1. P OSITIONING P ITFALLS : P OTENTIAL I NJURIES TO LOOK FOR IN THE POST - OP PATIENT

2. D ISCLOSURES Teresa Casio None Darin Prescott Speaker’s Bureau 3M Healthcare

3. O BJECTIVES Match positioning with common surgical and invasive procedures. Describe types of injuries acquired during invasive and operative procedures. Correlate patient reports or other physical assessment data with potential positioning injuries.

4. P RESSURE U LCERS REPORTED IN MN http://www.health.state.mn.us/patientsafety/ae /2013ahereport.pdf

5. A NATOMY R EVIEW Nerve Injuries Stretching Compression Pressure Points When external pressure exceeds capillary pressure Boney prominences Skin close to bone/implant Shear injuries Lateral pressure and compression of skin and underlying tissue

9. PositionPressure PointsPotential sites for Neural Injury PaddingAlignment concerns Arm (extended or tucked) Elbow, shoulderBrachial plexus and ulnar nerve Elbow; fingers if tucked Extended to side - <90  angle on armboard with pad level with table pad. Palm up. Support entire length of arm. Extended over head – not recommended Tucked at side – Palm facing thigh and tucked securely to avoid outward rotation of shoulder. Supine occiput, scapulae, thoracic vertebrae, olecranon process, sacrum/coccyx, calcaneae, knees Brachial plexus, ulna and pudendal nerves heels, elbows, knees, spinal column, and occiput. occiput, hips, and legs parallel. Ankles uncrossed. Arms see above. Head/neck neutral. *Use padded foot-board if steep reverse trendeleberg Prone head, eyes, nose, chest compression, breasts, male genitalia, iliac crests, knees, feet. optic nerve, brachial plexus, ulnar nerve head (provide access to airway & avoid pressure to optic nerve protect forehead, eyes, and chin); chest rolls, iliac crest roll, knees, feet (to maintain neutral position with no pressure on toes); support shoulders and avoid excess pressure on axilla from positioning devices. Chest rolls to allow chest movement and decrease abdominal pressure, Head/neck neutral – maintain cervical neck alignment; arms extended to sides and elbows flexed <90°, palm down; Breasts and male genitalia free from tortion. Lateral axilla, hip, tibial tuberosity, ankle, other boney prominences on dependent side. brachial plexus neck axillary role, pillow between legs (lower leg flexed at hip, upper leg straight), between knees, ankles, feet, and tibial tuberosity. Spinal column, prevent lateral neck flexion. Lithotomy occiput, scapulae, thoracic vertebrae, olecranon process, sacrum/coccyx, leg if touching stirrup, heel Obturator nerves, saphenous nerves, femoral nerves, common peroneal nerves, ulnar nerves, lumbar and sacral pressure occiput, elbows, lateral or posterior legs, knees (to protect from stirrups), heels Lower back supported; minimal rotation of hips, keep stirrups at even height. Elevate and lower legs slowly and together when using stirrups Knee-Chest head, eyes, nose, breasts, male genitalia, knees, feet, arms brachial plexus, optic nerve, ulnar nerve head (provide access to airway & avoid pressure to optic nerve protect forehead, eyes, and chin), chest block, knees, feet (to maintain neutral position with no pressure on toes), support shoulders and avoid excess pressure on axilla from positioning devices. Head/neck neutral, support shoulders, arm extended to sides and elbow flexed <90°, palm down; spine should be level, knees even, feet neutral. Jackson Table (Prone) head, eyes, nose, breasts, iliac crest, knees, feet, arms brachial plexus, optic nerve, ulnar nerve head (provide access to airway & avoid pressure to optic nerve protect forehead, eyes, and chin), chest block, hip support, knees in sling with pillows, protect legs form frame, feet (to maintain neutral position with no pressure on toes), support shoulders and avoid stretch injury. Head/neck neutral, support shoulders, arm extended to sides and elbow flexed <90°, palm down; spine should be level, knees even, feet neutral.

10. S HEAR

12. R ISK F ACTORS Who is at risk? Everybody! Diagnosis = Risk for positioning injury related to the operative or invasive procedure (Phippen, Ulmer, & Wells, 2009) Anesthetic drugs Previous injury Length of time of surgical procedure

13. P RE -A SSESSMENT Braden Scale Common tool for determining risk for skin breakdown Not useful to OR Nurse Eyes on patient; Head to toe assessment Appropriate for every surgery? Communication between the admit nurse and OR nurse Past medical history Physical limitations Presence of implants Skin integrity concerns (“Healthcare Risk Control” 2011)

14. P RE -A SSESSMENT Example – Patient admitted through Same Day unit then admitted after surgery Pre-op skin assessment documented “intact with small red area top of right 3 rd toe” 5 days post op the patient developed open pressure ulcer on right foot involving the 3 rd toe Same Day Admission and OR Nurses’ assessments & documentation supported this as a pre-existing condition

15. J EWELRY Risk of Jewelry in Surgery Infection or burn Pressure ulcers Third spacing Waivers

16. C OMMON E QUIPMENT Padding Tables Positioners Stirrups Specialty tables Other equipment

17. C OMMON P OSITIONS & P ROCEDURES Supine: Laparotomy Carpal Tunnel Release Knee Arthroscopy Eye procedures Lateral Total Hip Arthroplasty Thoracoscopy Nephrectomy Prone Laminectomy Pilonidal Cyst Lithotomy Vaginal Hysterectomy DaVincci robotic procedures

18. S UPINE

19. T RENDELENBERG

20. L ATERAL http://www.pitt.edu/~position/Lateral/lateral_basic.h tm

21. P RONE http://staanbiomedengg.tradeindia.com/prone-position-for-spine-surgery- 121222.html

22. L ITHOTOMY http://www.pitt.edu/~position/Lithotomy/lithotomy1_1.ht m

23. P OST O P A SSESSMENT Outcome Indicators Is the patient able to resume pre-procedure patters of ambulation? Does the patient report tingling, numbness, cramping, pain or ache in the joints? Does the patient report weakness and stiffness in the upper or lower extremity? Can the patient abduct, adduct, flex, and extend the upper and lower extremities without experiencing pain or discomfort? Does the patient show signs of disruption or breakdown of skin layers, especially over bony prominences? (Phippen, Ulmer, & Wells, 2009)

24. P ERIANESTHESIA /P ERIOPERATIVE FOCUS Munro Pressure Ulcer Risk Assessment Scale Masters Thesis AORN is currently working on validation of tool Plan for further research on its application Incorporates 3 phases of care Admission Intraoperative Recovery Score is based on cumulative time and patient position (Munro, 2010 )

25. R EFERENCES Bouyer-Ferullo, S. (2013). Preventing perioperative peripheral nerve injuries. Association of Peri-Operative Registered Nurses Journal, 97 (1), 110-124. doi:10.1016/j.aorn.2012.10.013 Healthcare risk control: Patient positioning. (2011). ECRI Institute, 4, 1-9. Retrieved September, 2013 from https://www.ecri.org/Documents/RM/HRC_TOC/SurgAn6ES.pdf https://www.ecri.org/Documents/RM/HRC_TOC/SurgAn6ES.pdf Fred, C., Ford, S., Wagner, D. & Vanbrackel, L. (2012).. Association of PeriOperative Registered Nurses Journal, 96 (3), 251-260. Retrieved from http://download.journals.elsevierhealth.com/pdfs/journals/0001- 2092/PIIS0001209212006837.pdf Galvin, P.A. & Curley, M.A. (2012). The braden Q+P: A pediatric perioperative pressure ulcer risk assessment and intervention tool. Association of PeriOperative Registered Nurses Journal, 96 (1), 261-270. doi:10.1016/j.aorn.2012.05.010 Munro, C.A. (2010). The development of a pressure ulcer risk-assessment scale for perioperative patients. AORN Journal, 92, 272-287. doi:10.1016/j.aorn.2009.09.035 Phippen, M.L., Ulmer, B.C., & Wells, M.P. (2009). Competency for Safe Patient Care During Operative and Invasive Procedures. Denver, CO: Competency Credentialing Institute. Primiano, M., Friend, M., McClure, C., Nardi, S. Fix, L., Schafer, M., Savochko, K. &McNett, M. (2011). Pressure ulcer risk prevalence and risk factors during prolonged surgical procedures. Association of peri- Operative Registered Nurses Journal, doi:10.1016/j.aorn.2011.03.014 Sutton, S., Link, T. & Makik, M.B (2013). A quality improvement project for safe and effective patient positioning during robot-assisted surgery. Association of Peri-Operative Registered Nurses Journal, 97 (4), 448- 456. doi:10.1016/j.aorn.2013.01.014