Perioperative Care of the Morbidly Obese Patient in the ... - AORN

More documents

Recommendations

Info

September 2010 Vol 92 No 3 BENNICOFFTHE LITHOTOMY POSITIONThe lithotomy position is used to allow maximumsurgical exposure in vaginal, rectal, and urologicprocedures. There are four levels of the lithotomyposition ranging from low lithotomy, whichplaces a patient’s legs at approximately a35-degree angle to his or her recumbent torso, tothe exaggerated lithotomy position with the patient’slegs at more than a 90-degree angle. 5Patient leg abductionshould be limited tothe degree neededfor adequate surgicalexposure to avoidstress on the patient’ship joints andprevent compromiseof lower extremitycirculation. 6 Physiologicresponses, including musculoskeletal, cutaneousand neurologic, and respiratory and hemodynamicresponses occur when the patient’s legsare elevated into lithotomy stirrups; perioperativeteam members must take these issues into considerationwhen caring for patients undergoing surgerythat requires the lithotomy position. 1,5,7Potential Musculoskeletal ComplicationsInjuries to the patient’s hips and knees can resultfrom lithotomy positioning. Abductor muscles andhip capsule joint problems can develop if the patient’slegs are stretched or the patient remains inthe lithotomy position for an extended period.The patient’s fingers, if tucked at his or her sides,are in danger of injury when the bottom of theOR bed is raised or lowered. 5Potential Cutaneous andNeurologic ComplicationsSoft tissue problems can result from incorrecthandling or positioning by health care providersand can include injuries to the patient’s femoral,cutaneous, sciatic, and obturator nerves. Pressurepoints from inadequate padding and positioningmay cause tissue damage. Shearing force fromchanges in position can damage skin tissue, especiallyin patients who are older, debilitated, orobese. Proper patient-moving techniques shouldbe used to prevent shearing forces.Potential Respiratory andHemodynamic ComplicationsRespiratory complications can occur because thepatient’s abdominal organs shift when the patient’slegs are raised and placed in stirrups. Thisincreases pressure onthe diaphragm andcan result in respiratorycompromise. 5Raising or loweringthe patient’s legs toorapidly can result influid volume shiftsthat affect bloodpressure. When teammembers lower the patient’s legs after the procedure,fluid volume deficits can quickly becomemore obvious, making the patient’s hemodynamicstatus unstable and complicating the anesthesiacare provider’s management of the patient. 5Patients who are morbidly obese can experiencethe common positioning problems that placeany patient at risk, and morbid obesity increasesa patient’s risk of additional complications thatthe nurse must consider in the plan of care.GENERAL NURSING CARE FOR PATIENTSWHO ARE MORBIDLY OBESEPatients who are morbidly obese present specialchallenges to all members of the perioperativeteam. These patients can experience any of thecommon positioning problems that place any patientat risk; however, morbid obesity increases apatient’s risk of additional complications thatmust be considered in the plan of care (Table 1). 8Nursing interventions to prevent problems includeensuring that sequential compression stockings fitto prevent constriction and monitoring the patient’sclothing and bed linen to prevent constrictionand prevent the patient from lying onbunched or wrinkled material that could causetissue damage. Drapes must be large enough tocover the patient and provide a sterile field. Instrumentsmust be large enough to provide adequateexposure and allow the surgeon to perform298 AORN Journal
CARE OF THE OBESE PATIENT IN LITHOTOMYwww.aornjournal.orgthe planned procedure, which may require specialbariatric instrument sets.Potential Musculoskeletal ComplicationsAs a result of the patient’s size and potential mobilitydifficulties, routine care may be more complicatedand require the help of additional supportpersonnel to avoid injury to the patient or staffmembers. 1,5,7 There is an increased risk of injuringthe patient’s joints, muscles, nerves, and softtissues when lifting and moving the patient becauseof his or her size, and the inability ofhealth care providers to clearly see the patient’sanatomic markers (eg, joints) can make safe kneeand hip flexion difficult to determine. 1,5,7 Overabductioncan occur because of the size and weightof the patient’s thighs and the need to create adequatespace in which the surgeon and staffmembers can work. 1,5,7 For example, the nurseshould have additional personnel support thepatient’s legs and prevent overabduction whenplacing the patient in the frog leg position duringinsertion of an indwelling urinary catheter.Potential Anesthetic ComplicationsPatients who are morbidly obese present significantchallenges for the anesthesia care provider.Often, these patients experience medication problemsas a result of altered absorption and increasedstorage of medications in their excess fat.Cardiovascular and respiratory concerns may includeincreased cardiac afterload, decreased oxygensupply, and a respiratory system taxed byincreased fat metabolism. 9 Additional chestweight, abdominal pressure, and the presence ofcoexisting conditions unrelated to the procedure(eg, hiatal hernia, sleep apnea) increase the patient’srespiratory workload. The patient’s chestweight and abdominal pressure also increase thepatient’s risk of aspiration and its serious consequences.9 Intubating a patient who is morbidlyobese can be difficult because of limited cervicalneck movement, reduced oxygen reserves, andincreased oxygen consumption. 9 Anesthesia careproviders may have difficulty seeing the vocalcords because of limited neck movement and fatdeposits that can obstruct the airway. As a resultof these complications, intubating the patientwhile he or she is awake may be necessary. 9 Theanesthesia care provider may require special headpositioning and support aids such as an airwaymanagement head cradle and an elevation wedgespecifically designed to assist with induction andhead support during procedures on patients whoare obese. Emergency response carts also shouldbe in the room in the event of a difficult intubationor other emergency. The patient also mayrequire appropriately sized blood pressure cuffs.Potential Cardiovascular ComplicationsCardiac conditions that often present in patientswho are morbidly obese may include hypertension,diabetes, bradycardia or tachycardia, andslow cardiac conduction and ischemia. As a complicatingfactor, the electrocardiogram conductionsignal may be distorted as a result of excess chestfat. Furthermore, patients who are obese have anincreased incidence of deep vein thrombosis, andsuperficial veins may be difficult to access for IVplacement. 9PLACING THE PATIENT WHO ISMORBIDLY OBESE IN THELITHOTOMY POSITION“Obese patients are more prone to difficulty withpositioning and positioning injuries during surgerybecause of the strain excessive weight places ontheir musculoskeletal and nervous systems.” 9(p45)Patients who are obese also may present with existingareas of skin damage that need to be assessedand taken into consideration during positioning.It is imperative that the perioperative nurse hasa preoperative discussion with the surgeon andthe anesthesia care provider about plans andneeds for the surgery. The circulating nurseshould perform a careful preoperative assessmentof the patient to identify cardiac, vascular, or neurologicconditions that could affect the patient’ssafety or care during surgery. Additionally, thenurse should identify any issues that mightAORN Journal 299
Page 1: Perioperative Care of theMorbidly O
Page 5 and 6: CARE OF THE OBESE PATIENT IN LITHOT
Page 15 and 16: CE EXAMINATIONwww.aornjournal.org1.

Perioperative Care of the Morbidly Obese Patient in the ... - AORN

Create successful ePaper yourself

Delete template?

Save as template?