pressure redistribution clinical training lateral position. pressure redistribution for the bony...

Pressure RedistributionClinical Training

August 2014

Goal:

To help clinicians better understand and execute proper patient pressure

redistribution and positioning

Contents

(Click the link to move to that section)

• Importance of Proper Positioning

• Economic Importance of Proper Positioning

• Overview of Patient Positioning

• Patient Assessment

• Team Responsibilities

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Contents

• Positioning Basics

– Supine

– Fowlers

– Lateral

– Prone

– Lithotomy

– Reverse Trendelenburg

– Trendelenburg

• Positioner Families

– Gel

– Foam

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Contents

• Positioning Challenges and Concerns– Occipital Protuberance

– Sacral Area

– Ulnar Nerve

– Heels

– Popliteal Nerve

– Ocular Nerve

– Shoulder

– Pelvis

– Knees

– Feet

– Calves

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Why proper positioning is important

• Prevention of pressure ulcers

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To Contents

• Patient comfort

• Surgical site access

• Anatomical access

• Reduction of pressure ulcers

• Hemodynamic Stability

Why proper positioning is important

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What is a Pressure Ulcer/Sore?

‘A pressure ulcer is an injury to skin as a result of

constant pressure due to impaired mobility’

JAMA, 2006 – Vol 296, No 8. Pressure Ulcers

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Economic Importance of Proper Positioning

• Surgical patients have a 6.3% - 7.7% chance of incurring a pressure ulcer1

• Stage III & stage IV pressure ulcers are a Never Event:

– Health care facilities will not receive payment if condition is not present on admission

• Avg. cost to treat a pressure ulcer: $37,800! 2

– Pressure ulcers can cost as much as $90K

1. Arch Intern Med. 1998;158(17):1940-1945. doi:10.1001/archinte.158.17.1940

2. HCUP study reported on NIH website. Patient Safety and Quality: An Evidence Based Handbook for Nurses. 2008.

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Economic Importance of Proper Positioning

• Avg. cost of malpractice expenses = $250,000! 1

• 50% increase in nursing care to treat each ulcer 2

PLEASE NOTE: These costs are only the costs to the facility. They do not include the VERY high price to the customer:

– Lost wages

– Lost quality of life

1. Bennett, R.G. et al. Journal of the American Geriatrics Society; 48(1): 73-81, January 2000. 2. Sanders, Ward et al. Pressure Management in the Operating Room. Managing Infection Control. Sept 2006.

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Benefits of Pressure Ulcer Prevention

• Increased patient comfort

• Better patient satisfaction scores

• Maintenance of reimbursement dollars potentially lost to a “Never Event”

• Decreased cost to facilities and patients

• Decreased incidence of nosocomial infection

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Basic Principles in Patient Positioning

• Maintain patient’s airway

– Avoid chest constriction

• Maintain circulation

• Prevent nerve damage

– Arms positioned to avoid nerve compression/ stretching

– Safety straps applied to avoid nerve compression

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• Proper positioning begins with the proper table surface:

– Surgical Surfaces:• Designed to maximize pressure distribution

• Types vary based on length of procedure

• Typically fluid proof

– Imaging Surfaces:• Designed for the particular needs of various imaging procedures

• Designed to maximize pressure distribution

• Typically fluid proof

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• RN must be aware of the anatomic and physiologic changes associated with:

– Anesthesia

– Patient repositioning

– The procedure

– Patient comorbidities

– Tissue perfusion

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• The following criteria should be met to prevent injury from pressure, obstruction, or stretching:

– No interference with respiration

– No interference with circulation

– No pressure on peripheral nerves

– Minimal skin pressure

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• The following criteria should be met to prevent injury from pressure, obstruction, or stretching:

– Accessibility to operative site

– Accessibility for anesthetic administration

– No undue musculoskeletal discomfort

– Maintenance of individual requirements

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Patient Assessment

• The team should assess the following prior to positioning of the patient:

– Procedure length

– Surgeon’s preference of position

– Required position for procedure

– Anesthesia to be administered

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Patient Assessment

• The team should assess the following prior to positioning of the patient:

– Patient’s risk factors

• age, weight, skin condition, mobility/limitations, pre-existing conditions, etc.

– Patient’s privacy and medical needs

– Basics of anatomy & physiology

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Team Responsibilities

• Physician:- Optimal procedural exposure

• Anesthesia:- Physiologic requirements (A-B-C’s)- Position timing

• Nursing:- Safe transfer using adequate personnel- Adequate padding and positioning aids- Provide an ongoing assessment

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Surgical Positions

• Four basic surgical positions include:

– Supine

– Prone

– Lateral

– Lithotomy

• Variations include:

– Trendelenburg

– Reverse trendelenburg

– Fowler’s

– Jackknife

– High lithotomy

– Low lithotomy

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• Surgical site access

– Maintain clinician access to the site

• Apply body mechanics / ergonomics principles

– Upper body and head aligned with hips

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Positioning Basics

Positioning Basics - Supine

• Pressure concerns

– Occipital protuberance

– Ulnar nerve

– Sacral area

– Heels

• Procedure Types

– Arthroscopic Knees

– Knees flexed

– Cataract Lens Replacement

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Positioning Basics – Fowlers Position

• Fowlers or Beach Chair

• Pressure concerns– Occipital protuberance

– Ulnar nerve

– Sacral area

– Popliteal nerve

– Heels

– Scapula

• Procedure Types– Arthroscopic shoulder

– Rotator Cuff

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Positioning Basics – Lateral

• Pressure concerns– Ocular area

– Shoulder

– Pelvis

– Knee

– Heels

– Chest

• Procedure Types– Spine

– Hips

– GI end Endoscopic

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Positioning Basics – Prone

• Pressure concerns– Ocular area - Scrotum– Knees - Elbow– Feet– Breast

• Procedures– Back or neck procedures

(cervical to sacral)– Procedures of the occipital or

postero-lateral cranium– Sacral, perianal & perineal

procedures- Some foot and ankle

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Positioning Basics – Lithotomy

• Pressure concerns– Occipital protuberance

– Sacral area

– Popliteal area

– Calves

– Feet

– Scapula

• Procedure Types– Urological procedures

– Gynecological procedures

– Colorectal procedures

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Positioning Basics - Reverse Trendelenburg



– Sacral area

– Popliteal area

– Bottom of feet

– Scapula

• Procedure Types

– Cranial Procedures

– GI Procedures

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Positioning Basics - Trendelenburg


- Occipital protuberance

- Sacral area

- Popliteal area

- Calves

- Feet

• Procedure Types

– GYN Procedures

– Robotic Procedures

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Gel vs. Foam

• Gel

– AORN Recommended

• Dry viscoelastic material

– Shear damage protection

– Widely accepted in surgical suites

– Cools when in contact with skin

– For cases that are over 2 hours long

• Foam

– Better pressure reduction then gel

• Shorter time period

– Lower cost

– Single-use options

– Often used in imaging

– Shorter cases

• Under 2 hours

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Positioner Families

Gels

Foams

Coated FoamSingle-Use Reusable

Standard Gel

Lightweight/ Pre-Contoured Specialized Gel

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Occipital Protuberance

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Positioning Concerns – Occipital Protuberance



The occipital bone is a thick, bowl-

shaped bone with an uneven surface

that provides the rounded appearance

at the bottom of the base of the skull.

The concern for the is due to the pressure

placed on the back of the head during

longer surgeries.

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Positions of concern

• Supine

• Fowlers

• Lithotomy

• Trendelenburg

Positioning Concerns – Occipital Protuberance

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Positioning Concerns - Occipital Protuberance

• Positioning Products

– Head donuts

Convoluted Foam Donuts

ReusableStandard Gel

Specialized Gel

Lightweight/ Pre-Contoured

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Sacral Area

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Positioning Concerns – Sacral Area

• Pressure concerns– Sacral Area

Pressure ulceration in the sacral area may lead to added complications if the patient has problems with urinary and fecal incontinence. Maintenance of the patient's skin integrity is vital to avoid added discomfort and distress due to moisture lesions. Prevention of wound and dressing contamination with urine and feces is difficult and can lead to increases in clinical risk (infection) and cost if not managed successfully.

Clinicians should also consider the pooling of surgical prep solutions near the sacral area

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• Supine

• Fowlers

• Lithotomy

• Trendelenburg

• Reverse Trendelenburg


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– Table overlay pads

– Dome positioners

Table overlay pads

Dome positioners

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Ulnar Nerve

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Positioning Concerns – Ulnar Nerve

• Pressure concerns– Ulnar Nerve

In surgery, arms on arm boards are not extended more than 45 degrees, which increases the likelihood that a surgeon or other caregiver could inadvertently lean on the arm while carrying out the surgical procedure. This can lead to ulnar nerve injury. The standard of care when arm boards are used is to have the arms positioned with palms up, with plenty of padding under them and with extensions of 45 degrees or less. Elbow protection is often recommended.

The placement of arm straps is very important in order to protect the ulnar nerve. Straps should not press down on the nerve itself.

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• Supine

• Fowlers

• Any position with the

arm extended


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– Arm board Pads

– Nerve Protectors

– Arm Cradles

Standard Arm board Pad

Arm CradleUlnar/Brachial Nerve Protector

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Heels

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Positioning Concerns – Heels


– Heels

Heel pressure ulcers can be particularly challenging for podiatric physicians, given the risk of complications, offloading challenges and the compromised vascular status of high-risk patients.

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• Supine

• Fowlers

• Lateral


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AliMed Heel Protector

Azure Heel Protector

AliMed Comfort Gel Heel Cups

AliMed Heel Protector Wraps

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Popliteal Nerve

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Positioning Concerns – Popliteal Nerve

• Pressure concerns–Popliteal Nerve

Linear pressure sores can form in the presence of poorly fitted, tight, thigh-length TED stockings, which may roll up at the popliteal fossa creating a focal linear compression in the presence of flexed knees.

This is one example of the concerns for clinicians when discussing the popliteal nerve in certain surgical positions.

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• Fowlers

• Lithotomy


• Trendelenburg


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Table Overlay Pads

Dome positioners

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Ocular Area

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Positioning Concerns – Ocular Area

• Pressure concerns–Ocular Area

This position is most frequently associated with position-related injuries. Many of these can be avoided if adequate staff members are present to facilitate the maneuver at both beginning and end of the procedure. The head and neck need to be carefully positioned to prevent excess pressure on the nose and eyes. These structures are at particular risk; even if the initial position appears adequate, small movements are potentially hazardous.

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• Prone

• Lateral


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Dome positioners

Prone HeadrestProne/Lateral Positioners

Contoured Chest Rolls

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Shoulder

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Positioning Concerns – Shoulder

• Pressure concerns–Shoulder

Pressure concerns for the shoulder arise when positioning the patient in the lateral position.

Pressure redistribution for the bony prominences of the shoulder, hips, knees and ankles are key in the prevention ulcers.

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• Lateral


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Lateral Positioner

Heel Cups

Knee Crutch Pads

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Pelvis

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Positioning Concerns – Pelvis

• Pressure concerns–Pelvis

Damage to the pelvis during many surgical procedures is very common. The pelvis absorbs a disproportional amount of the pressure during many procedures in many positions.

Prevention of ulceration of the pelvis starts with the proper surgical table surface which should be considered as part of any pressure redistribution plan.

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• Supine

• Lateral

• Fowlers

• Lithotomy


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Table pad Overlay

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Knee

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Positioning Concerns – Knees


The knees are particularly vulnerable to pressure ulcers in both the lateral and prone positions. Obviously the concerns for the knee are very different in each position.

The proper table surface helps in the pressure redistribution for both positions.

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• Lateral

• Prone

• Lithotomy


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Knee Crutch (Lateral)

Table pad Overlay

Dome Positioner(Under shins in prone position)

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Feet

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Positioning Concerns – Feet

• Pressure concerns–Feet

Think of a blister that develops on your foot when wearing a new pair of shoes for the whole day. The blister is caused by the constant rubbing of the skin against the inner surface of the shoe. In fact, that blister is characterized as a stage II pressure sore.

Pressure sores also develop on different areas of the body and usually occur when mobility is impaired.

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• Prone

• Lithotomy

• Trendelenburg


• Supine


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Dome Positioner

Heel Protectors

Lithotomy Boot Pads

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Calves

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Positioning Concerns – Calves


Though not a bony protuberance the calves are a place of potential problems during surgery. It is of the utmost importance to ensure that the pressure exerted by the calves is properly redistributed.

Without proper redistribution the calves can be at risk due to the larger surface area and the fact that there are very few positions in which the calves are not affected.

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• Supine

• Trendelenburg

• Lithotomy


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Dome Positioners

Lithotomy Boot Pads

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AliMed

• Please contact your local AliMed Representative to learn more.

• Please visit www.alimed.com to learn more about our pressure redistribution products and all of our products:– OR Accessories

– Imaging

– Safety/Infection Prevention

– Orthopedics

– Ergonomics

– Rehabilitation

– Custom Solutions

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http://www.alimed.com/

pressure redistribution clinical training lateral position. pressure redistribution for the bony...

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