Positioning (Pressure Injury Prevention and Tourniquet Safety) for Certified Perioperative Nurse (CNOR)

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Positioning (Pressure Injury Prevention and Tourniquet Safety)

Guidelines:

Positioning patients is one of the most important tasks and is the responsibility of all members of the surgical team.
Goals of patient positioning:
- Providing exposure of the surgical site
- Maintaining patient’s comfort and privacy
- Providing access to intravenous lines and monitoring equipment
- Allowing for optimal ventilation by maintaining a patent airway and avoiding constriction or pressure on the chest or
  abdomen
- Maintaining circulation and protecting muscles, nerves, and bony prominences, joints, skin, eyes, and vital organs from injury
- Observing and protecting fingers, toes, and genitals
- Stabilizing to prevent unintended shifting or movement
Goals of pneumatic tourniquet:
- Obtain a near bloodless field during extremity surgeries
- Confine a bolus of intravenous regional anesthesia in an extremity

Considerations:

Proper positioning and body alignment to prevent pressure injuries:
- SUPINE: the patient’s knees should be flexed approximately 5-10 degrees. The patient’s heels should be elevated off the underlying surface using a heel suspension device or a wide, pressure redistributing surface
  - Prevents popliteal vein compression and reduces risk for DVT
  - Don’t place pressure on Achilles tendon with heel-suspension
- TRENDELENBURG: Supine variation. Shortest time possible, minimize the degree of Trendelenburg position as much as possible
  - Decreases the potential for complications or patient injury
  - Retinal detachment and blindness may result from prolonged use of steep Trendelenburg position
- LITHOTOMY: shortest time possible, repositioned at established intervals during procedures
  - The longer the patient’s legs are maintained in lithotomy, the greater the potential for developing neuropathy, neurovascular complication, or compartment syndrome
- PRONE: Shortest time possible. Patients in prone position should be positioned 5-10 degree reverse Trendelenburg, if possible.
  - Intraocular pressure increases in the anesthetized patient in the prone position
  - The magnitude of this increase is related to the amount of time spent in the prone position
  - Positioning surgical patients with the head above the heart helps reduce venous congestion in the eye and orbit and decrease intraocular and intraorbital pressure
Pneumatic Tourniquet
- Some patient conditions increase risk for complications associated with pneumatic tourniquet use
  - Diabetic neuropathy
  - Previous revascularization
  - Sickle cell anemia
  - Severe infection
  - History or current VTE
  - High BMI
  - Low preop Hemoglobin
  - AV grafts or fistulas
  - Peripheral vascular disease (PVD)
  - Malignancy
  - Open fracture
  - Severe crushing injuries
  - Severe scar tissue at cuff location
IFU may specify contraindications for tourniquet use
Assessment/Diagnosis/Outcome Identification
- Conduct preoperative, intraoperative, and postoperative nursing assessments specific to patient positioning
- Understand the physiologic changes that occur during operative and invasive procedures
- Evaluating the patient’s risk for injury based on an assessment of identified needs and the planned operative or invasive procedure
- Anticipating the surgeon’s requirement for surgical access (site, laterality, etc)
- Respecting the patient’s individual positioning limitations
Planning/Implementation/Evaluation
- Identify, select, use, and maintain positioning equipment and devices
- Use neurophysiological monitoring to identify and prevent potential positioning injuries
- Implement interventions to provide for patient’s comfort and safety and to protect the patient’s circulatory, respiratory, musculoskeletal, neurological, and integumentary structures
- Prophylactic dressing may be applied to bony prominences (heels, sacrum) or other areas subjected to pressure, friction, and shear
- Support the activities of the anesthesia professional
- Implement safe practices for positioning patients in the supine, Trendelenburg, prone, reverse Trendelenburg, lithotomy, sitting and semi-sitting, and lateral positions and modifications of these position
- Documenting patient positioning and positioning-related activities
- Include in team communication
Follow manufacturer’s IFU and organization policies/procedures related to positioning and pneumatic tourniquet use in the OR
Document care and be specific about positioning, padding, repositioning, evaluation, etc.
Communicate positioning clearly and frequently to the interprofessional team. Include relevant information in handover reports. Include in briefing, time-out, debriefing as warranted.
Report device or positioning related injuries

Pitfalls:

Incorrect positioning and tourniquet application can result in serious injury
Primary cause of pressure injuries is sustained cell and tissue deformation
Surgical patients are at increased risk for positioning injury because of the effects of anesthesia and the lack of normal perception and protective reflexes
Frequent re-evaluation and team communication is key to patient safety

Examples:

Da Vinci’s Vitruvian Man

Linchpins (Key Points):

The risk for injury is multifactorial and may be related to the patient’s condition as well as the position
Many positioning injuries are associated with prolonged procedures
Surgical positioning creates a risk for skin breakdown and pressure injury development
Nursing interventions can prevent positioning injuries

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Transcript

References

Armstrong M. & Moore, R.A. (2022). Anatomy, Patient Positioning. StatPearls [Internet].
https://www.ncbi.nlm.nih.gov/books/NBK513320/
Association of periOperative Registered Nurses (AORN): Guideline Essentials (website), 2022, https://www.aorn.org/guidelines-resources/guidelines-fo r-perioperative practice/guideline-essentials
Rothrock, J. (2019). Alexander’s Care of the Patient in
Surgery (16th ed.). Elsevier Health Sciences.