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Positioning Pitfalls: Potential Injuries to look for in the post-op patient

Positioning Pitfalls: Potential Injuries to look for in the post-op patient. Disclosures. Teresa Casio None. Darin Prescott Speaker’s Bureau 3M Healthcare. Objectives. Match positioning with common surgical and invasive procedures.

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Positioning Pitfalls: Potential Injuries to look for in the post-op patient

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  1. Positioning Pitfalls: Potential Injuries to look for in the post-op patient

  2. Disclosures • Teresa Casio • None • Darin Prescott • Speaker’s Bureau 3M Healthcare

  3. Objectives • Match positioning with common surgical and invasive procedures. • Describe types of injuries acquired during invasive and operative procedures. • Correlate patient reports or other physical assessment data with potential positioning injuries.

  4. Pressure Ulcers reported in MN http://www.health.state.mn.us/patientsafety/ae/2013ahereport.pdf

  5. Anatomy Review • Nerve Injuries • Stretching • Compression • Pressure Points • When external pressure exceeds capillary pressure • Boney prominences • Skin close to bone/implant • Shear injuries • Lateral pressure and compression of skin and underlying tissue

  6. Shear

  7. Risk Factors • Who is at risk? • Everybody! • Diagnosis = Risk for positioning injury related to the operative or invasive procedure (Phippen, Ulmer, & Wells, 2009) • Anesthetic drugs • Previous injury • Length of time of surgical procedure

  8. Pre-Assessment • Braden Scale • Common tool for determining risk for skin breakdown • Not useful to OR Nurse • Eyes on patient; Head to toe assessment • Appropriate for every surgery? • Communication between the admit nurse and OR nurse • Past medical history • Physical limitations • Presence of implants • Skin integrity concerns (“Healthcare Risk Control” 2011)

  9. Pre-Assessment • Example – Patient admitted through Same Day unit then admitted after surgery • Pre-op skin assessment documented “intact with small red area top of right 3rdtoe” • 5 days post op the patient developed open pressure ulcer on right foot involving the 3rd toe • Same Day Admission and OR Nurses’ assessments & documentation supported this as a pre-existing condition

  10. Jewelry • Risk of Jewelry in Surgery • Infection or burn • Pressure ulcers • Third spacing • Waivers

  11. Common Equipment • Padding • Tables • Positioners • Stirrups • Specialty tables • Other equipment

  12. Common Positions & Procedures • Supine: • Laparotomy • Carpal Tunnel Release • Knee Arthroscopy • Eye procedures • Lateral • Total Hip Arthroplasty • Thoracoscopy • Nephrectomy • Prone • Laminectomy • Pilonidal Cyst • Lithotomy • Vaginal Hysterectomy • DaVincci robotic procedures

  13. Supine

  14. Trendelenberg

  15. Lateral http://www.pitt.edu/~position/Lateral/lateral_basic.htm

  16. Prone http://staanbiomedengg.tradeindia.com/prone-position-for-spine-surgery-121222.html

  17. Lithotomy http://www.pitt.edu/~position/Lithotomy/lithotomy1_1.htm

  18. Post Op Assessment • Outcome Indicators • Is the patient able to resume pre-procedure patters of ambulation? • Does the patient report tingling, numbness, cramping, pain or ache in the joints? • Does the patient report weakness and stiffness in the upper or lower extremity? • Can the patient abduct, adduct, flex, and extend the upper and lower extremities without experiencing pain or discomfort? • Does the patient show signs of disruption or breakdown of skin layers, especially over bony prominences? (Phippen, Ulmer, & Wells, 2009)

  19. Perianesthesia/Perioperative focus • Munro Pressure Ulcer Risk Assessment Scale • Masters Thesis • AORN is currently working on validation of tool • Plan for further research on its application • Incorporates 3 phases of care • Admission • Intraoperative • Recovery • Score is based on cumulative time and patient position (Munro, 2010)

  20. References Bouyer-Ferullo, S. (2013). Preventing perioperative peripheral nerve injuries. Association of Peri-Operative Registered NursesJournal, 97(1), 110-124. doi:10.1016/j.aorn.2012.10.013 Healthcare risk control: Patient positioning. (2011). ECRI Institute, 4, 1-9. Retrieved September, 2013 from https://www.ecri.org/Documents/RM/HRC_TOC/SurgAn6ES.pdf Fred, C., Ford, S., Wagner, D. & Vanbrackel, L. (2012). . Association of PeriOperative Registered Nurses Journal, 96(3), 251-260. Retrieved from http://download.journals.elsevierhealth.com/pdfs/journals/0001-2092/PIIS0001209212006837.pdf Galvin, P.A. & Curley, M.A. (2012). The braden Q+P: A pediatric perioperative pressure ulcer risk assessment and intervention tool. Association of PeriOperative Registered Nurses Journal, 96(1), 261-270. doi:10.1016/j.aorn.2012.05.010 Munro, C.A. (2010). The development of a pressure ulcer risk-assessment scale for perioperative patients. AORN Journal, 92, 272-287. doi:10.1016/j.aorn.2009.09.035 Phippen, M.L., Ulmer, B.C., & Wells, M.P. (2009). Competency for Safe Patient Care During Operative and Invasive Procedures. Denver, CO: Competency Credentialing Institute. Primiano, M., Friend, M., McClure, C., Nardi, S. Fix, L., Schafer, M., Savochko, K. &McNett, M. (2011). Pressure ulcer risk prevalence and risk factors during prolonged surgical procedures. Association of peri-Operative Registered Nurses Journal, doi:10.1016/j.aorn.2011.03.014 Sutton, S., Link, T. & Makik, M.B (2013). A quality improvement project for safe and effective patient positioning during robot-assisted surgery. Association of Peri-Operative Registered Nurses Journal, 97(4), 448-456. doi:10.1016/j.aorn.2013.01.014

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