Question 1

A 92-year-old frail female nursing home patient was admitted for dehydration,anemia,and respiratory symptoms.She has type 2 diabetes and low albumin levels,is underweight,and continues to smoke cigarettes.The patient is on complete bed rest in a hospital bed with an alternating pressure mattress overlay.She is not able to turn herself in bed and must be assisted to change position.Based on this description of the patient,which factor classification dominates her vulnerability and risk for injury?

Accepted Answer

Intrinsic factors lower a patient's tissue tolerance to pressure and decrease the time and pressure required for tissue breakdown.Certain preexisting conditions are regarded as intrinsic risk factors for OR-induced pressure ulcer development.These conditions include diabetes mellitus,smoking,peripheral vascular disease,cerebral vascular disease,urinary or fecal incontinence,anemia,malignancy,sepsis,steroid use,morbid obesity,malnutrition (serum albumin levels less than 3.5 g/dL),advanced age,body size (obesity as well as thin,frail build),and impaired mobility.

Question 2

A 14-year-old patient with marked scoliosis is in prone position with gel bolster rolls,gel pads,and pillows for a spinal fusion.Before the skin prep is begun,the perioperative nurse should check the positioning for pressure areas on the:

Accepted Answer

A final check of all areas of vulnerability should be conducted before the prep begins and the patient is draped.The male genitals,female breasts,and eyes are vulnerable to injury in the prone position.Eyes should be checked to ensure that they are not under pressure when the prone or lateral position requires the face to be in a dependent position.

Question 3

Recent studies on the relevance of the Braden pressure ulcer risk scale in the perioperative and critical care setting are inconclusive.In which perioperative setting would the Braden scale be most predictive as a baseline metric?

Accepted Answer

Although not specifically developed for the perioperative setting,the Braden Scale,as part of a comprehensive assessment,may be used as a preoperative baseline for predicting at risk perioperative patients.

Question 4

Select the positioning devices and accessories commonly used for bariatric surgery.

Accepted Answer

Bariatric patients present a higher risk of injury to both patient and staff during transfers.Special air-assisted transfer devices enable the patient to "float" on a small cushion of forced air.These devices may be placed deflated under the patient on the OR bed.After the procedure,they can be inflated and used to transfer the patient onto the PACU bed.

Question 5

Select the positioning device and accessory commonly used for neurosurgical procedures.

Accepted Answer

Pin fixation of the head (e.g.,Mayfield head positioner)is frequently used for craniotomies in prone position (as well as in other positions).The head is supported by three pins that are tightened into the skull.This allows complete stabilization of the head without the risk of pressure to the eyes or other facial structures.

Question 6

While basic positioning prevention strategies apply to all robotic-assisted procedures,in steep Trendelenburg with severe head-down position,strategies to prevent the patient from slipping toward the head of the OR bed must be considered.These strategies include:

Accepted Answer

Strategies to prevent the patient from slipping toward the head of the OR bed include use of accessories such as beanbag positioning systems (avoid abducting the arm),memory-foam positioners designed for steep Trendelenburg,and padded cross-torso straps.

Question 7

Select three basic criteria requirements that an OR bed mattress must meet.

Accepted Answer

OR mattresses should be durable,versatile for many uses,nonflammable,resistant to bacterial growth,radiolucent with low X-ray attenuation,compatible with warming and cooling devices,and covered with flexible nonallergenic antistatic fabric.Many mattress pads are now made without latex.OR mattresses should also have pressure-reduction capabilities.

Question 8

A 325-lb male is scheduled for a 6-hour abdominal surgery.While assessing the patient in the preoperative holding area,the perioperative nurse is concerned about the risk for pressure injury because of the weight of the patient's body pressing against the surface of the operating room (OR)bed for a long surgery.Which of these other factors may also produce pressure?

Accepted Answer

Pressure comes from the weight of the body as gravity presses it downward toward the surface of the bed.Pressure also comes from the weight of equipment resting on or against the patient,such as drills,Mayo stands,surgical instruments,rigid edges of the OR bed or its attachments,or vertical posts for self-retaining retractors.Positioning devices,such as stirrup bars,leg or arm holders,and edges of laminectomy frames,can rest or press against the patient under tension.

Question 9

The lateral kidney position allows approach to the retroperitoneal area of the flank.To render the kidney region readily accessible,the _______________ is raised,and the bed flexed so that the area between the twelfth rib and the iliac crest is elevated.Compression of the ____________ can occur when the flank is raised too high.

Accepted Answer

Raising the kidney bridge depends on the cardiovascular response of the body to increased pressure transmitted from this area.It should be raised slowly,and the anesthesia provider should monitor blood pressure frequently.The OR bed is flexed to lower the patient's head and legs.The patient's affected side thus presents a straight horizontal line from shoulder to hip.In this position,the gravitational force on the head and torso opposes that on the extended limb to facilitate operative exposure.Increased intra-abdominal pressure evoked by the kidney bridge and by flexion of the lower limbs toward the abdomen limits diaphragmatic movement.The acute angulations of the body in the lateral kidney posture and the effect of gravity also may decrease blood return to the right side of the heart.

Question 10

A 52-year-old 425-lb male patient is scheduled for surgery at the bariatric surgery center in 3 days.He has osteoarthritis and had a spinal fusion when he was 13.His long-time neighbor,a perioperative nurse at the bariatric center,has asked to be the patient's circulating nurse and is contemplating his plan of care.He shared his concern that he would not be able to move himself over to the OR bed and would be embarrassed if the nurses could not lift him.Based on this information,the nurse has identified this nursing diagnosis: ___________________ and these three positioning-relevant nursing interventions: _______ _______ _______.Select from the options to fill in the blanks.

Accepted Answer

He will not be able to transfer himself to the OR bed from the transport vehicle without considerable assistance.The encompassing nursing diagnosis related to the care of the patient during surgical positioning is the risk for perioperative positioning injury.Other potentially applicable nursing diagnoses are: impaired comfort,impaired transfer ability,and risk for falls.During transfer the OR bed and transport vehicle should be next to each other and locked.At least one individual should stand on either side to assist the patient in the transfer.Beds and accessories must accommodate the width and weight of morbidly obese patients.

Question 11

A patient undergoing a laparoscopic Nissen fundoplication procedure will be positioned in both high and low lithotomy during the procedure.After the patient is repositioned into low lithotomy,the perioperative nurse should:

Accepted Answer

The patient should be reassessed after any adjustment of the position and at appropriate intervals during long procedures as is possible with a draped patient.Assessment for pressure ulcer risk factors and development occurs during three periods: preoperative,intraoperative,and postoperative.Periodically recheck position,straps,and padding to ensure that nothing has slipped or moved.Reassess tissue integrity; document and verbally communicate any changes during hand-off report.

Question 12

Lateral,lateral chest,and lateral kidney positions all place pressure on structures of the dependent side: ears,shoulder,ribs,hips,greater femoral head,knees,and ankles.The potential for injury to the patient is significant,based on these pressure areas.Which resultant injury or harm could be related to these lateral positions?

Accepted Answer

A respiratory effect of lateral chest position is that the dependent lung is more perfused because of gravitational pooling of blood.The nondependent lung is more easily ventilated,however,because it is less compressed.This results in a ventilation-perfusion mismatch.Increased intra-abdominal pressure evoked by the kidney bridge and by flexion of the lower limbs toward the abdomen limits diaphragmatic movement.The acute angulations of the body in the lateral kidney posture and the effect of gravity also may decrease blood return to the right side of the heart.

Question 13

While Fowler's position offers the best respiratory excursion for the patient,the patient is at higher risk for ____________________ because of dependent pooling in the hips and legs.

Accepted Answer

This position poses significant circulatory compromises and risks.Blood pooling occurs in the lower torso and legs,which in turn causes significant orthostatic hypotension and diminished perfusion to the brain.Venous return from the lower extremities also lessens,and such hindrance increases the threat of venous thrombosis.

Question 14

Prolonged lithotomy positioning can result in neuropathies of the legs.The most frequently injured nerves are the obturator,sciatic,femoral,and _____________ nerves,which can result in injury from ______________.

Accepted Answer

The common peroneal nerve branches from the sciatic nerve behind the knee and becomes superficial as it wraps around the lateral head of the fibula.At this level,it is vulnerable to direct compression by stirrup bars.This risk may be increased in extremely thin patients who have minimal overlying tissue in this area.It is important to ensure that the lateral head of the fibula does not rest against stirrup bars or any other rigid surface.Compressive leg wraps (i.e.,intermittent pneumatic compressive devices,graduated compression stockings)also can put pressure on this nerve if the wrapping is too tight in this area.

Question 15

A frail and thin 91-lb,83-year-old woman is scheduled for a right pneumonectomy for non-small cell lung cancer.She will be positioned in left lateral position for her procedure.Based on the perioperative nurse's preoperative assessment,identify three position-related nursing diagnoses for this procedure.

Accepted Answer

The patient is at risk for hypothermia because of her age,weight,and amount of skin that will be exposed in the skin prep before draping.Falls are a risk during all stages of patient transfer and positioning and for a patient positioned in lateral position if not properly secured.The patient's thin frame is at risk for pressure injury and requires padding of all dependent bony prominences including her left hip,lateral knee,and ankle.

Question 16

While tucking the arms at the sides of the patient in supine position offers comfort,safety,and easy access to the patient by the scrubbed team,improper positioning,and securing of the arms can result in significant injury.Injury can be avoided by tucking the draw sheet ________ the arm and under the _________.

Accepted Answer

Many OR-induced peripheral upper extremity nerve injuries can be avoided by properly securing the arms if there are procedure-related reasons to tuck them at the patient's side.The arms should be tucked in such a way as to prevent them from sliding down the side of the OR bed and contacting the bed edge or rigid bed attachments.An effective technique to prevent arm slippage during surgery is to wrap the draw sheet smoothly around the arm,extending to above the elbow,and then tuck the draw sheet under the patient's body instead of under the mattress.

Question 17

The circulating nurse instructed the new anesthesia resident in the proper positioning of the arm and hands on the OR bed arm boards.She cautioned him to avoid pressure on the elbow to prevent:

Accepted Answer

The most common OR-related nerve injuries are to the ulnar nerve and brachial plexus.There is a good reason for this.As the ulnar nerve circles behind the elbow,it lies superficially in the shallow cubital tunnel of the humerus,where it is subject to pressure and to stretching from flexion of the elbow.

Question 18

Select the nursing activity that would reduce the impact of an extrinsic factor that could cause a pressure injury to the patient.

Accepted Answer

Negativity occurs when layers of materials,such as extra sheets or blankets,are placed over the OR mattress or padding.Negativity can override the pressure-relieving properties of mattresses and padding.Placing a warm blanket under a patient may be soothing initially,but if a surgical procedure is long,pressure to the bony prominences resting on the blanket will be higher than if only a sheet and draw sheet are used.Additionally,wrinkles and folds can cause further pressure points.

Question 19

A 325-lb male is undergoing a 6-hour abdominal surgery.While asleep and intubated,the surgeon requests the patient to be placed in lithotomy position for a sigmoidoscopy before the open procedure.The team of five nonscrubbed persons lifts the patient with the lift sheet,slides the patient down toward the foot of the OR bed,and places him into position.After the sigmoidoscopy,the perioperative nurse has the team roll the patient to his side for a skin assessment of his back before he is repositioned supine.What injury is the perioperative nurse concerned that she might see?

Accepted Answer

Shear is the folding of underlying tissue when the skeletal structure moves while the skin remains stationary.A parallel force creates shear,unlike the perpendicular force created by pressure.As gravity pulls the skeleton down,any stretching,folding,and tearing of the underlying tissues,as they slide with the skeleton,can occlude vascular perfusion,which can lead to tissue ischemia.

Question 20

The perioperative nurse noticed abrasions on a patient's elbows when she visited him in the intensive care unit (ICU)the day after his 6-hour abdominal surgery.The patient told her that the ICU nurses had difficulty pulling him back up in bed every time he slid down toward the bottom,and he was not able to be much help in moving himself.This skin injury was probably the result of which physical force?

Accepted Answer

Friction is the force of two surfaces rubbing against one another.Friction on the patient's skin can occur when the body is dragged across bed linen instead of being lifted.Friction can denude the epidermis and make the skin more susceptible to higher stage pressure ulcer formation,pain,and infection.

Quiz 6: Positioning the Patient for Surgery