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Lithotomy Positioning Devices
APRIL 1992, VOL 55. NO 4
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Lithotomy Positioning Devices FACTORS THATCONTRIBUTE TO PATIENT INJURY Charles R. Paschal, Jr ; Lorna R. Strzelecki, RN he standard lithotomy position and modifications of it are used for urologic, gynecologic, and obstetric procedures; it also provides access to pelvic viscera and superficial structures of the perineum during colorectal surgeries. Historically, the anklestrap stirrup has been used by surgical teams to support the legs in the lithotomy position. An ankle-strap stirrup has a support pole that attaches to the OR bed and two straps from which to suspend the patient’s foot (Fig 1). It is
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a simple device that requires little maintenance. Physician dissatisfaction with ankle-strap stirrups and their associated complications, and an increase in sophisticated surgical procedures requiring abdominal-perineal access have produced a broad spectrum of leg support devices. This article examines the literature on complications arising from lithotomy positioning, and discusses the diverse leg support devices used for lithotomy positioning. Comparative data for lithotomy positioning devices are rare
Charles R. Paschal, Jr, BS, is a biomedical engineer at the US Armv Biomedicul Resear~ch and Development Luhoiutory, Fi.cderick, Md. He earned his hachefor o j science clr
C h u r c h H o m e arid Hospital School of Nui.sin,y, Baltimore, anel her bachelor of science in nrirsing at Inc*rrrnare Word College, Sun Antonio, Te.v. She earned her master cf science i n goi’erriment a t C a m p b e l l Uniivr.sity. Buies Creek, NC.
Lorna R . Strzelecki, R N . B S N , C O L , U S Army Nurse Corp, is director of Research, De\~c~lopment, and Acquisition Mmiagement at the US Army War College, Cnrlisle Buri,acks, P a . She earned her cliplomu in nursing cit
The opinions or asserfions contained in this cuticle e m thc. private views .f the authors and ure not to he construed as official or as rejlecting the i9iew-softtie Deparmient oj‘the Army 01‘ the Depaiment .If DtfiJnse. 101 I
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Fig I . Ankle-strap stirrup. All illustrations are shown without patient padding or safety straps in place. despite the effort and ingenuity of private industry to develop these devices. This article makes comparisons based on published data. Each positioning device has advantages and disadvantages and favorable data may exist for specific devices, but no one device is superior in all cases. Preferably, the surgical team should have a group of devices to pick from and make their choice based on knowledge about the device and the needs of the patient.
tion also has been used during simultaneous nephroscopic and uteroscopic procedures (Fig 3 . 2
The anesthetized patient is at high risk for injuries from excessive abduction that exceeds normal range of motion and uncontrolled hyperextension when ankle-strap stirrups are used while in the lithotomy position (Fig 6 ) . Elderly patients, patients who are underweight, or those with poor nutrition have an added risk for postural injuries.
The Lithotomy Position Lithotomy Complications
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n the standard lithotomy position, the patient is supine with his or her buttocks at the end of the OR bed. Both hips and knees are flexed, and the patient’s thighs are abducted and externally rotated (Fig 2 ) . There are several modifications of the standard lithotomy position used in surgery. Hip and knee flexion may be extreme (eg, Young’s modification) (Fig 3), or it may be slight (eg, the modification for simultaneous perineal and abdominal access) (Fig 4),’ A reversed (ie, prone) lithotomy posi1012
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omplications associated with the lithotomy position are divided into three categories-nerve injuries, muscle and fascia1 injuries, and circulatory complications (Table 1). These complications can be attributed to the patient’s anatomical posture in the lithotomy position or to the physiological effects caused by the positioning device. Some complications are only associated with obstetric procedures.
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Fig 3. Young’s modification of the lithomy position.
Fig 2. Standard lithotomy position.
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Fig 4. Modified abdominal-perineal lithotorny position. I014
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7ig 5. Reverse
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(ie, prone) lithotomy position.
Fig 6. Hyperextension can occur when the patient is improperly placed in the lithotomy position. inis
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Table 1
Categories of Complications A. Nerve injuries 1. Sciatic nerve a. Great sciatic nerve b. External popliteal (ie, peroneal) nerve c. Internal popliteal (ie, tibial) nerve 2 . Femoral nerve a. Femoral nerve b. Saphenous branch 3. Obturator nerve
B. Muscle and fascial injuries I . Compartment syndrome 2 . Ligament and joint injuries
C. Circulatory complications I . Venous stasis 2 . Supine hypotensive syndrome and fetal acidosis
Nerve injuries. Several mechanisms are involved in nerve injury. Stretching or compression of a nerve can result in ischemia, and prolonged ischemia can result in necrosis.’ Damage to the capillaries surrounding a nerve can affect its nourishment, and capillary rupture can produce a hematoma within the nerve that can lead to c o m p r e s s i o n a n d necrosis. Lithotomy complications have been associated with damage to portions of the sciatic, femoral, and obturator nerves of the leg. The sciatic nerve originates at lumbar vertebrae 4 and 5 (L4, L5) and sacral vertebrae I , 2, and 3 (S I , S2, S3). It is anchored at the sciatic notch and the neck of the fibula (Fig 7). In the lithotomy position, the sciatic nerve may be overstretched if the patient’s thigh is hyperflexed at the hip or if his or her flexed thigh is externally rotated to its maximum range of motion. The external popliteal (ie, peroneal) nerve is a branch of the sciatic nerve. It is lateral and superficial to the proximal end of the
fibula. At the tibial condyles, it becomes flattened and vulnerable to pressure injury. Thc nurse should ensure that prolonged compression of the lateral aspect of the patient’s knee is avoided. The internal popliteal (ie, tibial) branch is the larger of the two branches of the sciatic nerve. It begins at the bifurcation of the sciatic nerve, and descends along the back of the thigh through the popliteal space. The patient’s tibial nerve may be injured during compression of the popliteal space. Because the tibial nerve has more supporting connective tissue and smaller, more numerous funiculi than the peroneal nerve, it is injured less frequently than the peroneal branch.J The femoral nerve originates at L2, L3, and L4. It runs along the anterotnedial surf a c e of t h e i l i o p s o a s s h e a t h a n d p a s s e s beneath the tough inguinal ligament (Fig 8). Externally rotating and abducting the patient’s flexed thigh compresses the nerve beneath this ligament. T o avoid excessive external rotation of the patient’s hip, the nurse must limit the degree of leg abduction with lateral thigh support.s The saphenous branch of the femoral nerve passes near the medial tibial condyle and along the medial aspect of the tibia. The patient’s saphenous nerve can be damaged if it becomes compressed against the tibia, The nurse, therefore, must ensure that any prolonged compression of the medial aspect of the patient’s knee and lower leg is avoidedeh The obturator nerve originates from L2. L3, and L4. It passes through the obturator foramen and into the adductors of the upper portion of the thigh (Fig 8). Occasionally, hyperflexion of the patient’s thigh at the hip can result in a compression injury of this nerve.’ Muscle and fascial injuries. Lithotomy complications also can result from the stretch and/or compression of muscle tissue and fascia. In the lithotomy position, even minor degrees of abduction can cause damage to the knee and hip joints and their associated ligaments. These complications can result from direct compression of tissue by the positioning device, or from
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L4 L.5 SI
s2 s3
sciatic nerve nerve femoral ner external popliteal (peroneal) branch
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internal popliteal (tibial) branch
branch
Fig 7. Posterior view of the leg showing sciatic nerve origin and location.
Fig 8. Anterior leg view showing the origin and location of the femoral and obturator nerves.
the anesthetized patient being unable to feel or relieve discomfort from excessive abduction or hyperextension of his or her leg. Compartment syndrome can result from unchecked, increasing pressure within a muscle compartment. External pressure on a muscle compartment can elevate local venous pressure and cause loss of capillary integrity and neuromuscular ischemia. A spiraling c y c l e of i n c r e a s i n g e d e m a and i s c h e m i a results. Compartment syndrome also can be caused by vascular occlusion, but in cases related to
the lithotomy position, it is attributed to prolonged, direct pressure on the muscle mass of the calf from the leg support system which increases the pressure within the muscle compartment.x In these cases, the anterior compartment or the deep posterior compartment of the leg is affected. When compartment syndrome occurs, a fasciotomy must be done immediately to terminate the cycle." Circulatory complications. When the nurse places the patient in the lithotomy position, the effects on the patient's circulatory system usually are rapid and must be monitored closely.
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Table 2
Positioning Device Support Categories Category
Examples
Heel
Standard and curved wpport pole
Knee
Knee crutch
Calf
Modified arm wpport
Heel and knee
Modified knee crutch
Heel and calf
Boot type stirrup
Knee and calf
Extended knee crutch
Heel, knee, and calf
Total leg wpport 5ystem
As the nurse elevates and lowers the legs of the patient, a disturbance in the blood pressure results because the legs are a major reservoir of blood and interstitial fluid. Prolonged elevation of the legs affects the arteries and veins and can increase the risk of vascular occlusion o r thrombosis.I" During pregnancy, the uterus can exert pressure on the underlying vena cava and aorta while the patient is supine, and this is aggravated by the lithotomy position. Blood flow through the heart is affected, and the patient's blood pressure falls-a condition known as supine hypotensive s y n d r o m e . During labor, this circulatory problem can uffect uterine perfusion and produce fetal acidosis. The nurse can prevent this and shift the patient's uterus away from the vena cava and aorta by placing a bolster under the right side of the patient.
Literature Discussion
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n gynecologic surgery, the reported complications show a trend. Femoral nerve injury is reported more frequently than sciatic nerve injury, and damage to the obturator nerve is rare.'? Excessive abduction of the thigh causes femoral nerve entrapment, and hyperflexion of the thigh can stretch and
d a m a g e the sciatic and o b t u r a t o r nervc. Researchers reported that nerve and m u s c l e injuries were directly related to thc positioning d e v i c e s i n a m a j o r i t y of c a s e s . " Techniques to prevent these coinplications. therefore, became the main focus in the liternture when comparing positioning devices. A substantial amount of research hns been done on how to minimize postoperative complications associated with the lithotomy position. As a result, ninny alternate configurutions to the standard ankle-strap stirrup have bcen designed. We performed computer assisted searches to investigate and to classify the diversity and availability of lithotomy positioning dcviccs used during surgery. We grouped the devices: according to the anatomical areas they contact to support the leg (ie, heel, calf, knee .joint). Combinations of these three support areus created seven general categories of devices. however, heel, calf, and heel-call support devices were most common (Table 2). Heel. The ankle-strap stirrup is an example of a leg support contacting the heel only. Most nerve injuries are attributed t o the ankle-strap stirrup, which does n o t control abduction of the thigh. Two researchers i n 1983 reported t w o s c i a t i c nerve injuries attributed to excessive abduction.l-' Another
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Fig 9. Heel and calf support positioning device.
group o f researchers reported three cases of femoral nerve entrapment related to abduction in ankle-strap stirrups.li Femoral nerve entrapment can be reduced by supporting the leg at the knee to control a b d u c t i o n of t h e t h i g h . Any leg s u p p o r t tlcvice that c o n i e s i n c o n t a c t with the poplitcnl space or thc lateral or medial aspects of the knee, however, puts the peroneal, tibial, and saphenous nerves at risk of compression"' A modified ankle-strap support pole that is curved to avoid contact with the knee area hns been o n the market for several years, but this design does not control abduction. Calf. Re s e a rc h s 11gge st s t h ii t c a I f- s u ppo rt devices are superior to ankle-strap stirrups. I n 1990, I W O researchers reported a decrease of 10.7%1in peripheral nerve palsy during radical retropubic prostatectomy when an arm support device was modified to provide calf s ~ i p p o rduring ~ these procedure^.'^ Calf-support devices, however, support the entire weight of leg in the area at greatest risk for
compartment syndrome. Heel and caffi In comparison. devices that distribute the load between the heel and the call probably lower the risk of compartment syndrome (Fig 9). A uniquely designed heel and calf support device was introduced in 1984. The device uses a molded foot piece that extends approximately two thirds up the lower leg. When padding and security straps are used. it has the appearance of a boot. Boot stirrups have a wider range of applications than other stirrups. They ciin be used in reverse lithotomy position and on amputee patients." The amputee's stumps can slide into the "cup" of the boot stirrup. I n addition, they control abduction while avoiding contact with the knee area altogether. Adjustment of an ankle-strap stirrup to accomodate a stump is much more difficult, and a modified arm board or a knee support device cannot cup the stump. Throughout the literature review process, we noticed a lack of comparative infornia-
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lion o n lithotomy devices; the literature primar i 1y reported i n d i v id u a I cases . A 1though t h e boot s t i r r u p c o n c e p t was introduced seven years ago, we were not surprised when we could not find comparative studies for this device.
Conclusions
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here are many complications associated with lithotomy positioning. They can be attributed to anatomical posture in the lithotomy position or to the physiological effects of pressure or stretching caused by the postioning device. Adequate padding of any positioning device can significantly reduce the risks of some compression injuries (eg, peroil e a I ne rv e coin pie s s i on, compartment sy ti drome), but padding will not reduce the risk of injuries associated with hypertlexion of the hip or compression injuries resulting from femoral nerve entrapment beneath the inguinal ligament. The literature review revealed that nerve damage was the primary complication arising from surgeries requiring the lithotomy position; muscle damage was secondary to nerve damage. Both were attributed to the positioning device and, therefore, became the focus for our comparison of positioning devices. Certain areas of the lower extremities are at high risk for coinpression and/or stretching in.jurics. These areas are the popliteal space (including the lateral and medial aspects of the knee) and the calf. The ideal lithototny positioning system would avoid contact with these areas and control rotation and abduction of the hip and extension of the leg to avoid injuries such as femoral nerve entrapment beneath the inguinal ligament. The boot stirrup has many of these qualities. Ultimately, the perioperative nurse must evaluate each device to select the one that best meets the needs of the individual patient. 0 Notes I . J T Martin, Posiriorrirtg iir Aiiesrhrsiu l / / d Srrr.,qc,y. second ed (Philadelphia: W B Saunders Co, 19x7) 45. 2. T Lehman, D H Bagley, “Reverse lithotomy:
Modified prone position for simultnneous nephroccopic and urcteroscopic procedures i n women.” U , o / o , ~ 32 y (December 19XX) 529-53I . 3. J C Lydon. F J Spielman. ”Bilateral compartment syndrome following prolonged surgery in the I it h o t o in y po s i t ion A rr P S / / I c .io~ / ( J S J 60 ( Marc Ii 19x4) 236-238. 4. Ihid. 5 . A S Tondare et al. ”Fenioral neuropathy: A coniplication of lithotomy position tinder spinal anesthesia: A report o f three cases,” Crrrrutlirrrr A/rues//i~~ti.s/’s Socicfq . / ( J / / / . / I u / 30 (January I 983) X4. 6. M a r t i n , Posiriorrirrg i r i A/ic.\//rc.siu urid .Sur,qivy, 275. 7. Lytlon, Spielinan, “Bilateral conipiirtiiieiitd syndrome following prolonged surgcry in the lithotomy position.” 235. 8. P K Reddy. K W Kayc, “Deep posterior coinpartmental syndrome: A serious complication 01‘ the lithotorny position,” ./ortrwtr/ of’ I l r ~ ) / o g yI32 (July 1983) 144-145. 9. K P Black. T K S c h u l t z , N 1, Clieung. “Compartment syndromes iii athletes,” C/i/ric,.si/r S p o r t s Mrtlic~irrc,9 (April 1990)47 1-387. 10. P K Reddy, A A Sidi. P H Lange, “Modified stirrups for dorsul lithotomy positioning.” U / W / O , ~ ! C/i~ric,.sof’ Nor.f/r Awro.ic,t/ I 7 (Fcbruury 1990) I3 1 133. I 1. M Humphrey et al. “The influences o f mtitcrnal posture a1 birth on the letus,” 7 h ,/oi/r/iu/of 0 h s / c /ric,.s ( I 11 il Gq rr u e co lo ,qq t o I‘ I / I c H r.i / i.s I / Conrnrorrwetrlfh X O (April 1973) 1075. 12. M S Hoffinnn, W S Roberts. D Cavanagh. “Neuropathies associated with radical pclvic surgery for gynecologic cnncer,” Gyrrcc~ologic.O/rc,olo,qq 3 I (November 19x8) 462-466. 13. L Groom e t al. “Sequelae of intraoperutivc I i t hot om y pos it i on i ng .” Se ni i ti a r p re se n ted ;it t he 35th mnunl AORN Congress, Dallus, 23 M a r c h
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19x8. 14. F Batres, D L Barclay. “Sciatic nerve injury
during gynecologic procedures using the lithotoniy , ~ ~(Scptenibcr position.” Oh.rtcwic,.so/td C ; , W W J / ~ J62 1983) 925-935. 15. Tondare et al. “Femoral neuropathy: A c o n pliciition of lithotoniy position under spiii;il anesheA report 0 1 three cases,” 84. 16. / h i t / ; Batres. Barclny. “Sciatic nerve in,jury during gynecologic proccdures using [he lithotoniy position,” 944; Martin, Po.si/io/rirr,q in A/ic.s/hcsitr atrd Srtr,q~ry,275-277; R e d d y , Sidi. Lange. “Modified stirrups for dorsal lithotomy positioning,“ 131-133. 17. /hid. 18. Lehman, Bagley. “Reverse lithotomy: Modified prone position lor siniultmeous nephroscopic and urcteroscopic procedures in women.” 529.
bxamination LITHOTOMY POSITIONING DEVICES
1. The standard lithotomy position provides access to a. pelvic viscera b. pelvic viscera and the superficial perineum c. abdominal viscera d. the perineum 2 . Choose the answer that best describes the standard lithotomy position. a. The patient is on his or her back with pillows under his or her calves. b. The patient is supine and his or her legs are “froglegged.” c. The patient is supine with his or her buttocks at the end of the OR bed, both hips and knees are tlexed, both feet are supported by stirrups, and both thighs are abducted and externally rotated. d. The patient is supine with his or her buttocks at the end of the OR bed, both hips and knees are tlexed, both feet are supported by stirrups, and both thighs are adducted and internally rotated. 3. When hip flexion is extreme, what is this called? a. Young’s modification b. ankle-strap position c. reverse lithotomy d. abdominal-perineal modification 4. When hip flexion is slight, what is this called‘? a. Young’s modification b. ankle-strap position c. reverse lithotomy d. abdominal-perineal modification 5 . Choose the answer that best describes the reverse lithotomy position.
6.
7.
8.
9.
a. The patient’s legs are suspended by the knees rather than the ankles. b. The patient is prone with hips at the end of the OR bed and stirrups that support the knees. c. The patient is prone with hips at the end of the OR bed and stirrups supporting the feet. d. The patient is prone with both legs “froglegged.” Historically, what was the most common leg support system used for the lithotomy position? a. Lloyd-Davies stirrups b. Allen stirrups c. Dilatation and curettage (D&C) stirrups d. ankle-strap stirrups When a patient’s feet are suspended from two straps by support poles attached to the OR bed, what stirrups are being used? a. Lloyd-Davies b. Allen c. D&C d. ankle-strap What are the three most common areas of the body that lithotomy positioning devices support? a. heel, calf, and combined heel/calf b. heel, back of the knee, and thigh c. foot, heel, and thigh d. foot, calf and back of knee A support device that controls abduction of the thigh would support the . a. heel b. calf c. knee d. thigh 1023
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10. Ankle-strap stirrups cannot control -.
a. flexion or abduction of the hip b. hyperextension of the legs c. extension and adduction of the hip d. abduction of the hip I I . Which answer describes complications that occur when patients are in the lithotomy position? a. nerve, muscle/facial, and circulatory injuries b. nerve and muscle injuries c. muscle/fascial injuries d. nerve and circulatory injuries 12. What factors cause these injuries? 1. anatomical position 2. physiological effects of the position 3. age, weight, nutritional status of the patient 4. length of time in the lithotomy position a. 2 a n d 3 b. 1,2, and4 c. 3 and 4 d. all of the above 13. What is the most serious complication of muscle/fascial injury? a. decubitus ulcers b. bruising and muscle wasting c. compartment syndrome d. stiff, sore legs 14. What common nerves can be injured in the lithotomy position? a. sciatic, femoral, popliteal b. sciatic, femoral, obturator c. obturator, popliteal, tibial d. peroneal, tibial, obturator 15. What circulatory system complications can be seen when patients are in the lithotomy position? 1. blood pressure changes 2. vascular occlusion, thrombosis 3. fetal acidosis 4. supine hypotensive syndrome a. 1 and 2 b. 2 c. 4 d all of the above 16. To prevent complications when patients are in the lithotomy position, the nurse can 1024
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1. Physically assess the patient and implement appropriate care if the patient is elderly, underweight, or poorly nourished. 2. Remove pads on the stirrups to decrease pressure on the patient’s legs. 3. Place the patient in correct body alignment. 4. Remove the patient from lithotomy position every two hours. a. 1 and 3 b. 2 a n d 4 c. 4only d. 3 only 17. Why is it important for the nurse to have assistance when raising or lowering the patient’s legs in lithotomy? 1. to prevent stretching injuries to the muscles and nerves of the legs 2. to control the amount of flexion and abduction of the legs 3. to avoid injury to the nurse’s back 4. to ensure that the surgeon participates in positioning the patient a. all of the above b. 2 and 3 c. 1 and 2 d. 1 and4 18. The nurse must be aware that a. Padding eliminates complications in the lithotomy position. b. Padding significantly reduces all compression injuries including peroneal nerve compression, compartment syndrome, injuries from hyperflexion of the hip, and compression injury to the femoral nerve from entrapment. c. Padding significantly reduces peroneal nerve compression and compartment syndrome, but i t does not reduce injuries from hyperflexion of the hip or compression injury to the femoral nerve from entrapment. d. Compression injuries can only be avoided by limiting time in lithotomy. 19. Why would the nurse want to place the patient in lithotomy while he or she is awake?
A O K N .IOIJKNAL
I . This saves time after the patient is anesthetized. 2. Anesthetized patients cannot alert the surgical team to discomfort; awake positioning ensures that the position is comfortable for the patient. 3. Patients with arthritis or kneehip prostheses must be carefully positioned to avoid injury to their joints; awake positioning ensures that they are not placed in a potentially damaging position. 4. Awake positioning helps to educate the patient about what will occur during surgery. a. 1 and 2 b. 2 a n d 3 c. 3 a n d 4 d. 2 only 20. When choosing a lithotomy positioning device, the nurse must remember that nerve and muscle damage are most common in this position and occur most frequently with ankle-strap stirrups. a. true b. false Professioriul wurses ure invited to submit clinical niunugeriul munusc~ripts$)r the home study program. Matiusi~riprso r queries should be sent to the Editor, AORN J o u r m ~ l ,101 70 E Mississippi Ave. Denver. CO 80231. As with ull manuscripts sent to the Journul. p i p e r s submitted for. home study pro
APRIL 1992. VOL 5.5, NO 4
Publication Includes Interesting Cancer Facts A new publication from the American Cancer Society, Atlanta, gives detailed information about how cancer affects minority populations in the United States. The publication, published in December 1991, is called C a n ~ w . Facts and Figures for Minority Amerkons, according to a news release from the American Cancer Society. The publication includes the latest cancer incidence rates and results of recent surveys on attitudes and practices toward cancer prevention, detection, and treatment. The following are some of the interesting facts included in the publication. 0 American Indians have lower incidence rates for lung cancer than the general population. 0 Hawaiians have the second highest cancer incidence rate of any American ethnic group. Chinese, Japanese, and Filipinos have overall lower incidence and mortality rates than American blacks or whites. 0 Hispanic American women are less likely to have pap tests and screening mammography than the overall population. 0 The risk for invasive cervical cancer is highest among African Americans, Hispanics, American Indians, and Hawaiians. 0 African Americans have the highest incidence rates for prostate, esophageal, and colon and rectal cancers. For more information, contact The American Cancer Society, magazine services, 1180 Avenue of the Americas, New York, N Y 10036.
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Answer Sheet LITHOTOMY POSITIONING DEVICES
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Learner Evaluation The lollowing evaluation is used to determine the extent to which this home study program met your learning needs. Rate the following items on a scale of 1 to 5. I . Objectives. To what extent were the following objectives of this home study program achieved? ( I ) Describe the lithotomy position and its modifications. ( 2 ) Identify the types of support devices available. (3) Discuss the complications of this position. (4) Identify nursing interventions that prevent patient injiiry in the lithotoiny position.
(Low)
(High)
(1)
(2)
(3)
(4)
(5)
(1) (1)
(2) (2)
(3) (3)
(4) (4)
(5) (5)
(1)
(2)
(3)
(3)
(5)
(1) (1) (1)
(2) (2) (2)
(3) (3) (3)
(4) (4) (4)
(5) (51 (5)
2 . Content. ( I ) Did this article increase your knowledge of the subject matter? ( 2 ) Was the conlent clear and organized? (3) Did this article facilitate learning'? (4) Were your individual objectives met? ( 5 ) Was the content of the article relevant to the objectives?
3. Test questionslanswers. ( I ) Were they reflective of the content'? ( 2 ) Were they easy to understand? (3) Did they address important points'?
4. What other topics would you like to see addressed in a future home study program'? Would you bc interested or do you know someone who would be interested in writing an article on this topic'! Topic(s):
Author names and addresses:
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Lithotomy Positioning Devices FACTORS THATCONTRIBUTE TO PATIENT INJURY Charles R. Paschal, Jr ; Lorna R. Strzelecki, RN he standard lithotomy position and modifications of it are used for urologic, gynecologic, and obstetric procedures; it also provides access to pelvic viscera and superficial structures of the perineum during colorectal surgeries. Historically, the anklestrap stirrup has been used by surgical teams to support the legs in the lithotomy position. An ankle-strap stirrup has a support pole that attaches to the OR bed and two straps from which to suspend the patient’s foot (Fig 1). It is
T
a simple device that requires little maintenance. Physician dissatisfaction with ankle-strap stirrups and their associated complications, and an increase in sophisticated surgical procedures requiring abdominal-perineal access have produced a broad spectrum of leg support devices. This article examines the literature on complications arising from lithotomy positioning, and discusses the diverse leg support devices used for lithotomy positioning. Comparative data for lithotomy positioning devices are rare
Charles R. Paschal, Jr, BS, is a biomedical engineer at the US Armv Biomedicul Resear~ch and Development Luhoiutory, Fi.cderick, Md. He earned his hachefor o j science clr
C h u r c h H o m e arid Hospital School of Nui.sin,y, Baltimore, anel her bachelor of science in nrirsing at Inc*rrrnare Word College, Sun Antonio, Te.v. She earned her master cf science i n goi’erriment a t C a m p b e l l Uniivr.sity. Buies Creek, NC.
Lorna R . Strzelecki, R N . B S N , C O L , U S Army Nurse Corp, is director of Research, De\~c~lopment, and Acquisition Mmiagement at the US Army War College, Cnrlisle Buri,acks, P a . She earned her cliplomu in nursing cit
The opinions or asserfions contained in this cuticle e m thc. private views .f the authors and ure not to he construed as official or as rejlecting the i9iew-softtie Deparmient oj‘the Army 01‘ the Depaiment .If DtfiJnse. 101 I
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Fig I . Ankle-strap stirrup. All illustrations are shown without patient padding or safety straps in place. despite the effort and ingenuity of private industry to develop these devices. This article makes comparisons based on published data. Each positioning device has advantages and disadvantages and favorable data may exist for specific devices, but no one device is superior in all cases. Preferably, the surgical team should have a group of devices to pick from and make their choice based on knowledge about the device and the needs of the patient.
tion also has been used during simultaneous nephroscopic and uteroscopic procedures (Fig 3 . 2
The anesthetized patient is at high risk for injuries from excessive abduction that exceeds normal range of motion and uncontrolled hyperextension when ankle-strap stirrups are used while in the lithotomy position (Fig 6 ) . Elderly patients, patients who are underweight, or those with poor nutrition have an added risk for postural injuries.
The Lithotomy Position Lithotomy Complications
I
n the standard lithotomy position, the patient is supine with his or her buttocks at the end of the OR bed. Both hips and knees are flexed, and the patient’s thighs are abducted and externally rotated (Fig 2 ) . There are several modifications of the standard lithotomy position used in surgery. Hip and knee flexion may be extreme (eg, Young’s modification) (Fig 3), or it may be slight (eg, the modification for simultaneous perineal and abdominal access) (Fig 4),’ A reversed (ie, prone) lithotomy posi1012
C
omplications associated with the lithotomy position are divided into three categories-nerve injuries, muscle and fascia1 injuries, and circulatory complications (Table 1). These complications can be attributed to the patient’s anatomical posture in the lithotomy position or to the physiological effects caused by the positioning device. Some complications are only associated with obstetric procedures.
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Fig 3. Young’s modification of the lithomy position.
Fig 2. Standard lithotomy position.
I
I
Fig 4. Modified abdominal-perineal lithotorny position. I014
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7ig 5. Reverse
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(ie, prone) lithotomy position.
Fig 6. Hyperextension can occur when the patient is improperly placed in the lithotomy position. inis
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Table 1
Categories of Complications A. Nerve injuries 1. Sciatic nerve a. Great sciatic nerve b. External popliteal (ie, peroneal) nerve c. Internal popliteal (ie, tibial) nerve 2 . Femoral nerve a. Femoral nerve b. Saphenous branch 3. Obturator nerve
B. Muscle and fascial injuries I . Compartment syndrome 2 . Ligament and joint injuries
C. Circulatory complications I . Venous stasis 2 . Supine hypotensive syndrome and fetal acidosis
Nerve injuries. Several mechanisms are involved in nerve injury. Stretching or compression of a nerve can result in ischemia, and prolonged ischemia can result in necrosis.’ Damage to the capillaries surrounding a nerve can affect its nourishment, and capillary rupture can produce a hematoma within the nerve that can lead to c o m p r e s s i o n a n d necrosis. Lithotomy complications have been associated with damage to portions of the sciatic, femoral, and obturator nerves of the leg. The sciatic nerve originates at lumbar vertebrae 4 and 5 (L4, L5) and sacral vertebrae I , 2, and 3 (S I , S2, S3). It is anchored at the sciatic notch and the neck of the fibula (Fig 7). In the lithotomy position, the sciatic nerve may be overstretched if the patient’s thigh is hyperflexed at the hip or if his or her flexed thigh is externally rotated to its maximum range of motion. The external popliteal (ie, peroneal) nerve is a branch of the sciatic nerve. It is lateral and superficial to the proximal end of the
fibula. At the tibial condyles, it becomes flattened and vulnerable to pressure injury. Thc nurse should ensure that prolonged compression of the lateral aspect of the patient’s knee is avoided. The internal popliteal (ie, tibial) branch is the larger of the two branches of the sciatic nerve. It begins at the bifurcation of the sciatic nerve, and descends along the back of the thigh through the popliteal space. The patient’s tibial nerve may be injured during compression of the popliteal space. Because the tibial nerve has more supporting connective tissue and smaller, more numerous funiculi than the peroneal nerve, it is injured less frequently than the peroneal branch.J The femoral nerve originates at L2, L3, and L4. It runs along the anterotnedial surf a c e of t h e i l i o p s o a s s h e a t h a n d p a s s e s beneath the tough inguinal ligament (Fig 8). Externally rotating and abducting the patient’s flexed thigh compresses the nerve beneath this ligament. T o avoid excessive external rotation of the patient’s hip, the nurse must limit the degree of leg abduction with lateral thigh support.s The saphenous branch of the femoral nerve passes near the medial tibial condyle and along the medial aspect of the tibia. The patient’s saphenous nerve can be damaged if it becomes compressed against the tibia, The nurse, therefore, must ensure that any prolonged compression of the medial aspect of the patient’s knee and lower leg is avoidedeh The obturator nerve originates from L2. L3, and L4. It passes through the obturator foramen and into the adductors of the upper portion of the thigh (Fig 8). Occasionally, hyperflexion of the patient’s thigh at the hip can result in a compression injury of this nerve.’ Muscle and fascial injuries. Lithotomy complications also can result from the stretch and/or compression of muscle tissue and fascia. In the lithotomy position, even minor degrees of abduction can cause damage to the knee and hip joints and their associated ligaments. These complications can result from direct compression of tissue by the positioning device, or from
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L4 L.5 SI
s2 s3
sciatic nerve nerve femoral ner external popliteal (peroneal) branch
\I
J
II
internal popliteal (tibial) branch
branch
Fig 7. Posterior view of the leg showing sciatic nerve origin and location.
Fig 8. Anterior leg view showing the origin and location of the femoral and obturator nerves.
the anesthetized patient being unable to feel or relieve discomfort from excessive abduction or hyperextension of his or her leg. Compartment syndrome can result from unchecked, increasing pressure within a muscle compartment. External pressure on a muscle compartment can elevate local venous pressure and cause loss of capillary integrity and neuromuscular ischemia. A spiraling c y c l e of i n c r e a s i n g e d e m a and i s c h e m i a results. Compartment syndrome also can be caused by vascular occlusion, but in cases related to
the lithotomy position, it is attributed to prolonged, direct pressure on the muscle mass of the calf from the leg support system which increases the pressure within the muscle compartment.x In these cases, the anterior compartment or the deep posterior compartment of the leg is affected. When compartment syndrome occurs, a fasciotomy must be done immediately to terminate the cycle." Circulatory complications. When the nurse places the patient in the lithotomy position, the effects on the patient's circulatory system usually are rapid and must be monitored closely.
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Table 2
Positioning Device Support Categories Category
Examples
Heel
Standard and curved wpport pole
Knee
Knee crutch
Calf
Modified arm wpport
Heel and knee
Modified knee crutch
Heel and calf
Boot type stirrup
Knee and calf
Extended knee crutch
Heel, knee, and calf
Total leg wpport 5ystem
As the nurse elevates and lowers the legs of the patient, a disturbance in the blood pressure results because the legs are a major reservoir of blood and interstitial fluid. Prolonged elevation of the legs affects the arteries and veins and can increase the risk of vascular occlusion o r thrombosis.I" During pregnancy, the uterus can exert pressure on the underlying vena cava and aorta while the patient is supine, and this is aggravated by the lithotomy position. Blood flow through the heart is affected, and the patient's blood pressure falls-a condition known as supine hypotensive s y n d r o m e . During labor, this circulatory problem can uffect uterine perfusion and produce fetal acidosis. The nurse can prevent this and shift the patient's uterus away from the vena cava and aorta by placing a bolster under the right side of the patient.
Literature Discussion
I
n gynecologic surgery, the reported complications show a trend. Femoral nerve injury is reported more frequently than sciatic nerve injury, and damage to the obturator nerve is rare.'? Excessive abduction of the thigh causes femoral nerve entrapment, and hyperflexion of the thigh can stretch and
d a m a g e the sciatic and o b t u r a t o r nervc. Researchers reported that nerve and m u s c l e injuries were directly related to thc positioning d e v i c e s i n a m a j o r i t y of c a s e s . " Techniques to prevent these coinplications. therefore, became the main focus in the liternture when comparing positioning devices. A substantial amount of research hns been done on how to minimize postoperative complications associated with the lithotomy position. As a result, ninny alternate configurutions to the standard ankle-strap stirrup have bcen designed. We performed computer assisted searches to investigate and to classify the diversity and availability of lithotomy positioning dcviccs used during surgery. We grouped the devices: according to the anatomical areas they contact to support the leg (ie, heel, calf, knee .joint). Combinations of these three support areus created seven general categories of devices. however, heel, calf, and heel-call support devices were most common (Table 2). Heel. The ankle-strap stirrup is an example of a leg support contacting the heel only. Most nerve injuries are attributed t o the ankle-strap stirrup, which does n o t control abduction of the thigh. Two researchers i n 1983 reported t w o s c i a t i c nerve injuries attributed to excessive abduction.l-' Another
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Fig 9. Heel and calf support positioning device.
group o f researchers reported three cases of femoral nerve entrapment related to abduction in ankle-strap stirrups.li Femoral nerve entrapment can be reduced by supporting the leg at the knee to control a b d u c t i o n of t h e t h i g h . Any leg s u p p o r t tlcvice that c o n i e s i n c o n t a c t with the poplitcnl space or thc lateral or medial aspects of the knee, however, puts the peroneal, tibial, and saphenous nerves at risk of compression"' A modified ankle-strap support pole that is curved to avoid contact with the knee area hns been o n the market for several years, but this design does not control abduction. Calf. Re s e a rc h s 11gge st s t h ii t c a I f- s u ppo rt devices are superior to ankle-strap stirrups. I n 1990, I W O researchers reported a decrease of 10.7%1in peripheral nerve palsy during radical retropubic prostatectomy when an arm support device was modified to provide calf s ~ i p p o rduring ~ these procedure^.'^ Calf-support devices, however, support the entire weight of leg in the area at greatest risk for
compartment syndrome. Heel and caffi In comparison. devices that distribute the load between the heel and the call probably lower the risk of compartment syndrome (Fig 9). A uniquely designed heel and calf support device was introduced in 1984. The device uses a molded foot piece that extends approximately two thirds up the lower leg. When padding and security straps are used. it has the appearance of a boot. Boot stirrups have a wider range of applications than other stirrups. They ciin be used in reverse lithotomy position and on amputee patients." The amputee's stumps can slide into the "cup" of the boot stirrup. I n addition, they control abduction while avoiding contact with the knee area altogether. Adjustment of an ankle-strap stirrup to accomodate a stump is much more difficult, and a modified arm board or a knee support device cannot cup the stump. Throughout the literature review process, we noticed a lack of comparative infornia-
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lion o n lithotomy devices; the literature primar i 1y reported i n d i v id u a I cases . A 1though t h e boot s t i r r u p c o n c e p t was introduced seven years ago, we were not surprised when we could not find comparative studies for this device.
Conclusions
T
here are many complications associated with lithotomy positioning. They can be attributed to anatomical posture in the lithotomy position or to the physiological effects of pressure or stretching caused by the postioning device. Adequate padding of any positioning device can significantly reduce the risks of some compression injuries (eg, peroil e a I ne rv e coin pie s s i on, compartment sy ti drome), but padding will not reduce the risk of injuries associated with hypertlexion of the hip or compression injuries resulting from femoral nerve entrapment beneath the inguinal ligament. The literature review revealed that nerve damage was the primary complication arising from surgeries requiring the lithotomy position; muscle damage was secondary to nerve damage. Both were attributed to the positioning device and, therefore, became the focus for our comparison of positioning devices. Certain areas of the lower extremities are at high risk for coinpression and/or stretching in.jurics. These areas are the popliteal space (including the lateral and medial aspects of the knee) and the calf. The ideal lithototny positioning system would avoid contact with these areas and control rotation and abduction of the hip and extension of the leg to avoid injuries such as femoral nerve entrapment beneath the inguinal ligament. The boot stirrup has many of these qualities. Ultimately, the perioperative nurse must evaluate each device to select the one that best meets the needs of the individual patient. 0 Notes I . J T Martin, Posiriorrirtg iir Aiiesrhrsiu l / / d Srrr.,qc,y. second ed (Philadelphia: W B Saunders Co, 19x7) 45. 2. T Lehman, D H Bagley, “Reverse lithotomy:
Modified prone position for simultnneous nephroccopic and urcteroscopic procedures i n women.” U , o / o , ~ 32 y (December 19XX) 529-53I . 3. J C Lydon. F J Spielman. ”Bilateral compartment syndrome following prolonged surgery in the I it h o t o in y po s i t ion A rr P S / / I c .io~ / ( J S J 60 ( Marc Ii 19x4) 236-238. 4. Ihid. 5 . A S Tondare et al. ”Fenioral neuropathy: A coniplication of lithotomy position tinder spinal anesthesia: A report o f three cases,” Crrrrutlirrrr A/rues//i~~ti.s/’s Socicfq . / ( J / / / . / I u / 30 (January I 983) X4. 6. M a r t i n , Posiriorrirrg i r i A/ic.\//rc.siu urid .Sur,qivy, 275. 7. Lytlon, Spielinan, “Bilateral conipiirtiiieiitd syndrome following prolonged surgcry in the lithotomy position.” 235. 8. P K Reddy. K W Kayc, “Deep posterior coinpartmental syndrome: A serious complication 01‘ the lithotorny position,” ./ortrwtr/ of’ I l r ~ ) / o g yI32 (July 1983) 144-145. 9. K P Black. T K S c h u l t z , N 1, Clieung. “Compartment syndromes iii athletes,” C/i/ric,.si/r S p o r t s Mrtlic~irrc,9 (April 1990)47 1-387. 10. P K Reddy, A A Sidi. P H Lange, “Modified stirrups for dorsul lithotomy positioning.” U / W / O , ~ ! C/i~ric,.sof’ Nor.f/r Awro.ic,t/ I 7 (Fcbruury 1990) I3 1 133. I 1. M Humphrey et al. “The influences o f mtitcrnal posture a1 birth on the letus,” 7 h ,/oi/r/iu/of 0 h s / c /ric,.s ( I 11 il Gq rr u e co lo ,qq t o I‘ I / I c H r.i / i.s I / Conrnrorrwetrlfh X O (April 1973) 1075. 12. M S Hoffinnn, W S Roberts. D Cavanagh. “Neuropathies associated with radical pclvic surgery for gynecologic cnncer,” Gyrrcc~ologic.O/rc,olo,qq 3 I (November 19x8) 462-466. 13. L Groom e t al. “Sequelae of intraoperutivc I i t hot om y pos it i on i ng .” Se ni i ti a r p re se n ted ;it t he 35th mnunl AORN Congress, Dallus, 23 M a r c h
.
”
19x8. 14. F Batres, D L Barclay. “Sciatic nerve injury
during gynecologic procedures using the lithotoniy , ~ ~(Scptenibcr position.” Oh.rtcwic,.so/td C ; , W W J / ~ J62 1983) 925-935. 15. Tondare et al. “Femoral neuropathy: A c o n pliciition of lithotoniy position under spiii;il anesheA report 0 1 three cases,” 84. 16. / h i t / ; Batres. Barclny. “Sciatic nerve in,jury during gynecologic proccdures using [he lithotoniy position,” 944; Martin, Po.si/io/rirr,q in A/ic.s/hcsitr atrd Srtr,q~ry,275-277; R e d d y , Sidi. Lange. “Modified stirrups for dorsal lithotomy positioning,“ 131-133. 17. /hid. 18. Lehman, Bagley. “Reverse lithotomy: Modified prone position lor siniultmeous nephroscopic and urcteroscopic procedures in women.” 529.
bxamination LITHOTOMY POSITIONING DEVICES
1. The standard lithotomy position provides access to a. pelvic viscera b. pelvic viscera and the superficial perineum c. abdominal viscera d. the perineum 2 . Choose the answer that best describes the standard lithotomy position. a. The patient is on his or her back with pillows under his or her calves. b. The patient is supine and his or her legs are “froglegged.” c. The patient is supine with his or her buttocks at the end of the OR bed, both hips and knees are tlexed, both feet are supported by stirrups, and both thighs are abducted and externally rotated. d. The patient is supine with his or her buttocks at the end of the OR bed, both hips and knees are tlexed, both feet are supported by stirrups, and both thighs are adducted and internally rotated. 3. When hip flexion is extreme, what is this called? a. Young’s modification b. ankle-strap position c. reverse lithotomy d. abdominal-perineal modification 4. When hip flexion is slight, what is this called‘? a. Young’s modification b. ankle-strap position c. reverse lithotomy d. abdominal-perineal modification 5 . Choose the answer that best describes the reverse lithotomy position.
6.
7.
8.
9.
a. The patient’s legs are suspended by the knees rather than the ankles. b. The patient is prone with hips at the end of the OR bed and stirrups that support the knees. c. The patient is prone with hips at the end of the OR bed and stirrups supporting the feet. d. The patient is prone with both legs “froglegged.” Historically, what was the most common leg support system used for the lithotomy position? a. Lloyd-Davies stirrups b. Allen stirrups c. Dilatation and curettage (D&C) stirrups d. ankle-strap stirrups When a patient’s feet are suspended from two straps by support poles attached to the OR bed, what stirrups are being used? a. Lloyd-Davies b. Allen c. D&C d. ankle-strap What are the three most common areas of the body that lithotomy positioning devices support? a. heel, calf, and combined heel/calf b. heel, back of the knee, and thigh c. foot, heel, and thigh d. foot, calf and back of knee A support device that controls abduction of the thigh would support the . a. heel b. calf c. knee d. thigh 1023
AORN JOURNAL
10. Ankle-strap stirrups cannot control -.
a. flexion or abduction of the hip b. hyperextension of the legs c. extension and adduction of the hip d. abduction of the hip I I . Which answer describes complications that occur when patients are in the lithotomy position? a. nerve, muscle/facial, and circulatory injuries b. nerve and muscle injuries c. muscle/fascial injuries d. nerve and circulatory injuries 12. What factors cause these injuries? 1. anatomical position 2. physiological effects of the position 3. age, weight, nutritional status of the patient 4. length of time in the lithotomy position a. 2 a n d 3 b. 1,2, and4 c. 3 and 4 d. all of the above 13. What is the most serious complication of muscle/fascial injury? a. decubitus ulcers b. bruising and muscle wasting c. compartment syndrome d. stiff, sore legs 14. What common nerves can be injured in the lithotomy position? a. sciatic, femoral, popliteal b. sciatic, femoral, obturator c. obturator, popliteal, tibial d. peroneal, tibial, obturator 15. What circulatory system complications can be seen when patients are in the lithotomy position? 1. blood pressure changes 2. vascular occlusion, thrombosis 3. fetal acidosis 4. supine hypotensive syndrome a. 1 and 2 b. 2 c. 4 d all of the above 16. To prevent complications when patients are in the lithotomy position, the nurse can 1024
APRIL 1992, VOL 55. NO 4
1. Physically assess the patient and implement appropriate care if the patient is elderly, underweight, or poorly nourished. 2. Remove pads on the stirrups to decrease pressure on the patient’s legs. 3. Place the patient in correct body alignment. 4. Remove the patient from lithotomy position every two hours. a. 1 and 3 b. 2 a n d 4 c. 4only d. 3 only 17. Why is it important for the nurse to have assistance when raising or lowering the patient’s legs in lithotomy? 1. to prevent stretching injuries to the muscles and nerves of the legs 2. to control the amount of flexion and abduction of the legs 3. to avoid injury to the nurse’s back 4. to ensure that the surgeon participates in positioning the patient a. all of the above b. 2 and 3 c. 1 and 2 d. 1 and4 18. The nurse must be aware that a. Padding eliminates complications in the lithotomy position. b. Padding significantly reduces all compression injuries including peroneal nerve compression, compartment syndrome, injuries from hyperflexion of the hip, and compression injury to the femoral nerve from entrapment. c. Padding significantly reduces peroneal nerve compression and compartment syndrome, but i t does not reduce injuries from hyperflexion of the hip or compression injury to the femoral nerve from entrapment. d. Compression injuries can only be avoided by limiting time in lithotomy. 19. Why would the nurse want to place the patient in lithotomy while he or she is awake?
A O K N .IOIJKNAL
I . This saves time after the patient is anesthetized. 2. Anesthetized patients cannot alert the surgical team to discomfort; awake positioning ensures that the position is comfortable for the patient. 3. Patients with arthritis or kneehip prostheses must be carefully positioned to avoid injury to their joints; awake positioning ensures that they are not placed in a potentially damaging position. 4. Awake positioning helps to educate the patient about what will occur during surgery. a. 1 and 2 b. 2 a n d 3 c. 3 a n d 4 d. 2 only 20. When choosing a lithotomy positioning device, the nurse must remember that nerve and muscle damage are most common in this position and occur most frequently with ankle-strap stirrups. a. true b. false Professioriul wurses ure invited to submit clinical niunugeriul munusc~ripts$)r the home study program. Matiusi~riprso r queries should be sent to the Editor, AORN J o u r m ~ l ,101 70 E Mississippi Ave. Denver. CO 80231. As with ull manuscripts sent to the Journul. p i p e r s submitted for. home study pro
APRIL 1992. VOL 5.5, NO 4
Publication Includes Interesting Cancer Facts A new publication from the American Cancer Society, Atlanta, gives detailed information about how cancer affects minority populations in the United States. The publication, published in December 1991, is called C a n ~ w . Facts and Figures for Minority Amerkons, according to a news release from the American Cancer Society. The publication includes the latest cancer incidence rates and results of recent surveys on attitudes and practices toward cancer prevention, detection, and treatment. The following are some of the interesting facts included in the publication. 0 American Indians have lower incidence rates for lung cancer than the general population. 0 Hawaiians have the second highest cancer incidence rate of any American ethnic group. Chinese, Japanese, and Filipinos have overall lower incidence and mortality rates than American blacks or whites. 0 Hispanic American women are less likely to have pap tests and screening mammography than the overall population. 0 The risk for invasive cervical cancer is highest among African Americans, Hispanics, American Indians, and Hawaiians. 0 African Americans have the highest incidence rates for prostate, esophageal, and colon and rectal cancers. For more information, contact The American Cancer Society, magazine services, 1180 Avenue of the Americas, New York, N Y 10036.
APRIL 1992, VOL 5.5. NO I
AORN JOURNAL
Answer Sheet LITHOTOMY POSITIONING DEVICES
P
lease fill out the application and answer forin below and the evaluation on the back of this page. Tear out the page from the Journal or make photocopies and mail to: AORN Accounting Department c/o Home Study Program 10170 E Mississippi Ave Denver, CO 8023 I Event # 9250 I3
Mark only one answer per question 1
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Session # 55 13
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Program offered April 1992 The deadline for this program is Oct 3 I , 1992.
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I . Record your identification number in the appropriate section below. 2. Completely darken the space that indicates your answer to the examination starting with question one. 3. A score of 70% correct is required for credit. 4. Record the time required to complete the program 5. Enclose fee: Members $7; Nonmembers $14.
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AORN (ID) # If nonmember, please provide Social Security
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Phone number (
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Learner Evaluation The lollowing evaluation is used to determine the extent to which this home study program met your learning needs. Rate the following items on a scale of 1 to 5. I . Objectives. To what extent were the following objectives of this home study program achieved? ( I ) Describe the lithotomy position and its modifications. ( 2 ) Identify the types of support devices available. (3) Discuss the complications of this position. (4) Identify nursing interventions that prevent patient injiiry in the lithotoiny position.
(Low)
(High)
(1)
(2)
(3)
(4)
(5)
(1) (1)
(2) (2)
(3) (3)
(4) (4)
(5) (5)
(1)
(2)
(3)
(3)
(5)
(1) (1) (1)
(2) (2) (2)
(3) (3) (3)
(4) (4) (4)
(5) (51 (5)
2 . Content. ( I ) Did this article increase your knowledge of the subject matter? ( 2 ) Was the conlent clear and organized? (3) Did this article facilitate learning'? (4) Were your individual objectives met? ( 5 ) Was the content of the article relevant to the objectives?
3. Test questionslanswers. ( I ) Were they reflective of the content'? ( 2 ) Were they easy to understand? (3) Did they address important points'?
4. What other topics would you like to see addressed in a future home study program'? Would you bc interested or do you know someone who would be interested in writing an article on this topic'! Topic(s):
Author names and addresses:
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