Pressure Redistribution Clinical Training. August 2014

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Ashlee Stone
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1 Pressure Redistribution Clinical Training August 2014

2 Goal: To help clinicians better understand and execute proper patient pressure redistribution and positioning

3 Contents (Click the link to move to that section) Importance of Proper Positioning Economic Importance of Proper Positioning Overview of Patient Positioning Patient Assessment Team Responsibilities 3

4 Contents Positioning Basics Supine Fowlers Lateral Prone Lithotomy Reverse Trendelenburg Trendelenburg Positioner Families Gel Foam 4

5 Contents Positioning Challenges and Concerns Occipital Protuberance Sacral Area Ulnar Nerve Heels Popliteal Nerve Ocular Nerve Shoulder Pelvis Knees Feet Calves 5

6 Why proper positioning is important Prevention of pressure ulcers To Contents 6

7 Why proper positioning is important Patient comfort Surgical site access Anatomical access Reduction of pressure ulcers Hemodynamic Stability 7

8 What is a Pressure Ulcer/Sore? A pressure ulcer is an injury to skin as a result of constant pressure due to impaired mobility JAMA, 2006 Vol 296, No 8. Pressure Ulcers 8

9 Economic Importance of Proper Positioning Surgical patients have a 6.3% - 7.7% chance of incurring a pressure ulcer 1 Stage III & stage IV pressure ulcers are a Never Event: Health care facilities will not receive payment if condition is not present on admission Avg. cost to treat a pressure ulcer: $37,800! 2 Pressure ulcers can cost as much as $90K 1. Arch Intern Med. 1998;158(17): doi: /archinte HCUP study reported on NIH website. Patient Safety and Quality: An Evidence Based Handbook for Nurses

10 Economic Importance of Proper Positioning Avg. cost of malpractice expenses = $250,000! 1 50% increase in nursing care to treat each ulcer 2 PLEASE NOTE: These costs are only the costs to the facility. They do not include the VERY high price to the customer: Lost wages Lost quality of life 1. Bennett, R.G. et al. Journal of the American Geriatrics Society; 48(1): 73-81, January Sanders, Ward et al. Pressure Management in the Operating Room. Managing Infection Control. Sept

11 Benefits of Pressure Ulcer Prevention Increased patient comfort Better patient satisfaction scores Maintenance of reimbursement dollars potentially lost to a Never Event Decreased cost to facilities and patients Decreased incidence of nosocomial infection 11

12 Basic Principles in Patient Positioning Maintain patient s airway Avoid chest constriction Maintain circulation Prevent nerve damage Arms positioned to avoid nerve compression/ stretching Safety straps applied to avoid nerve compression 12

13 Basic Principles in Patient Positioning Proper positioning begins with the proper table surface: Surgical Surfaces: Designed to maximize pressure distribution Types vary based on length of procedure Typically fluid proof Imaging Surfaces: Designed for the particular needs of various imaging procedures Designed to maximize pressure distribution Typically fluid proof 13

14 Basic Principles in Patient Positioning RN must be aware of the anatomic and physiologic changes associated with: Anesthesia Patient repositioning The procedure Patient comorbidities Tissue perfusion 14

15 Basic Principles in Patient Positioning The following criteria should be met to prevent injury from pressure, obstruction, or stretching: No interference with respiration No interference with circulation No pressure on peripheral nerves Minimal skin pressure 15

16 Basic Principles in Patient Positioning The following criteria should be met to prevent injury from pressure, obstruction, or stretching: Accessibility to operative site Accessibility for anesthetic administration No undue musculoskeletal discomfort Maintenance of individual requirements 16

17 Patient Assessment The team should assess the following prior to positioning of the patient: Procedure length Surgeon s preference of position Required position for procedure Anesthesia to be administered 17

18 Patient Assessment The team should assess the following prior to positioning of the patient: Patient s risk factors age, weight, skin condition, mobility/limitations, pre-existing conditions, etc. Patient s privacy and medical needs Basics of anatomy & physiology 18

19 Team Responsibilities Physician: - Optimal procedural exposure Anesthesia: - Physiologic requirements (A-B-C s) - Position timing Nursing: - Safe transfer using adequate personnel - Adequate padding and positioning aids - Provide an ongoing assessment 19

20 Surgical Positions Four basic surgical positions include: Supine Prone Lateral Lithotomy Variations include: Trendelenburg Reverse trendelenburg Fowler s Jackknife High lithotomy Low lithotomy 20

21 Basic Principles in Patient Positioning Surgical site access Maintain clinician access to the site Apply body mechanics / ergonomics principles Upper body and head aligned with hips 21

22 Positioning Basics

23 Positioning Basics - Supine Pressure concerns Occipital protuberance Ulnar nerve Sacral area Heels Procedure Types Arthroscopic Knees Knees flexed Cataract Lens Replacement 23

24 Positioning Basics Fowlers Position Fowlers or Beach Chair Pressure concerns Occipital protuberance Ulnar nerve Sacral area Popliteal nerve Heels Scapula Procedure Types Arthroscopic shoulder Rotator Cuff 24

25 Positioning Basics Lateral Pressure concerns Ocular area Shoulder Pelvis Knee Heels Chest Procedure Types Spine Hips GI end Endoscopic 25

26 Positioning Basics Prone Pressure concerns Ocular area - Scrotum Knees - Elbow Feet Breast Procedures Back or neck procedures (cervical to sacral) Procedures of the occipital or postero-lateral cranium Sacral, perianal & perineal procedures - Some foot and ankle 26

27 Positioning Basics Lithotomy Pressure concerns Occipital protuberance Sacral area Popliteal area Calves Feet Scapula Procedure Types Urological procedures Gynecological procedures Colorectal procedures 27

28 Positioning Basics - Reverse Trendelenburg Pressure concerns Occipital protuberance Sacral area Popliteal area Bottom of feet Scapula Procedure Types Cranial Procedures GI Procedures 28

29 Positioning Basics - Trendelenburg Pressure concerns - Occipital protuberance - Sacral area - Popliteal area - Calves - Feet Procedure Types GYN Procedures Robotic Procedures 29

30 Gel vs. Foam Gel AORN Recommended Dry viscoelastic material Shear damage protection Widely accepted in surgical suites Cools when in contact with skin For cases that are over 2 hours long Foam Better pressure reduction then gel Shorter time period Lower cost Single-use options Often used in imaging Shorter cases Under 2 hours 30

31 Positioner Families Gels Standard Gel Lightweight/ Pre-Contoured Specialized Gel Foams Single-Use Reusable Coated Foam 31

32 32 Occipital Protuberance

33 Positioning Concerns Occipital Protuberance Pressure concerns Occipital protuberance The occipital bone is a thick, bowlshaped bone with an uneven surface that provides the rounded appearance at the bottom of the base of the skull. The concern for the is due to the pressure placed on the back of the head during longer surgeries. 33

34 Positioning Concerns Occipital Protuberance Positions of concern Supine Fowlers Lithotomy Trendelenburg 34

35 Positioning Concerns - Occipital Protuberance Positioning Products Head donuts Lightweight/ Pre-Contoured Standard Gel Convoluted Foam Donuts Reusable Specialized Gel 35

36 36 Sacral Area

37 Positioning Concerns Sacral Area Pressure concerns Sacral Area Pressure ulceration in the sacral area may lead to added complications if the patient has problems with urinary and fecal incontinence. Maintenance of the patient's skin integrity is vital to avoid added discomfort and distress due to moisture lesions. Prevention of wound and dressing contamination with urine and feces is difficult and can lead to increases in clinical risk (infection) and cost if not managed successfully. Clinicians should also consider the pooling of surgical prep solutions near the sacral area 37

38 Positioning Concerns Sacral Area Positions of concern Supine Fowlers Lithotomy Trendelenburg Reverse Trendelenburg 38

39 Positioning Concerns Sacral Area Positioning Products Table overlay pads Dome positioners Table overlay pads Dome positioners 39

40 40 Ulnar Nerve

41 Positioning Concerns Ulnar Nerve Pressure concerns Ulnar Nerve In surgery, arms on arm boards are not extended more than 45 degrees, which increases the likelihood that a surgeon or other caregiver could inadvertently lean on the arm while carrying out the surgical procedure. This can lead to ulnar nerve injury. The standard of care when arm boards are used is to have the arms positioned with palms up, with plenty of padding under them and with extensions of 45 degrees or less. Elbow protection is often recommended. The placement of arm straps is very important in order to protect the ulnar nerve. Straps should not press down on the nerve itself. 41

42 Positioning Concerns Ulnar Nerve Positions of concern Supine Fowlers Any position with the arm extended 42

43 Positioning Concerns Ulnar Nerve Positioning Products Arm board Pads Nerve Protectors Arm Cradles Standard Arm board Pad Arm Cradle Ulnar/Brachial Nerve Protector 43

44 44 Heels

45 Positioning Concerns Heels Pressure concerns Heels Heel pressure ulcers can be particularly challenging for podiatric physicians, given the risk of complications, offloading challenges and the compromised vascular status of high-risk patients. 45

46 Positioning Concerns Heels Positions of concern Supine Fowlers Lateral 46

47 Positioning Concerns Heels Positioning Products AliMed Heel Protector AliMed Comfort Gel Heel Cups Azure Heel Protector AliMed Heel Protector Wraps 47

48 48 Popliteal Nerve

Positioning Concerns Popliteal Nerve Pressure concerns Popliteal Nerve Linear pressure sores can form in the presence of poorly fitted, tight, thighlength TED stockings, which may roll up at the

49 Positioning Concerns Popliteal Nerve Pressure concerns Popliteal Nerve Linear pressure sores can form in the presence of poorly fitted, tight, thighlength TED stockings, which may roll up at the popliteal fossa creating a focal linear compression in the presence of flexed knees. This is one example of the concerns for clinicians when discussing the popliteal nerve in certain surgical positions. 49

50 Positioning Concerns Popliteal Nerve Positions of concern Fowlers Lithotomy Reverse Trendelenburg Trendelenburg 50

51 Positioning Concerns Popliteal Nerve Positioning Products Table Overlay Pads Dome positioners 51

52 52 Ocular Area

53 Positioning Concerns Ocular Area Pressure concerns Ocular Area This position is most frequently associated with position-related injuries. Many of these can be avoided if adequate staff members are present to facilitate the maneuver at both beginning and end of the procedure. The head and neck need to be carefully positioned to prevent excess pressure on the nose and eyes. These structures are at particular risk; even if the initial position appears adequate, small movements are potentially hazardous. 53

54 Positioning Concerns Ocular Area Positions of concern Prone Lateral 54

55 Positioning Concerns Ocular Area Positioning Products Prone/Lateral Positioners Prone Headrest Contoured Chest Rolls Dome positioners 55

56 56 Shoulder

57 Positioning Concerns Shoulder Pressure concerns Shoulder Pressure concerns for the shoulder arise when positioning the patient in the lateral position. Pressure redistribution for the bony prominences of the shoulder, hips, knees and ankles are key in the prevention ulcers. 57

58 Positioning Concerns Shoulder Positions of concern Lateral 58

59 Positioning Concerns Shoulder Positioning Products Lateral Positioner Knee Crutch Pads Heel Cups 59

60 60 Pelvis

61 Positioning Concerns Pelvis Pressure concerns Pelvis Damage to the pelvis during many surgical procedures is very common. The pelvis absorbs a disproportional amount of the pressure during many procedures in many positions. Prevention of ulceration of the pelvis starts with the proper surgical table surface which should be considered as part of any pressure redistribution plan. 61

62 Positioning Concerns Pelvis Positions of concern Supine Lateral Fowlers Lithotomy 62

63 Positioning Concerns Pelvis Positioning Products Table pad Overlay 63

64 64 Knee

65 Positioning Concerns Knees Pressure concerns The knees are particularly vulnerable to pressure ulcers in both the lateral and prone positions. Obviously the concerns for the knee are very different in each position. The proper table surface helps in the pressure redistribution for both positions. 65

66 Positioning Concerns Knees Positions of concern Lateral Prone Lithotomy 66

67 Positioning Concerns Knees Positioning Products Knee Crutch (Lateral) Dome Positioner (Under shins in prone position) Table pad Overlay 67

68 68 Feet

69 Positioning Concerns Feet Pressure concerns Feet Think of a blister that develops on your foot when wearing a new pair of shoes for the whole day. The blister is caused by the constant rubbing of the skin against the inner surface of the shoe. In fact, that blister is characterized as a stage II pressure sore. Pressure sores also develop on different areas of the body and usually occur when mobility is impaired. 69

70 Positioning Concerns Feet Positions of concern Prone Lithotomy Trendelenburg Reverse Trendelenburg Supine 70

71 Positioning Concerns Feet Positioning Products Dome Positioner Heel Protectors Lithotomy Boot Pads 71

72 72 Calves

73 Positioning Concerns Calves Pressure concerns Though not a bony protuberance the calves are a place of potential problems during surgery. It is of the utmost importance to ensure that the pressure exerted by the calves is properly redistributed. Without proper redistribution the calves can be at risk due to the larger surface area and the fact that there are very few positions in which the calves are not affected. 73

74 Positioning Concerns Calves Positions of concern Supine Trendelenburg Lithotomy 74

75 Positioning Concerns Calves Positioning Products Dome Positioners Lithotomy Boot Pads 75

76 AliMed Please contact your local AliMed Representative to learn more. Please visit to learn more about our pressure redistribution products and all of our products: OR Accessories Imaging Safety/Infection Prevention Orthopedics Ergonomics Rehabilitation Custom Solutions 76

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$AliMed PATIENT COMPLETE FOR EVERY PROCEDURE \ \ POSITIONING. Patient Positioning Guide. AliMed.com. Call: Fax:$ AliMed Helping people help people Patient Positioning Guide COMPLETE PATIENT POSITIONING FOR EVERY PROCEDURE AliMed.com Email: info@alimed.com Call: 888.625.4633 Fax: 800.437.2966 \ \ SUPINE POSITIONING