Prevention of Perioperative Pressure Ulcers Tool Kit

The Basics of Positioning Patients in Surgery

Funded in part by grants from Sage Products, LLC and Medtronic through the AORN Foundation.

Objectives

1. Describe the most commonly used surgical positions.

2. State techniques for preventing injury to surgical patients.

Goals of PositioningProviding adequate exposure

Maintaining patient dignity

Allowing for optimum ventilation

Providing adequate access

Avoiding poor perfusion

Protecting fingers, toes, genitals

Protecting muscles, nerves, bony prominences

•General/Regional anesthesia–Physiologic changes–Reduced movement/sensation

Positioning Injuries

Positioning Injuries

Positioning Injuries

• Force placed on underlying tissuePressure

• Folding of underlying tissueShear

• Force of two surfaces rubbing against one another

Friction

Positioning Injuries

Moisture Heat

Cold Negativity

Positioning Injuries

MoistureProduces maceration

Positioning Injuries

HeatIncreases metabolism

Positioning Injuries

ColdReduces O2 delivery

Positioning Injuries

NegativityIncreases pressure

Positioning Injuries

Nerves

• Stretching or compression• Transient or permanent damage

Most common sites• Brachial plexus• Peroneal• Facial

•Bracheal plexus–Shoulder–Arm–Hand

Positioning Injuries

•Bracheal plexus injury–Armboards extended beyond 90°–Armboards higher or lower than

OR bed–Lateral rotation of patient’s head–Leaning against shoulder or arm–Shoulder braces

Positioning Injuries

Positioning Injuries

•Common peroneal–Lower leg–Foot–Toes

Sciatic

Common Peroneal

Tibial

•Common peroneal injury–Direct compression–Patients who are thin–Hyperextension of knees–Pressure behind knee–Graduated compression stockings too tight–Foot drop/Lower extremity paresthesia

Positioning Injuries

Positioning Injuries

Pulmonary

• Hypoxia• Respiratory compromise• Decreased 02 saturation• Pulmonary edema• Congestion• Atelectasis

Positioning Injuries

Ocular

• Corneal abrasion• Central retinal artery occlusion

Risk factors• Prone• Length of procedure• Blood loss

Positioning InjuriesObese or underweight

Poor nutritional status

Advanced age

Preexisting conditions

History of skin breakdown/pressure ulcers

Smoking

Positioning Process

•Collaborative process–Selection of equipment–Preoperative assessment–Positioning–Documentation–Postoperative

evaluation

Selection of Equipment

Inspected and

maintained

Checked prior to

procedure

Competent surgical

personnel

Selection of Equipment

•Pressure relieving surface–Disperses weight–Prevents “bottoming out”–Relieves shear and

friction

Preoperative Assessment

• Age/Height/Weight/Body mass index (BMI)• Nutritional status• Blood pressure• Skin integrity• ROM/Physical limitations• Internal/External devices• Preexisting conditions• Medical history• Diagnostic studies• Psychological/Cultural considerations

Selection of Position

Supine

Supine

Supine

Trendelenburg

Reverse Trendelenburg

Sitting/Modified-Sitting

Lithotomy

Low

Sta

nd

ard

Hem

i

Hig

hExag

gera

ted

Lithotomy

Lithotomy

Common peroneal

Femoral

Obturator

Lithotomy

Prone

Prone

Jackknife

Lateral

• Right = Left

Lateral

Obese Patients

Obese• BMI greater than 40

kg/m2

• More than 100 lbs overweight

Obese Patients

Health conditions

• Type II diabetes• Hypertension• Atherosclerosis• Arthritis• Sleep apnea• Alveolar hypoventilation• Urinary stress incontinence• Gastroesophageal reflux

(GERD)

Obese Patients

Respiratory issues

• Airway compromise• Difficult intubation• Aspiration• Hypoxia• Intra-abdominal pressure

Obese Patients

Circulatory issues

• Increased cardiac output• Increased pressure on

pulmonary artery• Risk of inferior vena cava

compression

Obese Patients

Skin issues• Difficult assessments• Skin breakdown• Moisture

Obese Patients

Special equipment

• Procedure beds• Extra-wide/long safety

straps• Side attachments/Stirrups• Pressure relieving

surfaces

Obese Patients

Position• Sitting/Modified-sitting• Lateral• Supine with wedge under

right side

Documentation

• Preoperative assessment• Names/titles participants• Patient position• Upper extremities• Lower extremities• Equipment/Padding• Specific actions• Repositioning• Postoperative assessment

• Nerve injury• Pressure injury• Reposition• Transfer of care

Postoperative Assessment

1. Guideline for positioning the patient. In: Guidelines for Perioperative Practice. Denver, CO: AORN; 2015.

References

Thank youSharon A. Van Wicklin, MSN, RN, CNOR, CRNFA(E), CPSN-R, PLNCSenior Perioperative Practice SpecialistAssociation of periOperative Registered Nurses (AORN)Denver, CO.

for preparing the content of this educational slide deck.

Prevention of Perioperative Pressure Ulcers Tool Kit

The End