Lmucrna2015 - Principles Positioning

Front 1

What are some factors that contribute to the risk of development of compartment syndrome?

Back 1

1. prolonged procedures 2. surgical positions 3. elevation of extremities4. intraoperative hypotension 5. increasing age 6. extremes of body habitus (very high or low body weight)

Front 2

What are the 4 basic surgical positions?

Back 2

1. supine 2. prone 3. lateral 4. lithotomy

Front 3

What is compartment syndrome?

Back 3

swelling of tissues within a muscular compartment which causes damage to neural and vascular structures

Front 4

How do you treat compartment syndrome?

Back 4

fasciotomy

Front 5

What are some reasons for intraoperative hypotension?

Back 5

1. the surgeon requests for patient to be hypotensive2. blood loss 3. decreased tolerance to anesthesia meds

Front 6

If compartment syndrome is not treated what happens?

Back 6

tissue necrosis which leads to myoglobinuria then acute renal failure

Front 7

Which nerves are most susceptible to nerve injury during surgery??

Back 7

superficial nerves, nerves with a long course (such as brachial plexus), nerves in areas where they are poorly covered by overlying tissue

Front 8

What nerve is most commonly injured of the lower extremities during surgery??

Back 8

peroneal nerve

Front 9

What is important to remember with tourniquets??

Back 9

it is your responsibility to keep track of timing on tourniquets... make sure to chart when they are up and down.. notify the surgeon when the tourniquet needs to be released

Front 10

What is the most common site of postoperative neuropathy??

Back 10

Ulnar neuropathy

Front 11

What are two causes of ulnar neuropathy?

Back 11

hyperextension of the elbow and compression on the nerve

Front 12

How will you know a patient has ulnar neuropathy??

Back 12

they are unable or abduct to oppose the fifth finger, they have decreased sensation in the 4th and 5th fingers, eventually they will present with atrophy of the hand muscles -- claw hand

Front 13

How should you position a patients hand to prevent damage to the nerves in the hand??

Back 13

palm up

Front 14

How will a patient with brachial plexus injury typically present??

Back 14

sensory deficit noted in ulnar distribution

Front 15

Why is the brachial plexus injured during surgery??Name 4 ways that this damage occurs.

Back 15

bc it is so long and superficial, it is easily susceptible to stretching or compression due to its length

most often occurs when:
1. the arm is abducted 90 degrees
2. there is lateral rotation of the head,
3. sternal retraction and
4. direct trauma/compression

Front 16

What causes radial neuropathy??

Back 16

direct pressure on nerve

Front 17

Damage to the radial nerve results in?

Back 17

wrist drop, inability to abduct the thumb or extend the metacarpphalangeal joints

Front 18

What causes median neuropathy??

Back 18

IV insertion into the AC area

Front 19

If you have damage to the median nerve how will you patient present??

Back 19

the patient will be unable to oppose the first and fifth digits, patient will also have decreased sensation over the palmar surface of the lateral three and half fingers

Front 20

What is the most common injury in the lithotomy position

Back 20

peroneal and sciatic neuropathy

Front 21

What causes damage to the sciatic and common peroneal nerves?

Back 21

stretching of sciatic nerve with external rotation of the leg, hyperflexion of the hips, extension of the knees- common peroneal nerves is often compressed between the head of the fibula and fetal frame of the stirrups

Front 22

How will the patient present with injury to the sciatic or common peroneal nerves?

Back 22

footdrop, inability to extend the toes in the dorsal direction, unable to evert the foot

Front 23

How will a patient present with damage to the femoral nerve?

Back 23

will have decreased flexion of hip, decrease extension of knee, loss of sensation of superior aspect of thigh and medial/anteromedial side of leg

Front 24

how will a patient present with damage to the obturator nerve?

Back 24

will have inability to adduct the leg & will have decreased sensation over medial thigh

Front 25

Nerve injuries are generally _____?

Back 25

transient-only require assurance

Front 26

How long does it typically take to recover from a nerve injury?

Back 26

3-12 months-to get full movement and sensation back

Front 27

What is the position of choice that causes the least amount of harm to the patient??

Back 27

supine

Front 28

Where should the safety belt be placed?

Back 28

2" above the knees while not impeding circulation-should be able to place one hand under belt

Front 29

Why should you not allow patients to be positioned with their feet/ankles crossed?

Back 29

decreases perfusion and causes damage

Front 30

The supine position is aka??

Back 30

dorsal recumbent

Front 31

What procedure typically use the supine position??

Back 31

procedures of the head, neck, extremities and chest

Front 32

How should you position a patients head if they have decrease cervical mobility??

Back 32

let the patient position themselves before induction

Front 33

Why do patients develop back aches during procedures??

Back 33

bc anesthesia blocks the normal spinal curvature and muscles...this is why you should pad the lumbar spine

Front 34

The alteration of the supine position to the lounge chair is favorable because??

Back 34

it helps increase comfort for patient

Front 35

What are cardiovascular considerations when taking care of a patient in the supine position during surgery??

Back 35

increase venous return (in comparison to standing),increased preload & increased CO,increased BP

Front 36

What are some respiratory considerations to be aware of when your patient is in the supine position during surgery??

Back 36

decreased FRC and TLC in comparison to a standing or sitting position-shift of the diaphragm towards the head-decreased elastic recoil and decreased A-P diameter-flexion of the head which can cause displacement of the ETT

Front 37

What should the anesthetist do before the OR staff turns a patient to the prone position??

Back 37

1. put the patient to sleep on the stretcher 2. turn the gas up and turn the o2 to 100% 3. then move the patient over to the OR table after securing the ETT good!

Front 38

Where are chest rolls placed in the prone position??

Back 38

two are placed lengthwise under the axilla and along the sides of the chest from the clavicle to the iliac crests (to raise the weight of the body off the abdomen and thorax,one roll is also placed at the iliac or pelvic level,should also have pillow under feet

basically support them from the clavicle to the iliac crest and all bony areas

Front 39

What is important to be concerned about when a patient is placed in the prone position??

Back 39

the position of the breasts and male genitalia must be free from pressure and torsion**you should also check the position of the dependent eye and nose if the patients head is facing to the side as well as monitoring of the ETT to ensure good position

Front 40

For what kind of surgeries is a patient placed in the prone position??

Back 40

procedures of the spine, posterior fossa, buttocks or rectum

Front 41

How do you avoid hyperextension of the neck when a patient is in the prone position???

Back 41

the shoulders should be position higher than the head

Front 42

List some modifications of the prone position..

Back 42

flat back prone position,jackknife position,sitting prone position

Front 43

The arms should never be ______. or you'll have injury to _____.

Back 43

abducted more than 90 degrees
will damage the brachial plexus

Front 44

How are the arms positioned when in the prone position?? and if you use armboards how should they be positioned?

Back 44

the arms can be tucked parallel to the trunk or they can be slightly pronated and lateral to the head,armboards should be lower than the shoulders

Front 45

What are 3 cardiovascular considerations to be aware of with a patient in the prone position during surgery??

Back 45

decreased CO,avoid pressure over the abdomen,avoid extreme flexion of the hips

Front 46

What are some respiratory considerations to be aware of with a patient in the prone position during surgery??

Back 46

FRC will be decreased compared to sitting but less than that of the supine position,if the abdomen can hang freely -the patient will have better diaphragmatic excursion,-there will be less pressure on the abdominal/thoracic region,-this position allows for increased oxygenation --better ventilation-perfusion ratios

Front 47

What can you do preoperatively to rule out the patient has a patent foramen ovale??

Back 47

TEE

Front 48

What is the gold standard intraoperatively to check for a VAE?

Back 48

do a TEE-can also use a precordial Doppler -- 3rd to 6th intercoastal spaces, right of the sternum (this is equally as sensitive as TEE in detecting, but less useful in localizing), a bovi may also pick this up.

Front 49

What are some complications of the sitting position?

Back 49

quadriplegia,pneumocephalus

Front 50

What is the most common cause of postoperative vision loss after surgery in the prone position??

Back 50

ischemic optic neuropathy

Front 51

All patients who are place prone for surgey should have a documented discussion r/t _____?

Back 51

vision loss

Front 52

Postoperatively... anemia should be corrected to a HCT of ?

Back 52

32

Front 53

What should a patient's bp be post op?

Back 53

20% above preop

Front 54

THE MAJORITY OF PATIENTS WITH POSTOPERATIVE VISUAL LOSS HAVE BEEN DIAGNOISED WITH ??

Back 54

ISCHEMIC OPTIC NEUROPATHY

Front 55

PERFUSION TO THE OPTIC NERVE MIGHT BE LIMITED BY??

Back 55

HIGH VENOUS PRESSURE OR EDEMA FORMATION

Front 56

HOW DO YOU CALCULATE CEREBRAL PERFUSION PRESSURE??

Back 56

MAP-CVP OR ICP (WHICHEVER IS HIGHEST)

Front 57

IN THE UPRIGHT POSITION

Back 57

THE EXTERNAL AUDITORY MEATUS IS THE EXTERNAL LANDMARK FOR??,CAN BE USED TO ESTIMATE THE POSITION OF THE BASE OF THE BRAIN

Front 58

List3 complications of the lateral position (other than resp and cardio complications).

Back 58

1. nerve injury (brachial, ulnar and peroneal are the most common) 2. damage to the dependent eye 3. rhabdo (caused by placing positioning devices against muscle rather than bony prominences)

Front 59

What surgeries is the sitting position typically used for?

Back 59

procedures of the posterior fossa, cervical spine, breast reconstruction and shoulder surgeries

Front 60

You want to avoid extreme flexion of the neck with the sitting position...what two things can be caused bc of excessive flexion???

Back 60

1. endobronchial intubation 2. jugular venous obstruction

Front 61

How can you check placement of the tube when in the sitting position??

Back 61

there should be 2 fingerbreaths between the neck and mandible to prevent endobronchial intubation

Front 62

What are some cardiovascular considerations for a patient in the sitting position for surgery??

Back 62

1. there are increased risk of profound hemodynamic effects depending on the level of elevation of the torso (ex. blood will pool in the lower extremities, decreased CI, CVP, PAWP, increased SVR)2. risk for threatened intracranial perfusion (hypocarbia, increased ICP, hypoperfusion due to hypotension)

Front 63

Your MAP ___ by ___mmHG per 1 cm of elevation?

Back 63

decreases/0.75

Front 64

Where should the transducer be positioned if an art line is used during the procedure?

Back 64

at the circle of willis

Front 65

How does a venous air embolism occur??

Back 65

due to air entering the venous system- negative pressure gradient between veins at the operative site and right atrium

Front 66

What will you hear when the air emboli gets to the heart with an esophageal stethoscope??

Back 66

mill-wheel murmur

Front 67

A bean bag is often used for the lateral position...what is it?

Back 67

it is put under patient and they are wrapped in it, it is hooked to suction, the air is sucked out, the bag will harden, it is then used as a holding device to keep the patient in place on the bed

Front 68

Which leg is flexed in the lateral position??

Back 68

the depended leg is flexed at the knee and hip..the nondependent leg stays straight.. a pillow should be placed between the legs

Front 69

how are the arms positioned in the lateral position??

Back 69

the dependent arm is typically supinated on a padded armboard, abducted less than 90 degrees - the nondependent arm should be parallel with the dependent arm, level with the shoulder on an arm holding device or with pillows/blankets between the two arms

Front 70

Where should the chest roll be placed when a patient is in the lateral position??

Back 70

under the dependent thorax, slightly caudad to axilla---not in the axilla

Front 71

What are some cardiovascular considerations for a patient in the lateral position for surgery??

Back 71

1. bp changes are usually minimal 2. hypotension is possible with severe flexion (lowering of the legs in comparison to the upper body)

Front 72

How does a venous air emboli occur?? how do you treat it?

Back 72

occurs due to negative pressures that develop if surgical site is higher than the heart-a central venous catheter tip is place at the junction of the IVC and RA to withdraw air from VAE

Front 73

The lithotomy position is typically used for what procedures??

Back 73

procedures requiring access to any perineal structures (gynourological, colo-rectal)

Front 74

What should you remember when positioning the legs for the lithotomy position???

Back 74

make sure to position them at the same time...if not you could cause trauma

Front 75

What is hemilithotomy??

Back 75

only one leg is elevated instead of the typical lithotomy position where both legs are elevated-sometimes used for orthopedic surgeries-rare!

Front 76

If you tuck a patients arms when in the lithotomy position it is important to remember to pay close attention to?

Back 76

their fingers...when raising the foot section of the bed... you can crush their fingers if the arms are left to the side-if you place the arms out from the side this allows easier access -- using armboards is recommended

Front 77

When should you position a patient in the lithotomy position before a procedure?

Back 77

once you have an airway

Front 78

Whenever a patient's position is changed what is the CRNA's responsibility???,

Back 78

always recheck the tube placement, listen for breath sounds, ensure that all monitors are attached properly and are reading correctly...then once that patient is finally in a position for the procedure...secure the tube how you want it!

Front 79

List a few cardiovascular considerations to be aware of for a patient in the lithotomy position...

Back 79

1. central blood volume will be increase (blood flows down the legs to the abdomen
2. this position doesn't effect healthy adults
3. this position can be detrimental if combined with trendelenburg in a patient with cardiac issues
4. if the patient has PVD there is increased risk for hypoperfusion, ischemia, and compartment syndrome
5. if the patient is hypovolemic, they may not have symptoms until the legs are lowered back into a neutral position--may develop severe hypotension

Front 80

What are some respiratory considerations to be aware of for a patient in the lithotomy position???

Back 80

1. this position is very similar the symptoms seen in the supine position (increased venous return so increased CO and ICP)
2. further decrease in FRC if patient in trendelenburg as well
3. diaphragm displacement

Front 81

What are some noncardiac and respiratory complications of the lithotomy position??

Back 81

1. hip dislocation (occurs when legs raised individually)
2. hip/back pain
3. femoral nerve or lumbosacral plexus stretch injury
4. arterial or venous occlusion or nerve palsy due to kinking of nerve structures
5. impaired venous outflow
6. compartment syndrome (due to stirrups)
7. peroneal nerve injury

Front 82

For what procedures would you use the lateral position for surgery??

Back 82

procedures involving the thorax, kidneys, posterior or lateral spine, craniotomies requiring access to lateral or posterior cranium, and some orthopedic surgeries

Front 83

What are some respiratory considerations for a patient in the lateral position for surgery??

Back 83

1. mediastinum will shift toward the dependent lung, decreasing the FRC in that lung as well as compliance and ventilation

ventilation-perfusion mismatch occurs because gravity pulls blood to the dependent lung but the independent lung is receiving the oxygenation

2. abdominal contents will force the diaphragm towards the head