AORN圍術(shù)期體位安全管理原文

RecommendedPracticesforPositioningthePatientinthePerioperativePracticeSetting圍術(shù)期病人體位的操作規(guī)程ThefollowingrecommendedpracticesforpositioningthepatientintheperioperativepracticesettingweredevelopedbytheAORNRecommendedPracticesCommitteeandhavebeenapprovedbytheAORNBoardofDirectors.Theywerepresentedasproposedrecommendationsforcommentsbymembersandothers.TheyareeffectiveJanuary1,2008.Theserecommendedpracticesareintendedasachievablerecommendationsrepresentingwhatisbelievedtobeanoptimallevelofpractice.Policiesandprocedureswillreflectvariationsinpracticesettingsand/orclinicalsituationsthatdeterminethedegreetowhichtherecommendedpracticescanbeimplemented.AORNrecognizesthevarioussettingsinwhichperioperativeregisterednursespractice.Theserecommendedpracticesareintendedasguidelinesadaptabletovariouspracticesettings.Thesepracticesettingsincludetraditionaloperatingrooms,ambulatorysurgerycenters,physicians'offices,cardiaccatheterizationlaboratories,endoscopysuites,radiologydepartments,andallotherareaswheresurgerymaybeperformed.Referencestonursinginterventions(I)usedinthePerioperativeNursingDataSet(PNDS)arenotedinparentheseswhenarecommendedpracticecorrespondstoaPNDSintervention.'ThereaderisreferredtothePNDSforfurtherexplanationofnursingdiagnoses,interventions,andoutcomes.PurposeTheserecommendedpracticesprovideguidelinesforpositioningthepatientintheperioperativesetting.Theyarenotintendedtocoveraspectsofperioperativepatientcareaddressedinotherrecommendedpractices.Preventionofpositioninginjuryrequiresanticipationofthepositioningequipmentnecessarybasedonthepatient'sidentifiedneedsandtheplannedoperativeorinvasiveprocedure,applicationoftheprinciplesofbodymechanicsandergonomics,ongoingassessmentthroughouttheperioperativeperiod,andcoordinationwiththeentireperioperativeteam1Attentionshouldbegiventopatientcomfortandsafety,aswellastoassessingcirculatory,respiratory,integumentary,musculoskeletal,andneurologicalstructures.Workingasamemberoftheteam,theperioperariveregisterednursecanminimizetheriskofperioperativecomplicationsrelatedtopositioning.2008PerioperativeStandardsandRecommendedPractices~AORN,Inc.Allrightsreserved.RecommendationIPersonnelwhopurchasepositioningequipmentshouldmakedecisionsbasedonthehealthcareorganization'spatientpopulation,currentresearchfindings,andtheequipmentdesignsafetyfeaturesrequiredtominimizeriskstopatientsandpersonnel.Thetechnologyusedtocreatemattresses,padding,andotherpositioningequipmentcontinuestoevolve,anditisimportantforperioperativeregisterednursestobeawareofproductsandcurrentresearchtosupporttheirproductselection.Theprimarysafetyfeatureconsiderationforpositioningequipmentisthatitredistributepressure,especiallyatbonyprominencesonthepatient'sbody.TheNationalPressureUlcerAdvisoryPanelSupportSurfaceStandardsInitiativedefinesasupportsurfaceas"aspecializeddeviceforpressureredistributiondesignedformanagementoftissueloads,micro-climate,and/orothertherapeuticfunctions(ie,anymattresses,integratedbedsystem,mattressreplacement,overlay,orseatcushion,orseatcushionoverlay).''2Althoughphysiologicbloodandlymphaticflowratesvaryamongindividuals,capillarypressuresmayincreasetoasmuchas150mmHgduringprolonged,unrelievedpressurewithoutpositionchange。3Thetraditionalprocedurebedmattressusuallyisconstructedofonetotwoinchesoffoamcoveredwithavinylornylonfabric.Researchstudieshavefoundthatfoamoverlaysorreplacementpads,whichrepresentmostORandprocedurebedmattresses,donothaveeffectivepressure-reductioncapabilities4Studiescomparingthepressure-reducingabilitiesofstandardfoamprocedurebedmattressestogelmattresses(ie,visco-elasticpolymer)havefoundgelmattressestobemoreeffective.4,5Oneresearchstudyreportedthatpolyethermattressesgeneratealowercapillaryinterfacepressurewhenthepatientwasinthesupinepositionthangelmattressesorfoammattresses2Anotherstudyfoundthatfoamandgelmattressesareeffectiveforpreventingskinchanges,butvisco-elasticoverlaysareeffectiveforpreventingbothskinchangesandpressuresoreformation.7Clinicalsupportsurfaces(ie,padding)functiondifferentlyforpersonsofdifferentheightandweight."Aperformanceimprovementstudyreportedthatsupplementalpaddingontheprocedurebedmattressortheuseofotherpositioningdevicesmaynotreducecapillaryinterfacepressureforallbodytypesorforallareasofbonyprominenceseveninpatientswiththesamebodytype?Postoperativeuseofalternatingpressuremattresseshasbeenfoundtominimizetheincidenceofpressureulcers.Intraoperativeuseofthistechnologymaybelimitedduetoconcernsaboutpatientmovement,electricalsafety,andasepsis2Therearestudiesreportingareductioninthepostoperativeincidenceofpressureulcerswhenpressure-relievingoverlaysareusedonprocedurebedmattressesandinthepostoperativeperiod;however,useofmattressoverlaysintraoperativelymaynotminimizethisrisk.'~Itisdifficult,therefore,todrawfirmconclusionsaboutthemosteffectivemeansofintraoperativepressurerelief.Futurestudiesofpressure-relievingsurfacesareneededandmustaddressmethodologicaldeficienciesassociatedwithmanyoftheavailablestudies.Examplesofcurrentstudylimitationsincludethefollowing:TrialsthatdonotclearlyreflectwhetherareductioninriskforskinchangesisduetointraoperativeorpostoperativepressurerelieforwhetherapplicationofthetrialisnecessaryinbothsettingstoachieveariskreductionJtStudiesthatdonotincludeinformationgatheredonthepostoperativeskincareofthepatientmakeitdifficulttoassesstheclinicalsignificanceofthestudies'findingsJCrosscomparisonsofstudyresultsoftenarenoteffectivebecauseofvariationsofselectioncriteria.Inaddition,limitedsamplesizes,interraterreliability,andcontradictoryfindingsfurthercontributetoweakscientificsupportforrecommendationsonhowtopredictandpreventpressureulcersresultingfromintraoperativeprocedurebedmattresses.'10Studiesthatmeasureonlyinterfacepressure(ie,thepressureondifferentpartsofthepatient'sbodythatareincontactwiththesupportsurface)haveseriouslimitations.Theprocessthatleadstothedevelopmentofapressureulcerinvolvesthecomplexinterplayofseveralfactors.'Themostfrequentpredictorsofperioperativepressureulcershavebeenfoundtobeincreasingageofthepatient,apatientdiagnosedwithdiabetesorvasculardisease,andvascularprocedures.a..Personnelselectingprocedurebedmattressesandpositioningequipmentforpurchaseanduseshouldmakedecisionsbasedoncriteriathatinclude,butarenotlimitedto,abilitytoholdthepatientinthedesiredposition;availableinavarietyofsizesandshapes;suitableforthepatientpopulationandanticipatedpositionrequirements;abilitytosupportmaximumweightrequirements;durablematerialanddesign(eg,maintainsresilienceunderconstantuse);evidencethatitisabletodisperseskininterfacepressure;resistancetomoisture;lowriskformoistureretention;radiolucent,ifnecessary;fireretardant;nonallergenic;promotesaircirculation;lowriskofharboringbacteria(eg,replacementsmaybeneededwhensoiled);easytouseandstore;andcosteffective.~'4,7,~2Onestudyfoundthevisco-elasticmattressoverlayappearstoofferthemostbenefitforolderpatientpopulations;patientswhohavemoreseriousorchronichealthproblems,wherethereisaprevalenceofvasculardisease;orinsituationswheresurgicalproceduresextendbeyondtwo-and-one-halfhours.7l.a.1.Positioningequipmentforobesepatientsshouldinclude,butisnotlimitedto,lateraltransferdevicesorpatientliftstomoveobesepatientsfromstretcherprocedurebedtotheORprocedurebed;~andstretchersandbedsinthepostanesthesiacareunit(PACU)thatareabletoaccommodateatleasta30-degreeelevationofthepatient'supperbodyandheadtoavoidrespiratorydistress.Whetherornotafacilityhasabariatricsurgeryprogram,itisnecessa