Protect your patient—it is never too late to reposition

AORN Journal, May, 2004 by Mona Lisa Macapagal

Even when patients are positioned properly for surgery, some obstacles may arise. A patient's shape and weight can present a challenge for optimal positioning. Vigilant observation of a patient's position, preoperatively and intraoperatively, is imperative to prevent dire consequences.

CASE STUDY

Ms J was scheduled for a posterior lumbar decompression and fusion. Ms J is morbidly obese with a height of 5 ft 6 inches and weight of 253 lbs. Her size presented some concern about how surgical team members would position her prone on the spinal surgery and imaging table.

During Ms J's interview, the circulating nurse verified consent and determined that Ms J understood the procedure. This procedure may include placing pedicle screws in the lumbar area. At the time this patient was undergoing surgery, the hospital was undertaking a study of this procedure, so the patient also signed a study consent form. The circulating nurse assessed the patient's laboratory results to identify abnormalities, such as below normal hematocrit and hemoglobin levels and prolonged prothrombin time and partial thromboplastin time. The circulating nurse verified the availability of blood products by ensuring that the patient's blood had been typed and cross matched, because a significant amount of blood loss can occur during this type of procedure.

The circulating nurse and anesthesia care provider discussed postoperative expectations, such as would drainage; indwelling urinary catheter placement; dressings; and invasive lines, such as IV arterial lines, with Ms J. The patient and her family members were informed that the procedure might last eight hours or more. Family members were told that they could contact the OR to receive an update on the progress of the procedure and Ms J's status from patient relations personnel.

POSITIONING THE PATIENT

After the anesthesia care provider completed intubation and placed venous and arterial lines, the circulating nurse inserted the indwelling urinary catheter and applied antiembolism stockings and a sequential compression device. With the patient on a stretcher next to the spinal surgery and imaging table, support pads for her chest, hips, and thighs were placed in their approximate locations. The patient then was transferred with the anesthesia care provider at her head, two team members on either side, and one team member at her feet. At least six people are needed to safely transfer a patient from the stretcher to the spinal surgery and imaging table.

Ms J's gown was removed immediately before she was turned to prevent any wrinkling of the gown underneath her, which could cause skin irritation. The patient was turned using the log roll method. Her head was placed face down on a foam prone pillow to protect pressure points, such as her forehead and chin. The anesthesia care provider lubricated and closed Ms J's eyes and secured eye pads on top for protection.

The circulating nurse and anesthesia care provider worked cooperatively to properly align Ms J's arms on the arm boards--her shoulders were not posteriorly or superiorly extended, her elbows were at a 90-degree angle, and her hands were pronated to prevent brachial nerve damage. Her arms were placed on egg crate foam to protect the pressure points of the elbows and wrists.

The chest pad, with a gel pad on top to protect the patient's chest pressure points, was adjusted so that the top of the chest pad was at the patient's suprasternal notch. The circulating nurse and surgeon ensured that the load of the patient's chest was mainly on the superior aspect of the chest to minimize pressure on her breasts. This also facilitates ventilation. This position also is better tolerated when the patient's breasts are medial and cephalad.

The circulating nurse placed hip pads with egg crate foam under the patient's iliac crest to prevent hyperextension of her lower back. The thigh pads with egg crate foam were adjusted under the patient's thighs and up against the hip pads for lower body support. The patient's legs were placed on pillows to bend her knees slightly to prevent peroneal and popliteal nerve damage. A suspension sling and egg crate pads were placed under the patient's feet to protect pressure points. The circulating nurse placed a safety strap padded with a blanket snugly around the patient's thighs. The circulating nurse then prepped the patient, after which the scrub person and surgeon draped the patient, and the procedure began.

REPOSITIONING THE PATIENT

In the exposure phase of the procedure, the anesthesia care provider stated that he was no longer satisfied with the patient's position. The circulating nurse noticed that Ms J's position was no longer optimum; her neck was hyperextended, and lordosis was very pronounced.

The anesthesia care provider assumed that because the surgeons were well into the procedure, the patient could not be repositioned. If the patient was not repositioned, however, she could experience severe injuries. With her neck hyper-extended, her airway might become obstructed and nerve damage could occur. Her shoulders were overextended, which could cause brachial nerve damage. The anatomical position of her spine could not be viewed optimally because of the pronounced lordosis, and this could prolong the procedure. If action was not taken to correct these problems, further changes to her position and skin sheering could occur.