Surgical Positioning: Evidence for Nursing Care

Abstracts

O posicionamento cirúrgico tem como principal finalidade promover o acesso ao sítio cirúrgico e deve ser realizado de forma correta para garantir a segurança do paciente e prevenir complicações. O presente estudo teve como objetivo buscar e avaliar as evidências disponíveis na literatura sobre os cuidados de enfermagem, relacionados ao posicionamento cirúrgico do paciente adulto no período intraoperatório. O método de pesquisa adotado foi a revisão integrativa da literatura. Para a seleção dos artigos, utilizaram-se as bases de dados PubMed, Cinahl e Lilacs. A amostra constitui-se de 20 artigos. Na síntese das evidências constatou-se que os artigos incluídos enfocaram três tópicos principais, a saber: os fatores de risco para o desenvolvimento de complicações; as complicações decorrentes do posicionamento cirúrgico e os cuidados de enfermagem relacionados ao posicionamento cirúrgico. Dentre as lacunas do tema investigado, destaca-se a necessidade de condução de estudos sobre dispositivos eficazes para cada tipo de posição cirúrgica.

Enfermagem Perioperatória; Cuidados de Enfermagem; Pesquisa

El posicionamiento quirúrgico tiene como principal finalidad promover el acceso al sitio quirúrgico y debe ser realizado de forma correcta para garantizar la seguridad del paciente y prevenir complicaciones. El presente estudio tuvo como objetivo buscar y evaluar las evidencias disponibles en la literatura sobre los cuidados de enfermería, relacionados al posicionamiento quirúrgico del paciente adulto en el período intraoperatorio. El método de investigación adoptado fue la revisión integradora de la literatura. Para la selección de los artículos, se utilizaron las bases de datos PubMed, Cinahl y Lilacs. La muestra se constituyó de 20 artículos. En la síntesis de las evidencias se constató que los artículos incluidos enfocaron tres tópicos principales, que son: los factores de riesgo para el desarrollo de complicaciones, las complicaciones provenientes del posicionamiento quirúrgico y los cuidados de enfermería relacionados al posicionamiento quirúrgico. Entre los vacíos del tema investigado, se destaca la necesidad de conducir estudios sobre dispositivos eficaces para cada tipo de posición quirúrgica.

Enfermería Perioperatoria; Atención de Enfermería; Investigación

REVIEW ARTICLE

Surgical Positioning: Evidence for Nursing Care¹

Camila Mendonça de Moraes Lopes^I; Cristina Maria Galvão^II

Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, WHO Collaborating Centre for Nursing Research Development, SP, Brazil:

^IRN, M.Sc. in Nursing. E-mail: [e-mail]

^IIRN, Associate Professor. E-mail: [e-mail]

^{Corresponding Author}

ABSTRACT

The goal of surgical positioning is to promote access to the surgical site. It should be carried out correctly to ensure patient safety and prevent complications. This integrative literature review aimed to search for and evaluate available evidences in literature about nursing care related to surgical positioning of adult patients in the intraoperative period. Pubmed, Cinahl and Lilacs databases were used for the selection of the articles. The sample consisted of 20 articles. The synthesis of the available evidence showed that included studies focused on three main topics: risk factors for developing complications, complications due to surgical positioning and nursing care related to surgical positioning. Among the gaps in the research theme, the need to conduct studies on effective devices for each type of surgical position is highlighted.

Descriptors: Perioperative Nursing; Nursing Care; Research.

Introduction

Intraoperative nurses are responsible for planning and putting in practice nursing interventions that minimize or make it possible to prevent complications deriving from the anesthetic-surgical procedure, with a view to the patient’s safety, comfort and individuality⁽¹⁾.

The patient’s surgical positioning is an important procedure in intraoperative nursing care. The main goal of this procedure is to promote optimal exposure of the surgical site and, at the same time, prevent complications deriving from surgical positioning. Therefore, teamwork and the use of specific positioning devices and equipment for each patient are essential. Nurses share the decision on how to best position the patient to facilitate activities during anesthesia and surgery with the team (surgeon, anesthetist and nursing staff). For this purpose, the patient’s anatomic and physiological alterations need to be identified, associated with the type of anesthesia, procedure type and surgical time he/she will be submitted to, so that the positioning is adequate and does not cause postoperative complications⁽²⁾.

This research is motivated by the lack of Brazilian research about nursing care in surgical positioning and the importance of research to support decision making by perioperative nurses, who have limited access to literature due to a lack of time and difficulties to seek and analyze available evidence and apply it in clinical practice.

The theoretical framework adopted to develop this research was Evidence-Based Practice (EBP). The EBP approach integrates the best evidence from research with professionals’ clinical competency and patients and family members’ preferences in decision making in high-quality health care⁽³⁾.

The practice of EBP in nursing encourages nurses to do research directed at clinical practice needs and/or the use of research results available in literature⁽⁴⁾.

Purpose

This research aimed to search for and assess evidence available in literature about nursing care related to surgical positioning of adult patients in the intraoperative period.

Methodological procedure

The adopted research method was an integrative literature review. This method includes systemized analysis and synthesis of research results on the same theme, contributes to deepen the research theme, supports decision making and, consequently, the improvement of clinical practice, based on preexisting research results^(5-6).

The following steps were followed to elaborate this integrative review: identification of theme or formulation of guiding question; sampling or literature search for studies; assessment of studies included in the review; discussion and interpretation of results and synthesis of knowledge evidenced in analyzed articles or presentation of integrative review results^(5,7).

The guiding question to elaborate the integrative review was: what is the nursing care related to surgical positioning of adult patients in the intra-operative period?

For the article search, the internet was used to access the following databases: PubMed (digital biomedical and health science files from the US National Institutes of Health), CINAHL (Cumulative Index to Nursing and Allied Health Literature) and LILACS (Latin American and Caribbean Health Science Literature).

Keywords related to the theme were selected and it was checked in the databases whether these were controlled descriptors according to each specific database indexation. Table 1 displays the descriptors used to conduct the integrative review.

With a view to a broad article search, all possible combinations among the descriptors were searched in each database. The following inclusion criteria were adopted: article on nursing care to adult patients in surgical positioning in the intraoperative period; published in English, Spanish and Portuguese between July 1998 and July 2008 and articles without distinguishing the adopted research design.

The articles were selected by their title and abstract, in line with the study goal and in compliance with the inclusion criteria. Six hundred references were preselected in PubMed, 140 in LILACS and 754 in CINAHL, totaling 1494 articles, which resulted in a sample of 20 articles that were analyzed in full. To extract the data, a previously published and validated data collection instrument was used⁽⁸⁾. To analyze the evidence level and research design of the studies included in the review, the concepts proposed by nursing researchers were used^(3,9).

The articles were analyzed and summarized descriptively, allowing readers to assess the quality of evidence (evidence level) available in literature on the research theme, support decision making in daily intraoperative nursing and identifying knowledge gaps with a view to future research.

Results

Twenty articles were included in the review, nineteen of which were published in English and one in Portuguese; among the publications’ countries of origin, the United States predominated with thirteen articles. Papers were published in a range of journals, particularly the AORN Journal (four articles).

With regard to the evidence level, only one study showed a strong evidence level (level II) with an experimental design, i.e. controlled randomized clinical trials; one study was considered of moderate evidence level (level III) with a quasi-experimental design, i.e. assessments (process analysis), and eight studies presented weak evidence (levels VI and VII), three with a non-experimental design, two descriptive, cross-sectional studies and three experience reports. In the same sense, the other ten studies (narrative literature reviews) are not classified according to the adopted hierarchical system. Tables ², ³, ⁴ and ⁵ show the synthesis of the analyzed articles.

Discussion

The synthesis of research data from the review studies revealed that these focused on three main themes, which were: risk factors for the development of complications, complications deriving from surgical positioning and nursing care related to the patient’s surgical positioning.

Preoperative assessment of each surgery patient’s risk factors and their consideration in the elaboration of the care plan can contribute so as not to develop complications in the intraoperative period^(20-28). All identified risk factors should be documented, as well as orientations patients received⁽²⁹⁾.

The main risk factors mentioned were:

general anesthesia – situation in which the body loses physiological protection for compensation mechanisms and is susceptible to muscle and/or nerve injuries and pain. Using drugs like muscle relaxants and pain medication can mask and delay the diagnosis of intraoperative injuries^(20-28);

age – elderly or very young patients can have a more sensitive skin and greater probability to develop skin injuries^{(20-21, 25, 27- 28)} ;

weight – assess the body mass index, as obesity and overweight can lead to a higher potential of complications due to positioning and low weight causes increased exposure of the patient’s bone prominences, which are regions more susceptible to the appearance of skin injuries^{(20-22, 24-28)};

immobility or mobilization problems – make surgical positioning more difficult and can favor the formation of blood clots and pressure points^{(20, 23--25, 27-28)};

body temperature control problems – as a result of hypothermia, body structures depend on more oxygen and, without the necessary inflow, this can favor the formation of necrosis or tissue death^{(20-21,26,28)};

preexisting health conditions - diabetes mellitus, cancer, kidney failure, low preoperative hematocrit and hemoglobulin levels, vascular, heart and respiratory diseases and conditions affecting the immune system can favor the development of complications^{(20-22, 24-28)};

prolonged surgery time - surgeries longer than two hours can affect the oxygenation of compressed tissues and favor the occurrence of pressure ulcers^(20-28) .

All studies assessed^(10-29) appointed that the patient’s surgical positioning causes some negative impact on body systems and can entail several complications, such as: musculoskeletal pain, joint dislocation, peripheral nerve damage, skin injuries, cardiovascular and pulmonary problems and even compartment syndrome.

The following stand out among nursing care recommendations in the analyzed articles: respect body alignment; take actions for pressure areas; reduce friction, shear and pressure; check bone prominences; select and make available positioning devices according to each patient’s needs and relate them with the surgery type and time; move, transport and position the patient with an adequate number of staff and using adequate equipment to avoid occupational and patient injuries; document all positioning procedures^{(10,20-22,24,26-28)}.

The main surgical position recommendations are:

supine – use pillows or supports for the head and below the knees, place arms at a maximum angle of 90º with the body, keep legs uncrossed, pay attention with hyperextension of the feet;

prone – protect face, eyes and chin, favor access to tubes and monitoring lines, maintain neck alignment, place roll cushion from the collar bone to the iliac crest and under the legs and feet, leave genitals free, protect feet against hyperflexion;

lateral – maintain spinal alignment, observe ears, place a support under the head, armpit region and between the legs, keep leg in contact with the table flexed in the hip region and the superior leg stretched;

lithotomy – maintain arms in arm holders at a maximum angle of 90º, pad hip, buttocks and body sides, use the lowest leg elevation for the shortest possible time and minimize the hip abduction degree.

Conclusion

The conclusion of this integrative literature review evidences the importance of nursing actions in surgical positioning, including the prevention of complications deriving from this procedure, the assessment of each patient’s needs and the availability of adequate equipment and devices. Nurses should become consumers of research results and/or conduct studies in response to daily problems, and should also seek strategies to put available evidence in clinical practice. In the authors’ opinion, this will imply the consolidation of Evidence-Based Practice.

Received: May. 6^th 2009

Accepted: Ago. 13^rd 2009

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1

Paper extracted from Master's Thesis "Posicionamento Cirúrgico: evidências para o cuidado de enfermagem", presented to Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, SP, Brazil.

Publication Dates

• Publication in this collection
  16 June 2010
• Date of issue
  Apr 2010

History

• Accepted
  13 Aug 2009
• Received
  06 May 2009