lateral positioning

Patient Positioning in Lateral Position in thePerioperative Setting

Presented byPuja Pushpan

Objectives of the presentation.

Discuss the principles of positioning the patient in the operating theatre.

Discuss the factors influencing safe positioning.

Describe patient risk factors and nursing considerations related to lateral positioning.

Discuss the nurses role in prevention of positioning injuries.

Basic principles of safe positioning.

• Optimal access for assessing and maintaining anaesthesia and vital functions (respiration, circulation).

• Protection of the patient from harm.

• Optimal visualisation of and access to the surgical site.

Uses.

• Surgery of the chest or lung.• Surgery on the kidney.

• Hip surgery.

Lateral Positioning Injuries.

• Wrong Side/Site Surgery.

• Nerve Damage.

• Skin breakdown.

• Eye injuries.

• Reduced respiration.

• Spinal misalignment.(Heizenroth 2007)

Factors influencing safe positioning.

• Knowledge of anatomy.

• Knowledge of physiological function.

• Knowledge of Surgeon preference.

• Knowledge of procedure and positioning aids.

• Planning action according to risks inherent in a given position and individual factors.

• Team work.

Nursing Considerations for patient positioning.

• Preoperative assessment.

• Developing a plan of action.

• Assembling essential positioning aids.

• The positioning of the patient.

• Re-evaluating the positioned patient for any problems.

• Evaluating postoperative outcome in respect to

complications of positioning.

• Documentation.(AORN 2010, AFPP 2007)

Preoperative assessment.

Factors limiting patient positioning

– Patient’s age, height and weight

– Pre-existing conditions (e.g. arthritis)

– Range of motion.

– Previous surgical procedures

– Presence of a joint prosthesis

– Nutritional status

The nature of the surgical intervention (position required for surgical access, duration (Stevens et al. (2004)).

Developing a plan of action.

• Discussing positioning manoeuvres with anaesthetist and surgeons.

• Ask for assistance.

Assembling essential positioning aids.

Check table.

Anticipate the positioning equipment needed for specific operative procedure.

Bean bag, pillows and padding material, axillary roll, headrest, straps for arms, pelvis and legs.

Positioning equipment.

• Should prevent uneven and potentially excessive pressure distribution.

• Resistant to moisture and fluids.• Allow chest expansion for proper ventilation and gas

exchanges• Non- allergic to the patient (latex free).• Fire resistant.• Easy to handle and store.

(AORN 2010, AFPP 2007)

• Proper padding will reduce, but not eliminate, injuries to peripheral nerves (Tuncali et al. 2005, Deane et al. 2008).

• AORN (2008) recommends the use viscoelastic (ie, gel) pad placed between the patient and any hard support.

Positioning equipment.

The positioning of the patient.

• Patient positioned supine on the operating table and anesthetized.

• Rolled onto the side- operative side up. Always the patient’s right/ left.

• Head supported in alignment with body.

• Bottom leg flexed; top leg straight helps to improve stability.

• Bottom arm on either placed on arm board, flexed to rest beside the patient’s head.

Contd.

• Upper arm rests on a carter braine support .

• Pillow is placed between the legs.

• The operating table adjusted gradually.

• A padded restraint was placed around the operating table and pelvis.

Anterior and Posterior view.

• Anterior view • Posterior view

Re-evaluating the positioned patient.

• Integumentary system. – Moisture.

– Pressure.

• Musculoskeletal system.

– Hyperextension of joints.

– Stretching muscles / ligaments

Improper positioning of arm

Tuncali et al. 2005

Contd.

• Respiratory system

– Pressure against the chest and diaphragm that interferes with breathing.

• Circulatory system

– Pressure on blood vessels.

• Nervous system

– Stretching or placing pressure on superficial nerves (Akhavan et al. 2010)

Evaluating the position.

(Warner & Martin 2001)

Documentation.

• A pre-operative assessment.

• The type and location of positioning, including pressure relieving devices used.

• Names and designation of staff members positioning the patient.

• Postoperative outcome.

• Signature.

Nurse’s role in safe positioning.

• Practice evidence based care.

• Assessing patient, pre-op, intra-op and post op.

• Coordinating with anaesthesia and surgeon.

• Evaluating patient post operatively.

Summary.

• We discussed:

– The principles of surgical positioning.

– The sequence of positioning the patient for thoracotomy.

– The perioperative team’s role in positioning.

• We described:

– Lateral position, patient risk factors, and nursing role.

References.

• AORN (2008) Recommended practices for documentation of perioperative nursing care. In Perioperative Standards and Recommended Practices, AORN, Denver ,pp. 497–520.

• AORN (2010) Recommended practices for documentation of perioperative nursing care. In Perioperative Standards and Recommended Practices, AORN, Denver, pp.327-349.

• Association for Perioperative Practice (2007). Standards and Recommendations for Safe Perioperative Practice, AFPP, Harrogate, pp. 76-82.

• Malan T. and McIndoe A.K. (2006) Positioning the Surgical Patient. The Foundation Years 2(5), 185-189.

• Washington S.J. and Smurthwaite G.J. (2009) Positioning the Surgical Patient. Anaesthesia & Intensive Care Medicine 10(10), 476-479.

• Ellsworth W.A. and Iverson R.E. (2006) Patient Safety in the Operating Room, Vol. 20. Thieme Medical Publishers, 214.

• Heizenroth P. A. (2007) Positioning the patient for surgery. In Alexander’s Care of the Patient in Surgery, 13th edn.(Rothrock JC., ed.), Mosby/ Elsevier, Missouri, pp. 130-157.

• Tuite P.K. and George E.L. (2010) The Role of the Clinical Nurse Specialist in Facilitating Evidence-Based Practice within a University Setting. Critical Care Nursing Quarterly 33(2), 117.

• Wicker P. and Nightingale A. (2010) Patient care during surgery. In Caring for the perioperative patient , 2nd edn. (Wicker P. &O’Neill J.,eds), Blackwell Publishing,UK, pp. 339-376.

• Source taken from Warner MA, Martin JT.(2001) Patient positioning. In Clinical anesthesia, 4th edn. (Barash PG., Cullen BF., Stoelting RK., eds.), Lippincott Williams & Wilkins, Philadelphia, pp. 651-661.

• Source taken from Tuncali B., Tuncali B., Kuvaki B., Cinar O., Do an A. and Elar Z. (2005) Radial Nerve Injury after General Anaesthesia in the Lateral Decubitus Position. Anaesthesia 60(6), 602-604.

• Deane L.A., Lee H.J., Box G.N., Abraham J.B.A., Abdelshehid C.S., Elchico E.R., Alipanah R., Borin J.F., Johnson R.W. and Jackson D.J. (2008) Third Prize: Flank Position Is Associated with Higher Skin-to-Surface Interface Pressures in Men Versus Women: Implications for Laparoscopic Renal Surgery and the Risk of Rhabdomyolysis. Journal of Endourology 22(6), 1147-1152.

• Stevens J., Nichelson E., Linehan W.M., Thompson N., Liewehr D., Venzon D. and Walther M.C.M. (2004) Risk Factors for Skin Breakdown after Renal and Adrenal Surgery. Urology 64(2), 246-249.

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