Different patient positions are required to provide access for different surgical procedures. Each position has implications for the patient, as well as exposing patients to complications such as nerve injury and pressure sores. The perioperative nurse plays an important role in minimising the risks associated with these positions.
Critically discuss the role of the perioperative nurse in the lateral positioning of a patient undergoing a left open nephrectomy, identifying the risks associated with this position and the risk reduction strategies to minimise or prevent these occurring intraoperatively.
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Patient positioning before surgery is an important part of the preparation for any operation. The aim of optimal positioning for surgery is to provide the best surgical access while minimizing potential risk to the patient and maintaining patient safety. Each position carries some degree of risk, and this is magnified in the anaesthetised patient who cannot make others aware of compromised positions (Sørensen, Kusk and Grønkjaer, 2015).
Safe appropriate positioning of the patient for surgery requires knowledgeable peri operative team which ensures that the patient is safely positioned considering the anatomical alignment and physiological functioning of the patient during their surgical procedure. Assessment of the individual patient will include their specific needs. The needs of the patient which includes their dignity, comfort, warmth, and safety (EORNA).
Lateral positioning of a patient undergoing a left open nephrectomy:
Lateral or decubitus position: The patient is positioned on their later side (right) with their arms parallel to each other for left open nephrectomy. This position provides exposure for a left sided nephrectomy. For nephrectomy patient is placed on their side arched over a ‘kidney rest’ in the table with the lower hip flexed. The dependent side is the reference point for documentation.
Potential risk factors associated with the lateral position: Proper positioning reduced the risk of pressure related damage to nerves, muscle, skin, and joints. Complications with poor patient positioning can occur in transit when moving the patient into and out of theatre or during the procedure itself. Risk factors for the development of complications depends on patients pre-existing conditions. Peri operative nurses should consider and assess that especially those affecting the vascular, respiratory, neurological, circulatory, and immune system, mobility, nutritional status and the patients skin condition and integrity. ((Miranda, Fogaça, Rizzetto and Cuvello Lopes, 2016). There are several risk factors related to positioning injury and pressure ulcers peri operative nurses should be considered during surgical positioning are divided in to two groups
Intrinsic Factors are age of the patient, body weight, nutritional status, and chronic diseases such as diabetesmellitus, vasculopathy, neuropathy, hypertension, and anaemia.
Extrinsic factors are type and duration of surgery- procedure lasting longer than 2 hours can impair the oxygenation of compressed tissues.
Loss of compensatory physiological protection due to general anaesthesia, hypotension, and vasodilation which can cause hypo perfusion and inadequate oxygen exchange of the body tissues leading elevated potential risk of injury like pressure ulcers, due to pre-existing pathological condition.
Duration of surgery: During prolonged surgery, the patient can experience local muscle compression with ischemia and subsequent reperfusion injury leading to compartment syndrome or rhabdomyolysis. AORN (2017)
This patient in the lateral position is at risk for injury from pressure on vulnerable points on the dependent side i.e., right eye, ear, acromion process, olecranon, iliac crest, greater trochanter, lateral knee, and malleolus. Therefore, peri operative nursing teamwork, assessment, care planning and the use of devices and equipment’s are essential to perform the positioning with quality.
Physiological changes with right lateral position:
For a left open nephrectomy, firstly, the patient is anesthetised in the supine position. Then the patient will be positioned in the right lateral kidney position, with the anaesthetist taking the lead and ensuring that the airway is always patent. Turning the patients from the lateral to the kidney position can cause significant haemodynamic changes. Postural changes during anaesthesia can cause haemo- dynamic changes with decreases in arterial pressure (Yokoyama, Ueda and Hirakawa, 2000).
Respiratory efficiency is affected by pressure from the weight of the body of the chest. The lower lung receives more blood from the right side of the heart in the lateral position, so it has increased perfusion but less residual air because of mediastinal compression and weight from abdominal contents.
Circulation is compromised by pressure on abdominal vessels, and pooling of blood in the lower extremities. In the right lateral position, compression on the vena cava impairs venous return.
Peri operative nurses Role:
The three critical elements of safe patient positioning are planning, knowledge and teamwork (EORNA). Peri operative nurse is responsible for planning and implementing nursing interventions to prevent complications from anaesthesia and surgery, assisting the patient together with the multidisciplinary team. Peri operative nurse should be aware of the potential risks associated with the lateral position, so it is vital to conduct a preoperative patient assessment to identify patients at risk for positioning injury, develop a plan of care, and implement interventions to prevent injury.
Prior to the patient arriving in the theatre, peri operative nurse should ensure that the correct operating table and all necessary attachments are available and in good working condition. The patient’s dignity should be preserved as far as possible during the transfer, by reducing exposure and thus also reducing heat loss. All positioning is completed in cooperation and communication with the anaesthetist to ensure airway and all access devices are patent, body alignment is maintained throughout, and head, extremities and joints are supported (EORNA 2022).
A head positioner or pillow should be placed under the patient’s head. Peri operative nurse should assess and monitor the patient’s right ear after positioning and during the procedure and proper care should be always taken (AORN 2017).
Skin pressure sores: Peri operative nurse should be initiative-taking in checking for signs of skin breakdown such as redness or bruising before and after the procedure. Also ensure that pressure points around bony prominences are well padded using the right equipment’s to reduce the risk for pressure ulcers and nerve injuries. Skin condition is assessed prior to the procedure, during positioning if possible and checked post operatively.
Nerve compression: Peri operative nurse be aware of the potential risk of nerve injury in a lateral position and appropriate padding should be used to distribute the pressure evenly over a larger surface area and superficial nerve areas from injury i.e., radial, ulnar, brachial plexus and peroneal nerves. The patients’ arms should be positioned and secured on two levels with great care, and both arms abducted less than 90 degrees making sure the forearm and wrist in a neutral position (AORN 2017).
Axillary role should be placed under patient’s dependant thorax which supports the rib cage, reduces pressure on the head of the right humerus and avoids compression of the axillary neurovascular bundle. Patients’ bilateral radial pulses should be checked after positioning in the lateral position and the placement of the axillary role. The patient’s chest and abdomen should not be compressed or hang over the edge of the operating table. A safety restraint should be placed across the patient’s hip.
The patient’s dependent leg should be flexed at the hip and knee with well padded, upper leg should be straight and supported with pillows between the legs facilitates venous drainage and helps to prevent pressure injury. The lateral position increases the risk for injury to the common peroneal nerve (REF. Using padding helps to protect the peroneal nerve on the dependent leg from being compressed between the fibula and the operating table.
Evaluating the positioned patient: Once the patient is in position for the surgery, before prepping and draping the patient, the peri operative nurse should do through once over check to ensure that the patient’s body is in alignment and not at risk of injury. Post procedure peri operative nurse should conduct a post operative assessment using the safe surgery checklist – sign off phase and hand over to Recovery room nurses Documentation of care delivered should ensure that appropriate attention is paid to recording of the position and position device used for the surgery.
AORN Journal, 2017. Guideline Summary: Positioning the Patient. 106(3), pp.238-247.
Adedeji, R., Oragui, E., Khan, W. and Maruthainar, N., 2010. The Importance of Correct Patient Positioning in Theatres and Implications of Mal-Positioning. Journal of Perioperative Practice, 20(4), pp.143-147.
Eorna.eu. 2022. https://eorna.eu/wp-content/uploads/2020/09/EORNA-Best-Practice-for-Perioperative-Care-Edition-2020.pdf on 22 nd of April 2022.
Miranda, A., Fogaça, A., Rizzetto, M. and Cuvello Lopes, L., 2016. Surgical positioning: Nursing care in the trans operative period SOBECC, 21(1), pp.52-58.
Sørensen, E., Kusk, K. and Grønkjaer, M., 2015. Operating room nurses’ positioning of anesthetized surgical patients. Journal of Clinical Nursing, 25(5-6), pp.690-698.
Yokoyama, M., Ueda, W. and Hirakawa, M., 2000. Haemodynamic effects of the lateral decubitus position and the kidney rest lateral decubitus position during anaesthesia. British Journal of Anaesthesia, 84(6), pp.753-757.
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