle and the arms outstretched in front of the patient. Examination and instrumentation of the rectum are facilitated by this position.

POSITIONING STEPS:

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1. The patient is induced on the transport cart, which is positioned next to the OR table.

2. With multiple assistants, the patient is flipped prone onto the OR table while the CRNA commands at the head and secures the airway.

3. Parallel thoracic or chest rolls (made from tightly rolled sheets and blankets or manufactured gel rolls) are placed under the thorax, lateral to the breasts, following the long line of the body to free the abdomen from compression.  Care is given not to compress the breasts with the rolls or cause undue pressure under the axilla.

4. The head is positioned prone, with face placed in a foam prone-cutout pillow (with ETT, OGT and EGS exiting out the side), in a skull-pin head clamp, or in a rocker-based face/forehead rest.  It can alternatively be placed laterally, using a gel donut, pillow or blankets, while avoiding forced rotation of the pronated head.  Eyes, ears, and nose should be checked to assure that these areas are free from pressure.  Most important:  *The C-spine should be in neutral alignment (check for neutral position of the neck in all 3 planes).  The tube should be free without kinking or undue traction, and the anesthesia provider should be able to visually see or reach in and check all connections.

5. The arms are padded and positioned to prevent nerve stretch or compression.  This can be accomplished in a variety of ways depending on the exact nature of the surgery and access required (check with the surgeon).  The arms are secured to prevent accidental dislocation or trauma from movement or falling off of table during the procedure.

6. Legs are maintained in the long axis of the body.  Knees should be padded with egg crate or gel.  Pillows should be placed under the calves and feet to take pressure off the lumbar spine and prevent pressure sores on toes. 

7. The patient is secured to the table with tape or a belt across the thighs immediately under the buttocks.

8. Break the table from the middle hinge at the hips, bringing both the thorax and thighs lower than the hips.  Caution should be taken to not allow the lower portion of the bed to hit the floor. The degree of flexion depends on surgeon preference, patient tolerability, and table surface hinges.

Uses: The jackknife (Kraske) position is used for surgery on the coccyx, buttocks, or rectum, particularly when the patient has had spinal anesthesia and there is no objection to his being placed either face downward or head low.

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Trendelenburg PositionThe body is laid flat on the back with the head lower than the

pelvis, in contrast to the reverse Trendelenburg position, where the body is tilted in the opposite direction. This is a standard position used in abdominal and gynecological surgery. It allows better access to the pelvic organs as gravity pulls the intestines towards the head. It was named after the German surgeon Friedrich Trendelenburg.

Uses: The Trendelenburg position is used for operations on the bladder, prostate gland, colon, female reproductive system, or for any operation in which it is desirable to tilt the abdominal viscera away from the pelvic area for better exposure.

Procedure:

1. Place the patient in the supine (dorsal recumbent) position and adjust the mattress so that his knee joints are directly over the lower break. The knees must bend where the table breaks to prevent pressure on blood vessels and nerves in the popliteal region, avoiding complications of phlebitis or paralysis of the leg. Secure patient's arms and legs.

2. Attach well-padded shoulder braces to the table. Check to see that the braces are the same distance from the head of the table.

3. Adjust braces so that they are on the outer part (bony joint) of the shoulders rather than against the neck. Braces should be adjusted one-half inch from shoulders to prevent excessive pressure when the head of the table is lowered.

4. Flex the table at the knees, dropping the leg portion usually to an angle of 30 to 40 degrees.

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5. Tilt the entire table, the head low, to the angle desired by the surgeon, usually 30 to 40 degrees. The head should be lower than the knees.

Variation: REVERSE TRENDELENBURG POSITION

Use: The reverse Trendelenburg position may be used for surgery on the neck, such as thyroidectomy, and for certain abdominal surgery, such as liver or gallbladder operations.

Procedure:1. Place the patient flat on his back. Adjust the mattress so that his

shoulders are at the upper break of the table. If surgery is in the neck area, place a small pillow or a folded sheet transversely under the neck and shoulders, as shown in figure 1-7.

2. Attach the padded footboard at a 90-degree angle to the table and adjust it so that the soles of the feet are resting against it. Place padding under the legs(see figure 1-7) to take pressure off the heels.

3. Secure the arms and legs.4. Tilt the table, foot forward, to the desired angle.

Sources:http://www.pitt.edu/~position/Prone/prone4_1.htm;http://www.moondragon.org/health/disorders/patientpositions.html;http://encyclopedia.thefreedictionary.com/; http://

www.wikipedia.org/; http://www.moondragon.org/health/disorders/patientpositions.html; SUBCOURSE MD0927 (PDF File)

Related Reading

Simple clinical interventions improve patient safetyMay 3rd, 2009

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Maternal and newborn outcomes were greatly improved when doctors implemented a series of simple clinical interventions at Yale-New Haven Hospital's obstetrical unit. Yale School of Medicine researchers report their results in the May issue of the American Journal of Obstetrics & Gynecology.

Starting in 2004, the researchers sought to determine if improving communication between medical staff and standardizing procedures would reduce the number of adverse outcomes. First author Christian Pettker, M.D., senior author Edmund Funai, M.D., and their colleagues attacked the problem from many different angles. They designed and implemented clinical patient safety interventions that included communication training for hospital staff, standardizing interpretation of fetal monitoring, and creating a novel staff role—the patient safety nurse.

In tracking and analyzing 14 markers for adverse outcomes, the team found that the rate of adverse events decreased by about 60 percent over 2.5 years, while the staff's own perception of the overall safety climate increased by 30 percent, according to a survey given by a third party.

"We used these basic principles to make obstetrical care a great deal safer and they can also be applied to other areas of care as well," said Pettker, senior research scientist in the Department of Obstetrics, Gynecology & Reproductive Sciences at Yale School of Medicine.

Funai, associate professor in the medical school's Department of Obstetrics, Gynecology & Reproductive Sciences and section chief, maternal-fetal medicine at Yale-New Haven Hospital said, "Interventions of this sort involve fundamental culture change, requiring enormous effort and persistence, but the benefits to our patients are priceless."

"We found that implementing various safety techniques could reduce unanticipated adverse outcomes in an obstetrical unit," said Pettker. "After taking these steps to improve safety, both patients and staff report that the care is more seamless and better organized."

Pettker said the next steps in the research are to implement more safety measures, particularly in the operating room, and standardizing practices with checklists to improve efficiency in the unit.

Source:

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American Journal of Obstetrics & Gynecology 492 (May 2009), http://www.ajog.org/article/S0002-9378(09)00092-1/fulltext

MY TAKE

o Summary:

In 2004, the authors/researchers namely Christian Pettker, M.D., Senior Author Edmund Funai, M.D., and colleagues started their study on proving out the effectiveness of good communication between the medical staff and the procedures they used in order to reduce the quantity of unfavorable outcomes. Through this they started on designing and implementing their clinical patient safety interventions which included communication education for hospital staff, standardizing interpretation of fetal monitoring, and creating a novel staff role which they coined the patient safety nurse.

While they’re following and analyzing the 14 indicators for adverse outcomes, the team found out that the rate of adverse happenings decreased by 60% over 2 ½ years, and 30% is the staff’s perception on the overall safety environment according to a survey given by a third party.

According to Pettker they used those basic principles to make obstetrical care a great deal safer and which can also be applied to other areas of care as well and Funai added that interventions of this sort involve fundamental culture change, requiring enormous effort and persistence, but the benefits to our patients are priceless.

Mr. Pettker also stated that they found that implementing various safety techniques could reduce unanticipated adverse outcomes in an obstetrical unit and after taking these steps to improve safety, both patients and staff report that the care has improved and well organized. The next ladders in the said research are to implement more safety measures, particularly in the operating room, and standardized practices with checklists to improve efficiency in the unit.

o Reaction or Comment:

After reading this article, I realized how learning and research are important in the field of science and health. As evidenced by the article, through the studies made by Dr. Pettker, M.D. and Dr. Funai, M.D. they helped the medical institution/s to furthermore develop new trends in managing the client’s health.

I realized that being a neophyte in this field of learning, I should learn more and not be contented on what I have now. It is not only for my good but for the betterment of the community – to give a quality patient care.

Another is that through this article, I realized how important is updating our nursing interventions or procedures. We should be knowledgeable on the new nursing interventions which could give a more effective comfort for our patient.

o Application:

After reading this article one thing appeared into my mind and that is to apply this learning when doing my nursing interventions.

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I should be updated in all new trends about health. An example is having this RR because through this I’m keeping myself in line with the latest health news, discoveries, treatments, and et. al. which would guide me to give a quality patient care (during my studies and for the near future).

o Why did you choose this article?

This was my chosen article because of its interesting title and content. Plus, it’s also connected with our area assignment for this week which is the operating room.

o Are you in agreement with this article? Why?

Yes, I am in agreement with this article because it gives me an encouragement to do will in my works and improve my mistakes as a nursing student. I should learn the right and true principles in my nursing actions which could help me to practice a good quality of care to my clients (today and in the near future). Nursing is a matter of certainty and not conjecture.

o Is this related with our country? Why?

Yes, but not that quite. Our government as of today only prioritized the health care needs by giving only 3% of its budget. Obviously, with that percentage and also through our observations we can say that the health status of the Filipinos is in a lower percentage and huge improvement in giving care is really needed by the medical staff and clients or patients.

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