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why is patient positioning important?

When actively working with positioning, it is possible to give
bedridden people stability and safety, which will leave them more calm and
relaxed. Regardless of the situation, stability and safety will have a great influence
on the perceived comfort and well-being.

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It is evident positioning also has a clear influence on how different
pathological circumstances can develop, as a part of the treatment but
definitely also as a part of the preventive measures.

 

Risks and complications involved?

 

There are several issues to consider when you’re trying to provide safe
patient care in the operating department. As an ODP, it is a requirement to
promote an environment that has high standards of care and safety in line with
national guidelines, policies and protocols.

These issues include; airway management, ensuring accurate monitoring
equipment, maintaining and ensuring access to intravenous lines, ensuring
patient’s circulation and nerves are not compromised. Patient positioning
carries risks to staff as well as patients because in 2009, there has been many
cases where staff have been injured due to moving and handling of patients.

Common positions are;

1.      Supine-

Complications that can arise from this position include neuropathies
and pressure areas, where a reduction in perfusion leads to tissue ischaemia
and later result to tissue breakdown. Pressure areas of concern during supine
positioning include the occiput, sacrum and heels. Common mechanisms
contributing to nerve injuries include compression, excessive stretch or
ischaemia. To minimise the risk of injury to the nerve, the forearm should be
supinated and slightly flexed. This is because the nerve may be compressed
against the table if it is pronated and extended.

How patient safety is maintained?

•      Head is supported by
headrest or pillow to prevent stretching of the neck muscles. Arms are
supinated, padded and angled less than 90 degrees from the body to prevent
radial and nerve damage or from being compressed.  Pillow are placed under the lumbar curvature
to prevent back strain- something that happens when the paraspinal muscles are
relaxed from the anaesthetic. Pregnant women’s head is tilted 20 degrees to the
left to prevent pressure on the inferior vena cava which is associated with
hypotension.

2. Lithotomy is used for variety of procedures including gynaecological. Lithotomy
position is often combined with Trendelenburg position, which may aggravate
cardiovascular and respiratory implications. Placing the legs in lithotomy
position decreases the blood volume in the leg veins and redistributes this
blood volume centrally, increasing venous return to the heart and therefore
cardiac output. In vulnerable patients, this increase in central blood volume
can lead to pulmonary oedema. On returning the legs to the supine position at
the end of the procedure, blood will again fill the venous system of the legs.
Venous return will decrease, leading to a fall in cardiac output. Hypotension
may result until baroreceptor reflexes are activated. Blood pressure must be
monitored closely during these periods and treated accordingly. Decreased
arterial perfusion to the legs may lead to hypotension, hypovolaemia depends on
the degree of the elevated legs.

How patient safety is maintained?

•      Arms are secured on
padded arm boards to prevent crushing fingers 
when the bottom of the table is removed. Also, hi dislocation can be
prevented if the legs are raised and lowered slowly by 2 members of staff. Feet
should be padded and secured in stirrip.

3. The lateral position is utilised for a variety of surgical
procedures including thoracic, hip and shoulder surgery. Access to the airway
when a patient is positioned laterally is difficult. Therefore the airway
device must be properly secured to prevent involuntary displacement during the
procedure. Perfusion is greatest in the dependent lung and ventilation is
greatest in the non-dependent lung, which leads to V/Q mismatch This can lead
to hypoxia in susceptible patients. This differs from the awake spontaneously
breathing patient where both perfusion and ventilation are greatest in the
dependent lung.

How patient safety is maintained?

•      Extra Care is taken
to ensure the patient’s spine is aligned at all time and for maintaining
normothermia as heat loss is a big risk with this position.

The radial nerve and the common peroneal nerve are when the arm is
suspended, if the shoulder is abducted to greater than 90 degrees. To prevent
this injury, abduction of the shoulder should be limited to less than 90
degrees. The forearm can be supported with specially designed rests, or the
upper arm can hug a pillow. The common peroneal nerve may be compressed against
a hard table, to ensure patient safety, it should be appropriately padded.
Additionally, the saphenous nerve needs to be protected with padding placed
between the legs. The head must be supported so as to maintain the neck in a
neutral position and prevent stretching of the brachial plexus. An axillary
roll can be used to support the thorax and prevent compression of the lower.
Ensure the ear has not folded during positioning and all pressure areas have
been appropriately padded/protected.

4. Prone – This position is utilised for several different types
of surgery including spinal surgery. The airway is very difficult to access
after a patient has been positioned prone and therefore care and attention must
be spent securing it. Tapes or ties are appropriate, but consider the pressure
that a tie may exert on the face when the patient is turned. Ventilation may
actually improve with prone positioning due to an increase in FRC relative to
the supine position. However, if pressure is exerted on the abdomen this effect
may be reduced due to raised intra-abdominal pressure and a decrease in
compliance. Patients should be supported on bony areas with supports placed
across the chest (just below the clavicle) and the pelvis, allowing the abdomen
to remain free of pressure. Access to the patient is limited once the patient
is positioned. Consider this when securing intravenous access and avoid
intravenous cannulae in the antecubital fossa, as these are likely to become
kinked while prone. Disconnect nonessential lines when turning the patient to
minimise the risk of inadvertent removal. Cardiopulmonary resuscitation is
problematic in the prone position and positioning of defibrillator pads is very
difficult. In high risk cases, consider application prior to turning the
patient prone. There are many potential pressure areas in the prone patient.
Special head rings minimise pressure areas on the face, but it is important to
ensure there is no pressure on the eyes or nose. Pressure areas may develop on
the breasts, genitalia and over bony prominences. Post-operative visual loss
has been reported following prone surgery. Retinal ischaemia can result from
direct pressure on the eye, so the head should be carefully positioned to
ensure no pressure is exerted on the eyes at any time.

How patient safety is maintained?

The staff will get prepared by collected all the necessary equipment.
The females breast and genitals are properly positioned to prevent compression.
At least four people should be involved to support and manage the head, rotate
tors and position the patient. This is done gently and slowly to allow the body
time to adjust to the change of position. Head rest is also used.

5. Sitting – this position is when a patient is sat down and is
commonly used in shoulder surgery and in some intracranial surgery,
particularly of the posterior fossa. Access to the airway may be limited by
surgical draping and the surgical field will be close to the airway, so it is
essential to ensure the endotracheal tube is well secured. Hypotension may
result after sitting the patient up. In an awake patient, the sympathetic
nervous system will be activated by the baroreceptors upon sitting up and there
will a rise in systemic vascular resistance which maintains blood pressure. In
the anaesthetised patient, these reflexes are less active and significant
hypotension can result. It is important to sit patients up slowly and treat
hypotension with volume resuscitation and vasopressors. If hypotension is
unable to be effectively treated, lay the patient supine. Hypocapnia should
also be avoided in ventilated patients, as it may lead to cerebral vasoconstriction
and may impair cerebral perfusion. Consider the appropriateness of each patient
for sitting position surgery, particularly those who are at increased risk of
cerebral ischaemia.

6. Trendelenburg is the term used when the patient is tilted 15
degrees or greater head down. Prolonged Trendelenburg positioning can lead to
facial and laryngeal oedema. This should be assessed for prior to extubation
with a cuff leak test in cases with steep positioning, or where there is
evidence of facial oedema. Minimising the amount of intravenous fluid
administered during the case may help lessen the incidence of this
complication. The endotracheal tube tip may move caudad during positioning,
leading to endobronchial intubation. The Trendelenburg position leads to a
further reduction in FRC from the supine position, due to further cephalad
movement of the diaphragm. Trendelenburg predisposes to atelectasis and causes
decreased respiratory compliance, so patients may need higher airway pressures
to achieve adequate tidal volumes. Barotrauma may result from high peak
inspiratory pressure.

How patient safety is maintained?

With steep Trendelenburg positioning, the patient may slide down the
table and care must be taken to secure the patient prior to tilting the bed.
Arms must be secured to prevent falling from arm boards, which can lead to
brachial plexus injury. Trendelenburg position will lead to increases in
intracranial and intraocular pressure and should be avoided in patients who
cannot tolerate this. REVERSE TRENDELENBURG FRC is increased in the reverse
Trendelenburg position relative to supine. Lung compliance also increases and
therefore care must be taken with lung volumes during positive pressure
ventilation. Hypotension may result from positioning in reverse Trendelenburg
and the anaesthetist should account for the hydrostatic gradient between the
blood pressure cuff and the brain, to prevent cerebral hypo perfusion.

Skin Ulcer sores

There are extra precautions when positioning vulnerable patients for
example, patients with great BMI will be provided with a bed that can hold
their weight, a wedge is placed under right flank to relieve pressure on the
vena cava in supine position. Slide sheets, pat slide and long safety straps
for safety.

challenges

Skin breakdown is a challenge with obese patients because moisture and
fluids from skin prep solutions may become trapped in tissue fold. Adipose
tissue is not well vascularised and pressure from positioning may cause a
decrease in circulation to peripheral body areas. Peri-operative staff note
down the patients skin condition prior and following procedure. Staff are
trained to understand factors that lead to skin damage formation.

•      Pressure that is put
onto the patient

•      Shear when handling
and moving patients

•      And friction.  Staff ensure patient safety by using the
waterflow scale to keep patients hydrated not leaning during patient transfer
and carrying out skin assessments.

Cost is another challenge because lack of resources can put patients at
risk especially with short staffing levels and not having enough safety
equipment.

 

What
is effective communication?

Communication
is a process of sharing information, thought and feelings between people
through verbal and non-verbal language. The main cause of medical errors and
mortality rate is down to communication breakdown in a health care setting
specially in the surgical department. Communication is a tool that enhances
patient safety and serves as a basis for effective teamwork. “According to
The Joint Commission, nearly 66% of all reported never events incidents from
1995 to 2005 happened because of ineffective communication. ”

It
gets worse because between 2010 to 2013 ineffective communication was one the
three causes of accidents and tragedies for wrong site surgery, administration
of incorrect medicines and surgical fires.

 

Non-verbal
and Verbal communication?

 Verbal
communication is used to inform patient’s needs and is for clarification.
Verbal communication helps to clarify misunderstandings and provides missing
information whereas, Non-verbal involves communication through body language,
pictures, gestures and facial expressions. Touch is a non-verbal communication
that is widely used in pre-op and post-op. 
Appropriate touch may be used by scrub nurses or ODP’s to reassure the
patients before and after surgery. 
Pictures and images are used to help patients with hearing impairment so
that they are also informed and perhaps reduce any anxiety or worries they may
have.

 

How
good communication enhance patient safety?

Effective
communication encourages critical thinking and greater team engagement. In the
perioperative department, effective communication is applied in everywhere
because staff members must work as a team to achieve a good quality of care and
patient outcomes.

During
a handover, vital information needs to be passed on for the continuity of care
especially when you are transferring a patient from the operating room to the post
anaesthesia care unit because post-operative care instructions from the
anaesthetist and surgeons need to be followed carefully so the patient can
recover with no complications.

 

Poor
handover is when a staff speaks too quickly dismissing important information
that can put patients at risk because the receiver does not follow up medical
test results or is not made aware of certain health conditions then he or she
misses the opportunity to do something about it. Handover involves shift
patterns and so, it is very important that on call staff are made aware of all
patients being admitted. Errors in communication can have serious consequences
because often it leads to hostile patient safety events such as delays in
treatment, medication errors, patient falls, transfusion incidents, hospital
acquired infections, and patient being discharged early.

To
ensure patient safety, perioperative staff follow the pathway starting with
pre-operative information such as patient details and medical history to post
operative care instructions such as the type of medication to be given. A
handover receiver is to ask questions and clarify information, confirm
appropriate steps in the patient’s plan and address any issues or concerns.
Managers ensure all staff are trained to use these transition techniques so
that they use the same vocabulary and standardised approach to communicate
about patients.

Another
safety measure is the use of checklist if used correctly can reduce adverse
events and errors. The pre-op and post-op department, have all adjusted to the
open culture that promote openness, information sharing and a no blame culture.

 

However,
there are barriers in all three departments that need to be addressed;

Language
and accents- language may lead to misunderstandings and delays in treatment.

Hand
writing and documentation – surgeons write so quickly and messy that makes it difficult to read
his instructions or the type of medication he prescribed. This can lead to
confusion for staff who are seeing the notes for the first time.

Interruptions- ward nurses are so busy
and are always fidgeting when post-operative staff are giving the handover.

And
the use technologies – when the WIFI is not working, the iPad become useless
and people have to walk to departments to communicate wasting the time you have
to care for patients.

 

1.       Why do patients need to be monitored?

Postoperative patients are monitored and assessed closely because their
health can deteriorate at anytime and the relevant postoperative pathway must
be implemented.

On placement, I rotated around between departments from theatre,
anaesthetics to recovery where I spent most of my time caring for
patients. I noticed that patient monitoring is very important at maintaining
patient safety because the patients are in an unstable physiological state.
When the patient arrives in the recovery room, a quick visual check is done to
pick up things that machines cant notice.

2. What is being monitored?

Temperature – the first thing that is being monitored is temperature. This is because
Children, older adults and patients who have been in theatre for a long period
are at risk of hypothermia. Shivering can be due to anaesthesia or a high
temperature indicative of an infection, while a drop in temperature might
indicate a bacterial infection or sepsis. Patients with high temperature will
have their operations cancelled to avoid further complications.

Patients’ temperature is constantly monitored and for safety, actions
are taken to return them to normal parameters. When patients are hypothermic,
forced air blankets such as Bair huggers or warm blankets are used to warm the
patient and if they are hyperthermia, antipyretics, fanning, cold ice blocks
and tepid sponging are used to cool them down. Peri-operative staff watch out
for signs such as shivering, increased blood loss during surgery, increased
carbon dioxide production, respiratory acidosis, peripheral vasoconstriction,
piloerection of the hair and goose bumps to support the patient especially when
they are under anaesthetics. The reason being is that patients under
anaesthesia have no control over their body heat as they are unconscious. Enzymes
in your body work best at 37 Celsius and if hypothermia is not controlled,
patients may experience skin break down, infection, low blood supply to vital
organs or even worse “cell death”. Cell death can occur when the cells in your
body are no longer working due to unbalanced homeostasis.

Respiration status- in post-operative department, the airway is constantly monitored
because respiration is one of the main causes of patient death. Failure to
monitor patient oxygen saturation could have serious implications because if
the oxygen saturation drops below 95%, a patient may have inadequate tissue
perfusion or have hypoxia. Staff ensure patient safety by recognising the signs
of respiratory complications such as; disorientation, bradycardia, tachycardia,
cyanosis and headaches. To prevent harm and these complications, patients are
given oxygen therapy to maintain the saturation levels above 95%. Also, depends
on the surgery the patient had, they may be advised to turn into lateral
position to reduce the risk of aspiration if they have excessive secretions.
Mapleson Mask and other emergency airway equipment are places by the patient’s
bed if the situation gets life threatening.

Blood pressure and circulatory status – hypovolaemic shock
occurs when systolic blood pressure falls leading to inadequate blood
perfusion, cellular damage and organ failure. This why it is important to
monitor patients blood pressure, pulse rate, pain and fluid balance. The body
tries to compensate for fluid loss after surgery but staff look out for signs
such as; restlessness, confusion, hypotension, low urine output, increased
temperature to treat hypovolaemia shock early. If this persist, staff may
request blood transfusion for their patients or fluid resuscitation. The fluids
we use in recovery are crystalloids which is hartmans and colloid solution
which is geleston.

Another complication is cardiogenic 
shock which can result in death if blood pressure is not monitored. This
may happen if the myocardial pump fails to respond in surgery. Treating
cardiogenic shock requires close observation because the anaesthetist may be
able to give digoxin which is a drug to treat arrhythmias and improve
contractility of the heart.

 

Why do
patients need medication?

Patients
undertaking surgery are usually given drugs, analgesia, induction agents,
inhalation agents or muscle relaxants by the anaesthetist. The whole purpose of
receiving drugs in anaesthetics is to produce loss of consciousness, relax
muscles and not feel any pain during surgery.

what are the safety issues
surrounding medication?

Medication
errors in anaesthetics and during postoperative care can leave patients
extremely vulnerable.  In any patient, an overdose of anaesthesia can lead
to a dangerous decline in blood pressure, and if left untreated, patients are
at risk of serious injuries or even death. Some patients can also have an
anaesthesia allergy and if the ODP’s and the anaesthetics fail to take a
thoroughly check medical history or carefully monitor vital signs, including
heart rate, blood pressure and blood oxygen levels, after administering
medication, the patient’s condition may deteriorate and leave a permanent
disability. This may have an impact on their families and personal lives;
unemployment, homes may be repossessed and their quality of life may be
infringed.

The
literature suggests that many medication errors are related to human error and
environmental factors, since drug administration often takes place in noisy
environments with poor lighting (Jones, 2009) (Table 2). Fry and Dacey
(2007) suggest that to reduce human and environmental error, such as
distractions, protected time during medication administration could be
introduced. This includes the use of a bright tabard (Hitchen, 2008) or the use
of a visual reminder such as a ‘do not disturb’ message (Pape et al, 2005),
whereby patients and staff are discouraged from disturbing a nurse who is
administering medications. However, the effectiveness of this intervention in
reducing human factor errors has not been thoroughly researched.

 

What procedures are being taken to ensure patient safety?

One of the recommendations to reduce medication errors and patient harm
is to use the “five rights”: the right patient, the right drug, the right dose,
the right route, and the right time.

•      Right patient

Staff ensure all medications are administered to the correct patient by
checking the patient’s wristband  and
asking the patient to confirm their identity. At my placement, at least two
staff have to check the medicines to eliminate room for mistakes.

•      Right drug

The prescription of a drug should be clear and legible. The generic
name, and not the trade name, should be used. Highlight any antibiotics
allergies on the wristband as well as on the drug chart. Medication labels and
orders are checked for expiry date and its uses.

Right dose

Staff confirm appropriateness of the dose using a current drug
reference.

Staff calculate the dose and have another staff to calculate the dose
again.

•      Right time

A drug needs to be administered at the appropriate time for effective
outcomes e.g. antibiotics.

•      Right route

Some drugs cannot be administered by the oral route (GTN or insulin,
for example). Others have to be administered IV for 100% bioavailability.

•      Incident reporting
and documenting

Document administration after giving the ordered medication. Chart the
time, route, and any other specific information as necessary. For example, the
site of an injection or any laboratory value or vital sign that needed to be
checked before giving the drug.

Are there any challenges to giving medications?

Poor calculation or competence, or lack of confidence Unclear error
reporting processes, which provide no clear definitions of medication errors
and near-miss events,  Distractions from
other nurses or patients (which can be hard to ignore) , Poor adherence to
prescription/ administration protocols Limited or no easily accessible
resources, such as electronic databases, to research unfamiliar drugs Lack of
awareness of when and where an error can occur Poor knowledge of medications
Lack of staff, poor management or leadership, or lack of funds Poor lighting on
night shifts Complacency, misconceptions or incorrect interpretations Ambiguous
protocols, policies and procedure guidelines for prescribing and drug
administration Busy ward Misinterpretation of packaging information (‘not for
oral use’, for example) Drug companies’ packaging not clearly marked or
labelled Noisy environments Fatigue, inexperience or poor communication Lack of
training and no regular updates or courses provided Time pressures Medical
professionals’ poor handwriting or unclear prescriptions Poor teamwork Increase
in nurses’ workload.

 

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