Chapter 12: Surgical Case Management; Short Answer: Positioning and Skin Preparation

Describe the goal of positioning.

Provide the best possible access and visualization of the surgical site while causing the least possible compromise in physiological function and stress to joints, skin, and other body parts, and preserving patient safety. Also to provide access to the patient for the administration of IV fluids and anesthetic agents.

Identify the three basic positions.

1) Supine

2) Prone

3) Lateral

Identify the alternate name of the supine position.

Dorsal Recumbent

Describe the anatomical position of supine position. Is the palm up or down if on armboards?

Laying on back, palm up.

Analyze the Trendelenburg position. Describe the purpose(s) of the position.

Modified supine, head down. Used to displace abdominal organs; visualize pelvic organs.

Analyze the reverse Trendelenburg position. Describe the purpose(s) of this position.

Modified supine, head up. Used to displace abdominal organs; Visualize gallbladder.

Analyze the Fowler's position. Describe the purpose(s) of this position.

Sitting position. Used mainly in neurosurgery and breast reconstruction/augmentation.

Analyze the lithotomy position and describe the purpose(s) of the position.

Supine with legs in stirrups. Used for urethral, vaginal, and rectal case access.

Describe what is needed to put the patient into the lithotomy position.

Stirrups (Candy cane or Allen)

Describe how the table is set up for lithotomy prior to the patient entering the room.

Remove to head of the bed and place at the foot.

Describe the position of the patient for lithotomy on the table. Where are the hips located?

Patient: Supine; Hips: At the table break

How many people does it take to put the legs in stirrups? Describe how the legs are placed in stirrups. Which nerve can be injured along the calf of the legs?

2; Legs raised slow and simultaneously, hips rotated externally; Peroneal nerves

Describe the uses of prone position.

Posterior cranium, dorsal body surface, spine, posterior lower extremity.

Describe how the patient's arms are moved onto the armboards.

Lowered to floor using normal motion placed over head, making sure to not over extend.

Identify the alternate name for kraske.

Jackknife

Describe how the prone position is modified for kraske.

Patient's hips at table break, tilt head downward to elevate hips.

Describe the purpose(s) of the kraske position.

Anorectal and pilonidal procedures

Describe the uses of lateral position.

Retroperitoneal space, hips, and hemothorax, some orthopedics.

Identify the alternate name(s) for lateral position.

Lateral recumbent, lateral decubitus, lateral kidney, lateral sims, lateral chest, lateral jackknife, right/left lateral.

If the patient is having a right thoracotomy, what position is he or she placed in?

Left lateral position.

What is the purpose of the axillary roll?

To prevent compression of the dependent brachial plexus and allowing greater respiratory expansion.

Which leg is flexed to stabilize the patient on the OR table?

Bottom

Describe each variation of lateral, any position tools, and the use of each position.

A) Sims

B) Kidney

A) Patient is placed on left side, apply padding to knees, ankles and elbows if needed.

B) Patients flank is located over kidney life of OR table, kidney rests are placed behind and in front of patient.

When positioning the patient, considerations must be made to prevent complications. Describe what can be done to prevent shearing.

Be mindful and careful when moving patient.

Describe what can be done to prevent venous stasis with resultant possible thrombus formation and pulmonary embolus.

Use antiembolic devices.

When the patient is in the Fowler's position, there is a potential complication that is unique due to the sitting position. Identify the complication.

Postural hypotension, pressure injury-ischial tuberosities, blood pressure changes, respiratory compromise.

Pressure is a second consideration when positioning a patient. What areas have to be monitored for pressure?

Any body part that is pushed against the bed.

What can be done to prevent pressure injuries?

Proper positioning, padding, no wrinkles in sheets.

During supine positioning of the patient, care is made to check the patient after the patient is anesthetized. What areas must be assessed?

Head and neck, anterior upper extremity, chest/breast, abdomen, pelvis, anterior lower extremity.

During positioning of the patient prone or placement of the upper extremities in variations of supine, care is given to prevent pressure on the chest. Describe what possible problems can occur with pressure on this area.

Venous stasis, cardio and respiratory compromise.

Who controls the timing when moving the patient?

Anesthesia or CRNA

Why is it important for this person to direct the movement of the patient?

Tubing and intubation.

Describe the potential hazard if the patient is not kept in anatomical alignment during movement (head and spine straight with control of all limbs).

Injury, Soreness.

All movement of the patient is completed slowly, including leveling of the OR table and lifting of lower extremities. Describe what complications can occur with rapid movement.

Cardiovascular problems.

Describe what complications can occur due to contact with metallic parts of the OR table.

Conduction, burn patient.

Describe how to prevent a brachial plexus injury. In which position(s) is this likely to occur?

Position armboard less than 90 degrees and move patients arm in neutral movement to place on the board; Supine.

Describe how to prevent an ulnar nerve injury. In which position(s) is this likely to occur?

Pad elbows, place armboards with palms up, place arms next to patients body with palms facing inward; Supine.

Describe how to prevent a peroneal nerve injury. In which position(s) is this likely to occur?

Pad areas; Trendelenburg

Describe how to prevent a sciatic nerve injury. In which position(s) is this likely to occur?

Pad pressure points; Fowler's position

Describe how to prevent foot drop. In which position(s) is this likely to occur?

Foot board; Supine

Describe how to prevent back, knee, and hip pain from muscle strain or back injury that may occur with the lithotomy position.

Buttock resting completely on table, stirrups at equal lengths and height, raise and lower legs slow and simultaneously.

Describe how to prevent crushing injuries of the extremities when there is movement of the operating table, such as dropping the foot section of flexing of the table for positions such as the lithotomy or the kraske.

Observe the patient when moving so as not to crush.

Analyze what can be done to prevent patient falls during the surgical procedure. Describe what mechanisms can be used to prevent the patient from falling when recovering from anesthesia, sliding off the table during table rotations, or modifications such as Trendelenburg/reverse Trendelenburg.

Straps, axillary pads, bean bags, tape.

Describe the important checkpoints regarding the application of the safety strap.

Not too tight, 2 inches above the knee, 2 fingers in strap.

Contaminated areas requiring surgical preparation are prepped last or as separate skin prep. Analyze the abdominal preparation for a routine exploratory laparotomy and identify which areas are prepped separately or last.

Contaminated prepped last; start with incision site, work in widening circles until periphery is reached then work outward again.

Where does the preparation begin and how does it extend?

At the incision site toward the periphery.

Why is there great care in the prevention of pooling of the antiseptics under the patient?

Irritation, chemical burn, laser burn.