What's one thing that all surgical facilities are constantly trying to improve? If you said proper patient positioning for pressure injury prevention, then you nailed it — and probably need to get your tongue untwisted. Mary Fearon, MSN, RN, CNOR, one of AORN's perioperative practice specialists, takes a condensed look at 4 of the 22 new patient positioning recommendations you'll find in AORN's 2018 Guidelines for Perioperative Practice. If you're not already taking these preventive measures in your ORs, you might want to consider doing so.

1. Place pressure dressings over sacrum. Many studies document the usefulness of padded, prophylactic dressings to reduce pressure, sheer and friction on the regions of a patient's skin over bony body parts. While the new AORN recommendations suggest using the dressings over bony areas such as the sacrum, they caution against stacking multiple dressings on top of one another. If a dressing becomes damaged or worn, just replace it with a new one, says Ms. Fearon. Don't use the dressings in lieu of other positioning devices, but you can use them in tandem with other aids. Of course, you should consult the manufacturer's IFU to make sure the devices are compatible with pressure dressings.

Because there are many types of prophylactic dressings to choose from, AORN recommends assembling a team to determine which dressings best promote your facility's pressure injury prevention program. The team should include staff familiar with the different types of dressings and the effects the dressings have on the temperature and on the moisture of skin when applied, says Ms. Fearon.

2. Float the heels. This next change is for you if you use a pad or a piece of egg crate foam to protect a patient's heels from pressure ulcers when a patient is in the supine position. Instead, AORN recommends you use a boot-like heel-suspension device to raise the heels off the operating surface and redistribute the weight of the patient's leg along the calf without placing pressure on the Achilles tendon. Besides keeping pressure off both the heels and the sacrum, the heel-suspension device also keeps the knees from hyperextending while the leg is bent the recommended 5 to 10 degrees.

3. Neuromonitor patients during surgery. To prevent pressure injuries on areas of the body not visible during surgery, AORN recommends neurophysiological monitoring during surgery, which can detect decreased nerve activity in areas under pressure. Intraoperative neuromonitoring will alert the team if there is a problem in real-time so they can adjust the patient as necessary.

Say your surgical team is performing a procedure that requires the patient to have his shoulder held down or his arm tucked so the surgeon has access to a site. The recommended method to tuck a patient's arm involves running a sheet over the arm and under the patient above the mattress. The sheet can then be pulled tight — keeping his arm in position. The patient is under anesthesia during positioning, so he can't tell you if there is too much pressure on his shoulder or if the sheet used to tuck his arm is pulled too tight. In a 2013 study published in Otolayngol-Head and Neck Surgery, researchers found that attaching an automated somatosensory evoked potential (SSEP) device to the brachial plexus during crainial surgery alerted the team to positioning problems by showing a decreased signal within the first hour of positioning the patient. After loosening the sheet and repositioining the arm, the signal reappeared, which showed a loss of signal due to pressure on the nerve.

4. Take a positioning time out. In the situation described above, the surgical team had a way to monitor, in real-time, the effects of the patient's position on a specific region of the body and had to pause to make adjustments. This pause for positioning assessment is something that should occur regardless of whether your facility offers intraoperative monitoring.

Some facilities have already added this "second safety pause" during procedures. The pause gives the team a chance to take stock of the length of the procedure and the patient's positioning to decide if it's necessary and safe to reposition the patient mid-procedure. Throughout the updated guidelines, AORN recommends making time during procedures to assess a patient's position and intervene if it looks like there is potential for a pressure injury. This gives the nursing team the chance to speak up if there are any concerns about patient positioning.

Pressure-free

The goal of these positioning guidelines is to help shape your facility's approach to pressure injury prevention. These new recommendations give you even more ways to catch pressure injuries before they happen and to provide pressure relief to areas that need it most. OSM