Rene Camille L.

Laguda
BSN III

POSITIONING (SURGICAL POSITIONS)

- The position in which the patient is placed on the operating table depends on the surgical
procedure to be performed as well as on the physical condition of the patient.
- Factors to consider includes the following:
- The patient should be in as comfortable a position as possible, whether asleep or
awake
- The operative are must be adequately exposed.
- The vascular supply should not be obstructed by an awkward position or undue
pressure on a part.
- There should be no interference with the patients respiration as a result of
pressure of the arms on the chest or constriction of the neck or chest caused by a
gown.
- Nerves must be protected from undue pressure, improper positioning of the arms,
hands, legs, feet may cause serious injury or paralysis. Shoulder braces must be
well padded to prevent irreparable nerve injury, especially when the Trendelenburg
position is necessary.
- Precautions for patient safety must be observed, particularly with thin, elderly, or
obese patients.
- The patient needs gentle restraint before induction, in case of excitement.
- Arms are secured with the lift sheet or placed on arm boards.
- Used for procedures on the anterior surface of the body, such as abdominal,
abdominothoracic and some lower extremity procedures.
-

Types of Surgical Position:

1 Supine
2 Trendelenburg
3 Reverse Trendelenburg
4 Fowlers Position
5 Lithotomy Position
6 Prone Position
7 Modified Prone Position
8 Lateral (Side-Lying) Position

- Modifications of the supine position are used for specific body areas:
1. Supine- lying down with the face up, as opposed to the prone position, which is face down.
(a)Procedures on the face or neck
- Neck may be slightly hyperextended by lowering the head section of the operating bed or by
placing a shoulder roll.
- Head may be supported on a head rest or donut and/or turned toward the unaffected side.
- Eyes are protected from injury by shields, goggles, or nonallergic tape.
(b) Shoulder or anterolateral procedures
- A small sandbag, water bag, roll or pad is placed under the affected side to elevate the shoulder
off the operating bed for exposure.
- Length of body is stabilized to prevent the spine from rolling or twisting.
- Hips and shoulders should be kept in a straight plane.
- Operating bed can also be tilted laterally to elevate the affected part.
(c)Dorsal Recumbent position
- For some vaginal or perineal procedures.
- Patient in supine position except that the knees are flexed upward and the thighs are externally
rotated.
- Soles of the feet rest on the Operating bed.

- Pillows maybe placed under the knees if needed for support.

(d) Modified dorsal recumbent (frog-legged) position
- For some surgical procedures on the region of the groin.
- Patient lies on back with arms at sides.
- Knees are slightly flexed with pillow under each knee.
- Thighs are externally rotated.
(e) Arm extension
- For surgical procedures of the breast, axilla, upper extremity or hand.
- Arm on the affected side is placed on an arm board or upper extremity table extension that locks
into position at right angle to the body.
- Hyperextension of the arm is avoided to prevent neural or vascular injury, such as brachial plexus
injury or occlusion of the axillary artery. The arm board is well padded.
2. Trendelenburg Position
3. Reverse Trendelenburg Position- Patient lies on back in supine position with soft roll under
shoulders for thyroid, neck or shoulder procedures.
- The entire operating bed is tilted 30-40 deg. So the head is higher than the feet; a padded foot
board is used to prevent the patient from sliding toward the tilt.
- Thigh safety belt is positioned 2 inches above the knees.
- Small pillow may be placed under the knees and the lumbar curvature.
- Venous stasis can cause complications, and prevention of deep vein thrombosis is an important
consideration. The use of sequential compression devices, antiembolic stockings, or foot pumps is
suggested to improve venous return.
4. Fowlers Position- Patient on his back with the buttocks at the flex in the operating bed and the
knees over the lower back.
(a)Sitting Position (High-fowlers)
(b) Beach chair or modified sitting position
- Arms are typically placed across the abdomen, and a safety strap is across the thighs.
- Head and feet are elevated 10-20 degree angle above the level of the heart.
5. Lithotomy Position- Used for female pelvic exam
- Client lies on back with the knees well flexed and separated
- Frequently stirrups are used ( adjust for proper feet and lower leg support)
6. Prone Position- Client lies on his abdomen
- Head turned to one side on small pillow or a flat surface
- Small pillow just below diaphragm to support lumbar curve, facilitate breathing, and decrease
pressure on female breasts.
- Pillow under lower leg to reduce plantar flexion and flex knees.
- May be modified in amputees where flexion of hips and knees may be contraindicated.
7. Modified Prone Position
(a) Kraske (Jackknife position)
- Patient remains supine until anesthetized and then turned into his abdomen (prone position)
- Hips over the center break of the operating table.
- Chest rolls or bolsters are placed to raise the chest.
- Arms on arm boards with elbows fixed and palms down
- Head to the side and supported on a donut or pillow. Feet and toes rest on pillows.
- Safety belt placed below the knees.
- Leg section is lowered at desired amount and operating bed tilted head downward to elevate hips
above the rest of the body.
(b) Knee-Chest position
- Client first lies on the abdomen with head turned to 1 side on a pillow
- Arms flexed to either side of the bed.

Finally the client is assisted to flex and draw knees up to meet the chest

8. Lateral (Side-Lying) Position

- Client lies on his side
- Pillow under neck to prevent lateral neck flexion and fatigue
- Both arms are slightly flexed in front of the body.
- Rolled pillow behind clients back.
(a)Sims recumbent position
- A modified left lateral recumbent position
- Similar to lateral, but with weight supported on anterior aspects of the ileum, humerous, and
clavicle.
- Client placed on side with head turned to side on a pillow.
- Upper arm flexed in front of body and supported by a pillow.
- Upper leg is sharply flexed over pillow with the lower leg slightly bent.
(b) Kidney position
- Patient is in lateral position with kidney region over operating bed break, or body elevation bar.
- Table is flexed, straps across hips to stabilize the body
- Raised kidney elevator for hyper extending surgical site, and pillow between legs
- Lower leg is flexed more than the upper leg.
- Patients side is horizontal from shoulder to hip.
- Arms supported by a double airplane board.
(c)Lateral Jackknife position
- Similar to kidney position, the lateral jackknife position is not well tolerated.
- Bed is flexed at the level of the patients flank or lower ribs; this drops the legs into a dependent
position
(d) Lateral chest ( thoracotomy) position
- Turned to unaffected side and positioned as described in lateral position.
- A gel pad under axilla elevates the surgical site and relieves pressure on the lower arm.
SUTURES
Surgical sutures as defined by the United States Pharmacopeia are divided into two classifications:
absorbable and non-absorbable.

I Absorbable sutures are sterile strands prepared from collagen derived from healthy mammals or
from a synthetic polymer. They are capable of being absorbed by resistance to absorption.
Types of absorbable sutures:
1 Surgical gut is collagen derived from submucosa of sheep intestine of the serosa of beef
intestine. It is digested by body enzymes and absorbed by tissue thus no permanent
foreign body remains.
2 Plain surgical gut is used to ligate small vessels and to suture subcutaneous fat. It losses
tensile strength relatively quickly, usually in five to ten days and is digested within 70
days because collagen strands are not treated to resist absorption.
3 Chromic surgical gut is treated in a chromium salt solution to resist absorption by
tissues for varying lengths of time depending on strength of the solution, duration and
method of process. It is used for ligation of larger vessels and for suture of tissues in
which non-absorbable materials are not usually recommended because they may act as
nidus for stone formation, as in the urinary and biliary tracts.
4 Collagen sutures are extruded for a homogenous dispersion of pure collagen fibrils from
tendons of beef. They are used primarily in ophthalmic surgery.
5 Synthetic absorbable polymers are used for ligating or suturing except in tissues where
extended approximation of tissues under stress is required.
6 Polydioxanone is a monofilament suture extruded from the polyester and is particularly
useful tissues where both an absorbable suture and extended would support are
desirable.
7 Polyglycolic 9/0 are controlled combination of glycolide and lactide resulting in a

copolymer with a molecular structure that maintains tensile strength longer than a
surgical gut. These sutures are available in two forms: uncoated monofilament and
coated multifilament.
Polyglycolic acid is a homopolymer which loses tensile strength more rapidly and
absorbs within 30 days. It is braided suture material available in two forms: uncoated
and coated.

II Non-absorbable sutures are strands of natural or synthetic material that effectively resist enzymatic
digestion of absorption in living tissue.
Types of non-absorbable sutures:
1
2
3
4
5
6
7
8

Surgical silk is animal product made from the fiber spun by the silkworm larvae in making
cocoons. It gives good support to wounds during ambulation and generally promotes wound
healing a little more rapidly than surgical gut.
Virgin silk suture consists of several natural silk filaments drawn together and twisted to form 80 and 9-0 strands for tissue approximation of delicate structures primarily in ophthalmic
surgery.
Surgical cotton suture is made from individual, long-staple cotton fibers that are combed,
aligned and twisted into a smooth multifilament strand.
Surgical linen is spun from long-staple, flax fibers, and then twisted into tight strands and thread
from smooth passage through tissue. It is used almost exclusively in gastrointestinal surgery.
Surgical stainless steel sutures are drawn from 316L-88(L for low carbon) iron alloy wire. It is
used in surgical stainless steel implants and prostheses. Synthetic nonabsorbable sutures are
used to replace silk because they have higher tensile strength and elicit less tissue reaction.
Surgical nylon is a polymide polymer derived by chemical synthesis from coal, air and water.
Polymer fiber is a polymer of terephthalic acid and polyethylene such as silicone, mersilene,
person and others.
Polypropylene is a long-chain plastic polymer extruded into a blue dyed monofilament suture
strand. This is an acceptable substitute for stainless steel in situations where strength and
reactivity are required and the suture must be left in place for prolonged healing.

SURGICAL NEEDLES
A. Point of Needles:
1 Cutting point a razor-sharp hand cutting point may be preferred when tissue is
difficult to penetrate such as skin, tender and tough tissues or eye.
2 Conventional cutting tissues two opposing cutting edges form a triangular
configuration with a third edge on the body of the needles.
3 Reverse cutting needles a triangular configuration extends along the body of the
needle.
4 Side cutting needles relatively flat on top and bottom angulated cutting edges on
the sides.
5 Taper points these needles are used in soft tissues, such as intestines and
peritoneum, which offer a small amount of resistance to the needle as it passes
through.
B. Body of Needles:
The body of shaft varies in wide gauge, length, shape and finish. The nature and location of the
tissue to be sutured influence selection of needles with variable features.
1Tough or fibrous tissue requires a heavier gauge needle than the fine gauge wire needed in
microsurgery.
2 Depth of bite through tissue determines appropriate length.
3 Body may be round, oval, flat or triangular.
4 Curve needles that have longitudinal ribbed depressive or grooves along the body inside
and outside curvatures create a cross-looking action of the needle in the needle holder.
5 Body of all needles must have smooth finish.
C. Eye of Needle:
1 Eyed needle the closed eye of an eyed surgical needle is like that of any household
sewing needle. Shape of the enclosed needle may be found oblong, or square.
2 Eyeless needle is continuous unit with the suture strand. The needle is swigged onto
the end of strand in the manufacturing process.

Types of Eyeless Needle-suture Attachments:

a Single-armed attachments have one needle swigged to the suture strand.
b Double-armed attachments have one needle swigged to each end of the suture strand.
c Permanently swigged needle attachment is secure so that the needle will not separate
from the needle inadvertently but does not released when pulled off intentionally.

URINARY CATHETER INSERTION

Introduction
The ability to insert a urinary catheter is an essential skill in medicine.
Catheters are sized in units called French, where one French equals 1/3 of 1 mm. Catheters vary from 12
(small) FR to 48 (large) FR (3-16mm) in size.

They also come in different varieties including ones without a bladder balloon, and ones with different
sized balloons - you should check how much the balloon is made to hold when inflating the balloon with
water!
Universal precautions
The potential for contact with a patient's blood/body fluids while starting a catheter is present and
increases with the inexperience of the operator. Gloves must be worn while starting the Foley, not only to
protect the user, but also to prevent infection in the patient. Trauma protocol calls for all team members
to wear gloves, face and eye protection and gowns.

Indications
By inserting a Foley catheter, you are gaining access to the bladder and its contents. Thus enabling you to
drain bladder contents, decompress the bladder, obtain a specimen, and introduce a passage into the GU
tract. This will allow you to treat urinary retention, and bladder outlet obstruction.
Urinary output is also a sensitive indicator of volume status and renal perfusion (and thus tissue
perfusion also).
In the emergency department, catheters can be used to aid in the diagnosis of GU bleeding.
In some cases, as in urethral stricture or prostatic hypertrophy, insertion will be difficult and early
consultation with urology is essential.

Contraindications
Foley catheters are contraindicated in the presence of urethral trauma. Urethral injuries may occur in
patients with multisystem injuries and pelvic factures, as well as straddle impacts. If this is suspected, one
must perform a genital and rectal exam first. If one finds blood at the meatus of the urethra, a scrotal
hematoma, a pelvic fracture, or a high riding prostate then a high suspicion of urethral tear is present.

One must then perform retrograde urethrography (injecting 20 cc of contrast into the urethra).

Equipment
Sterile gloves - consider Universal Precautions
Sterile drapes
Cleansing solution e.g. Savlon
Cotton swabs
Forceps
Sterile water (usually 10 cc)
Foley catheter (usually 16-18 French)
Syringe (usually 10 cc)
Lubricant (water based jelly or xylocaine jelly)
Collection bag and tubing

Procedure

Insertion of an urinary catheter

in a female

1.

Insertion of an urinary catheter

in a male

Gather equipment.

2. Explain procedure to the patient

3. Assist patient into supine position with legs spread and feet together
4. Open catheterization kit and catheter

5.

Prepare sterile field, apply sterile gloves

6. Check balloon for patency.

7. Generously coat the distal portion (2-5 cm) of the catheter with lubricant
8. Apply sterile drape
9. If female, separate labia using non-dominant hand. If male, hold the penis with the nondominant hand. Maintain hand position until preparing to inflate balloon.
10. Using dominant hand to handle forceps, cleanse peri-urethral mucosa with cleansing solution.
Cleanse anterior to posterior, inner to outer, one swipe per swab, discard swab away from sterile
field.
11. Pick up catheter with gloved (and still sterile) dominant hand. Hold end of catheter loosely coiled
in palm of dominant hand.
12. In the male, lift the penis to a position perpendicular to patient's body and apply light upward
traction (with non-dominant hand)
13. Identify the urinary meatus and gently insert until 1 to 2 inches beyond where urine is noted
14. Inflate balloon, using correct amount of sterile liquid (usually 10 cc but check actual balloon size)
15. Gently pull catheter until inflation balloon is snug against bladder neck
16. Connect catheter to drainage system
17. Secure catheter to abdomen or thigh, without tension on tubing
18. Place drainage bag below level of bladder
19. Evaluate catheter function and amount, color, odor, and quality of urine
20. Remove gloves, dispose of equipment appropriately, wash hands
21. Document size of catheter inserted, amount of water in balloon, patient's response to procedure,
and assessment of urine

Complications
The main complications are tissue trauma and infection. After 48 hours of catheterization, most catheters
are colonized with bacteria, thus leading to possible bacteruria and its complications. Catheters can also
cause renal inflammation, nephro-cysto-lithiasis, and pyelonephritis if left in for prolonged periods.
The most common short term complications are inability to insert catheter, and causation of tissue
trauma during the insertion.
The alternatives to urethral catheterization include suprapubic catheterization and external condom
catheters for longer durations.

Source/s: http://www.med.uottawa.ca/procedures/ucath/
http://idomino.tk/