.svg?sfvrsn=be606e78_3)
Proper patient positioning improves a surgeon's access to the surgical site, helps anesthesia providers maintain a patient's airway, and keeps those in your care safe and comfortable during procedures. Since sedated patients can't alert your surgical team when they're uncomfortable, your nurses need to identify the causes of pressure ulcers before a case begins, especially when managing the positioning challenges associated with these 3 special patient groups.
1. The elderly
Patients with minimal tissue between their skin and bones are more likely to suffer shearing injuries when the skin stays stationary and the flesh is dragged across a pointy bone. When positioning older patients, look for existing injuries or the beginnings of skin breakdown and position them so that you don't exacerbate trouble spots. Closely examine elderly patients' heels, because as people age, their feet become less padded and more susceptible to injury.
Just as importantly, determine the range of motion of elderly patients by asking them how far they can reach out or raise their arms. This will help you avoid overstretching their nerves and muscles during positioning. Geriatric patients may seem more flexible after they've been given muscle relaxants, but in fact they're nearly as vulnerable to overstretching as before.
2. The obese
Some obese patients won't tell you their actual weight because they're embarrassed. So assume bariatric patients are heavier than they claim, because you need to determine whether the equipment you have is strong enough to effectively hold patients, especially when placing them in various surgical positions. A table designed to hold a 500-lb. patient may not be able to hold a 475-lb. patient in the lithotomy position, for example, so make sure your stirrups and arm boards can support the additional weight.
Anatomical landmarks on some obese patients, such as the bellybutton or joints, can be harder to locate than they would be on smaller patients. This makes it difficult when, for example, you need to line up the bellybutton with the break in the OR table. To ensure that obese patients are in the proper position, verify the location of anatomical landmarks by touch.
Obese patients are often more prone to pressure injuries because the weight of excess tissue presses down on their bones and organs. They might also have cardiovascular problems and experience decreased blood flow to the extremities. For those reasons, use arm stackers made of memory foam for all obese patients. A foam stacker's channel helps contain the arm and disperses the weight while the memory foam helps alleviate pressure points on the skin.
Always use a lateral transfer device when positioning the extremities of obese patients because dragging their heavy arms and legs across the surgical surface could result in friction injuries.
|
7 Positioning Pearls |
|
1. Work around implants. Make sure you ask patients about any implants they may have and position them accordingly. For example, position patients with pacemakers or other cardiac devices just below the skin in a way that doesn't apply pressure on the device, which could cause skin breakdown from the inside of the body. Patients with orthopedic implants also need special attention because the tissue around the scar has already been altered and is more susceptible to breakdown. 2. Avoid towels. They don't reduce pressure on the skin because the fabric doesn't absorb body weight as well as foam or gel. Friction injuries can also occur when a patient's skin rubs across a towel's coarse fabric. 3. Check the head. Look for hair clips and pins that could cause pressure injuries at the scalp. Remove any clips or pins that you find. 4. Assess vascular patients. This patient group is at higher risk for pressure ulcers, so extra precautions should be taken during positioning. They often have decreased blood flow to extremities and may have pre-existing tissue ischemia. After final positioning, verify adequate blood flow to all extremities. 5. Look out for lithotomy. When lifting a patient's legs into stirrups, place them together so they're raised at the same time. Repeat the technique when lowering the legs. Keeping the legs together and moving them in a controlled manner will help prevent sudden fluctuations in the patient's blood pressure during positioning. 6. Monitor conscious sedation. These patients can tell you if they're uncomfortable, but they're also more likely to move during the procedure. Keep close watch in order to maintain proper positioning and make sure positioning devices remain in place. 7. Inspect table mattresses. Surgical surfaces should redistribute pressure and not bottom out. When inspecting an older mattress or choosing a new one, push down on it with your hand. You shouldn't be able to feel the hard surgical surface below. — Jay Bowers, RN, BSN, CNOR |
3. The diabetic
Diabetic patients tend to have poor vascular flow and pre-existing nerve damage, particularly in the lower extremities. Additionally, their skin injuries tend to heal slowly, meaning it's important to look for existing injuries, to pay particular attention to the feet, heels and ankles and to position these patients accordingly.
For instance, a diabetic's heels should not touch any underlying surface during surgery. Place positioning or elevation devices under the ankles when positioning these patients. And since many diabetics suffer from poor blood flow, ensure that the position they're placed in allows for adequate circulation. A member of the surgical team should make periodic circulation and tissue perfusion checks on the lower extremities throughout surgery.
If you notice an injury
Pressure ulcers might not develop until a couple days after surgery, so document any skin redness that you notice during or after a procedure, even if the irritation appears to be only a minor mark. Make sure you note on patients' charts any positioning interventions you've made throughout a case. And tell the re-ceiving nurse in PACU about your observations so she can keep a watchful eye on problem areas and document any changes she observes to the skin's integrity in the minutes or hours following surgery.
.svg?sfvrsn=56b2f850_5)