Positioning Prepping PDF

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Summary

the basics of positioning, prepping, and beginning of the procedure
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Description

Positioning Prepping, and draping  Three basic surgical positions o Supine- patient on back o Prone- patient on stomach o Lateral- patient on side  Equipment and supplies used in positioning  Operating room table- used to achieve any desired position through manual or electrical controls, accepts attachments  Safety belt (knee strap)- used to secure patient during all inductions and most positions except lithotomy  Anesthesia screen- holds drapes off the patient’s face, and separated nonsterile area from sterile field  Drawsheet (patient lifter or armholder) o Used as an arm restraint o Used to support the body during transfer  Armboard- used to support the arm o When giving the iv fluid o When the site of the operation is the arm or hand o When the arm would be in the way o For a very obese patient o To support the arm on the unaffected side in lateral position  Padded body and kidney rest- used to stabilize the body in lateral positions  Footboard o Used as a horizontal extension of table o Can be placed perpendicular to support feet in reverse Trendelenburg position o May be used as a shelf on foot of table which was been lowered for vaginal procedures  Stirrups and lithotomy leg holders (Allen or candy cane) -raise and support and the legs in lithotomy position  Pillows, doughnuts, headrests, wrist straps. And sandbags- used for additional immobilization and support  Basic surgical positions and their variations  Basic supine (dorsal) o Patient lies on back with face upward o Arms are placed along side body with palms pronated o Legs are straight and parallel, in line with head and spine o Feet are slightly separated and supported by a pillow or padded board o Restraint strap is placed across the middle to upper thigh, 2 “in about the knees o The patient’s knees are over the break of the operating table  Modified supine o Same as supine, but head is rotated o Same as supine, but the shoulder is elevated o Same as supine, but knees are flexed, and thigh are externally rotated (dorsal recumbent)

Same as supine, but knees are slightly flexed, and thighs are externally rotated (modified recumbent) o Same as supine, but arms are extended on armboards Trendelenburg o Patient lies on back with face upward o Restraint strap is placed across the middle to upper things 2” above the knees o Shoulder braces are sometimes used o Entire table is placed in approximately 20-degree slant with head downward. The foot section may be dropped to facilitate mayo proximity Reverse Trendelenburg o Patient lies on back with face upward o Padded footboard is commonly used o Entire table is tilted so head end is higher than foot end o Operative area is usually elevated Sitting (fowler’s position) o Patient lies on back with knees over knee break on table o Table is moved into chair-like position o Restraint straps may be used to support the upper body o Arms rest on pillows on lap or arm attachment Lithotomy o Patient lies back o Patients butt oks rest along break between body and leg sections of the table o Patients legs are placed on stirrups o Leg section is lowered or removed Basic prone o Patient lies on abdomen with face turned sideways o Shoulders and sides of chest may be elevated with bolsters or chest rolls to facilitate respiration o Safety restraint strap is placed across the middle to upper thighs 2” above the knees o Arms are supported at sides of the body, raised above the head or placed on arm boards o Ankles and feet may be supported by padding or pillows Kraske (jackknife) o Patient lies on abdomen with face turned to side o Head is supported by donut or pillow o Shoulders and sides if chest raised using chest rolls or bolsters to facilitate respirations o Hips are placed over the center table break o Safety strap across thighs 2” above knees o Arms are supported on arm boards o Feet and toes are supported by pillow o Table is broken at the center with both ends tilted downward to form approximately a 90-degree angle Lateral chest o Patient lies on unaffected side o

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o Lower leg is flexed, upper leg is straight, and large pillow is placed between them o One body rest is placed at lumbar area, another at chest axillary area o Arms are supported on double arm boards or similar arrangements o safety restraint straps or wide tape is placed over hip and knees lateral kidney o patient lies on unaffected side o lower leg is flexed, upper leg is straight, pillow between them o arms may be supported on double arm boards o kidney elevator is used so that area between 12 th rib and iliac crest is raised o table is flexed to lower head and foot sections o safety strap or wide tape is placed over hip and knees supine- used for abdominal and abdomino-thoracic procedures, as well as some extremity procedures Trendelenburg- used for lower abdominal and pelvic procedures when surgeon wants abdominal contents to be separated from pelvic contents reverse Trendelenburg- used for thyroid and biliary tract procedures, and for some ENT procedures sitting- used for neurosurgical and some otorhinology procedures lithotomy- used for vaginal, perineal, and rectal procedures prone- used for procedures on the posterior surface of the body lateral kidney- used for procedures on the kidney and distal ureter and for colonoscopies lateral chest- used for thoracic procedures when a lateral approach is desired by surgeon qualities of good positioning o makes operative site prominent and accessible o does not interfere with circulation to any part o does not interfere with respiration o does not put any pressure on any nerves or bony prominences o allows maximum safety and comfort for the patient guidelines for positioning a patient o the surgeon decides on the position to be used based on the diagnosis with allowances made for anesthesia o the surgeons selected positions for various procedures will be on preference cards  if not listed ask or have circulator ask o the circulator is primarily responsible for positioning the patient o the surgeon, anesthesia provider, or surgeon’s assistant will assist the circulator with this o the proper time to position the patient depends on type of surgery, age, and size of patient, type of anesthetic, and if the patient has pain with movement o the patient is not moved until anesthesia give permission o pillows and other padding are used in strategic places, especially bony prominences, to prevent pressure on nerves and blood vessels o patient tubing must not be obstructed o anesthetized patients must be positioned slowly and carefully to give the circulatory time to adjust

excessive pressure on the chest must be avoided to prevent respiratory impairment legs must not be crossed extreme or embarrassing positioning should be done after the patient is anesthetized undue exposure of the patient should be avoided movement of joints must be gentle and within their limited range of motion to avoid damage and pain o when using arm boards, avoid hypertension of the arm, no more than 90 degrees o position palms up when supine to prevent pressure on the ulnar nerve o radial, median, or ulnar nerve damage can occur if extreme care is not used in supporting the elbow region o extreme positions of the head and arm can cause injury to the brachial plexus o stirrups that are inadequately padded or improperly placed can cause pressure on the peroneal nerve, which can produce foot drop if the damage is severe o the legs should be raised simultaneously by two people when placing the in stirrups to avoid hip dislocation o the stirrup height is adjusted according to the length of the patient’s legs, both stirrups should be equal o after surgery, the legs in stirrups are brought together and lowered very slowly and simultaneously, over a period of not less than two minutes to avoid a sudden drop in blood pressure o each patient is treated individually, and adjustments in positioning are made according to the patient’s size, age, and physical state purpose of prepping o to make the operative site as free from microorganisms and dirt as possible procedures involved in prepping o bathing- before coming to the OR, the patient will bathe or shower using bacteriostatic soap designed for skin use o hair removal hair from an operative site is commonly removed since it can harbor microorganisms  the area to be clipped is determined by the site of the incision and the nature of the operation  eyebrows are not clipped unless specifically ordered by the surgeon  clipping for head and neck surgery may be done after anesthesia is administered for psychological reasons  skin prep for severe trauma wounds may be done after induction  nicks or cuts should be reported as incidents and the surgeon notified the hair is removed by shaving, clipping or hair removal cream o a disadvantage of shaving is the possible breaking of the skin o a disadvantage of the cream is patient sensitivity injuries to the skin may occur during hair removal. Nicks and cuts provide a source of entry for microorganisms and a source of infection hair removal carried out by nursing personnel as close to the time of surgery as possible, either in the preoperative unit or in the OR o o o o o

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o hair must be contained to prevent contamination  OR skin prep o A basic rule of prepping is “proceed from clean to dirty” o Expose only the skin area to be prepped by folding back blanket and gown to 2” beyond prep o Using a sterile prep set, the circulator dons’ sterile gloves and cleanses the operative site o Scrub skin from proposed incision site in a circulator motion gradually working to the outer edges, being carful never to go back toward the clean areas o After reaching the edges, a new sponge should be used beginning at the incision site and working outwards o The skin prep should last at least 5 minutes. Some preps may be longer o When an open wound or body orifice is present, those areas will be scrubbed last or with separate sponges, whether they are the incision site  The umbilicus is considered contaminated and should be scrubbed last with a separate sponge or be cleaned first with separate sponges to avoid run off of dirty solution over clean skin  The vaginal prep includes the pubis, labia, perineum, anus, and inner aspects of the upper thighs. Sponges are discarded after they pass the anus. The vagina is prepped last  Contaminated wounds should be irrigated to flush out debris  Solutions must not be allowed to pool under the patient to prevent chemical burns  Flammable solutions must be allowed to evaporate before drapes are applied to decrease the risk of fire with electrocautery  Iodine o May be combined in solution with water or alcohol o Is irritating to skin o Is a good bactericide but stains fabric and tissue  Iodophor (betadine) o Is a complex or iodine and detergent o Is non-irritating to skin and mucous membranes o Removes debris from skin surfaces while slowly releasing 1% iodine for residual sporicidal effect o Leaves a brown film to define the prepped area o Effective against gram-negative and gram- positive microorganisms  Antiseptic o Chlorhexidine gluconate (hibiclens)  Good alternative for those allergic to iodine  Nontoxic, rapid acting, broad spectrum, antimicrobial agent  Is not absorbed through intact skin, but is an eye irritant and is contraindicated for facial antisepsis  Has a residual effect for at least 4 hours o Hexachlorophene (pHisoHex)  Develops a cumulative action after reported use  Effective against gram-positive microorganisms ineffective against gram-negative microorganisms  Neutralized by alcohol

Alcohols (isopropyl or ethyl)  Broad spectrum agents that denature cell proteins  For skin disinfection, a 70% solution is safe to use  Should NOT be used on mucous membranes or open wounds  FLAMMABLE, must be used in small quantities and must not be allowed to pool Purposes of draping o To create and maintain a sterile field by covering the patient and surrounding areas with sterile barriers Types of draping materials o Plastic with complete or partial adhesive backing o Nonwoven, disposable (paper) o Woven, reusable (cloth, linen) Towels o Usually 4 towels outline the operative site. May be secured with towel clips Plain sheets o Used to cover the operating table, instrument tables, and body regions Split sheets o Plain sheets with a split up the middle for draping extremities Stockinette o Used to cover an extremity o Made of porous and absorbent material so it is not a microbial barrier o An opening will be cut through the stockinette over the incision site Drapes o Fenestrated sheets (drapes)  Have windows (fenestrations) which allow exposure of the operative site  Available in several sheet and window sizes and positions  The top and bottom of the folds are marked so they can be correctly unfolded and placed on the patient Guidelines for draping o Draping is very important part of prepping the surgical patient and must be done correctly using strict sterile technique o Circulator should observe for breaks in technique o Scrub must have all necessary drapes arranged in proper sequence and assist the surgeon in placing the drapes o Scrub carries the folded drape to the OR table o Surgeon and assistant place the self-adhering plastic drape and or towel clips to outline the incision site o Do not hand surgeon towels or towel clips across and unsterile field. Take them to the side of the table from which they will be applied o When draping, a sterile person should stand back from and unsterile table o Gloved hands are protected while draping by cuffing the end of the drape over them to prevent contact from other surfaces o Drapes must not be placed on wet areas o

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Excess handling of drapes should be avoided Draping is done from a sterile area to an unsterile area The incision site is draped first once a drape is placed, it must not be adjusted If a drape becomes contaminated, discard it If in doubt as to sterility, consider is contaminated The points of a towel clip that have been fastened through a drape are considered contaminated...