Perioperative Care of the Morbidly Obese Patient in the Lithotomy Position

Article Outline

• Abstract
• The Lithotomy Position
  • Potential Musculoskeletal Complications
  • Potential Cutaneous and Neurologic Complications
  • Potential Respiratory and Hemodynamic Complications
• General Nursing Care for Patients Who Are Morbidly Obese
  • Potential Musculoskeletal Complications
  • Potential Anesthetic Complications
  • Potential Cardiovascular Complications
• Placing the Patient Who is Morbidly Obese in the Lithotomy Position
  • Candy-Cane Shaped Stirrups
  • Knee-Crutch Stirrups
  • Boot-Type Stirrups
  • General Concerns With Any Type of Stirrup
• Case Study
  • Practice Session
  • Preoperative Phase
  • Intraoperative Phase
  • Postoperative Phase
  • Evaluation
• Continued Success
• Examination. Continuing Education Program
  • Perioperative Care of the Morbidly Obese Patient in the Lithotomy Position
    • Questions
• Learner Evaluation. Continuing Education Program
  • Perioperative Care of the Morbidly Obese Patient in the Lithotomy Position
    • Objectives
    • Content
• References
• Biography
• Copyright

Abstract 

The lithotomy position is used daily in the OR to position patients for vaginal, rectal, and urologic procedures. Use of this position requires a careful nursing assessment to ensure that the patient can tolerate having his or her legs placed in the stirrups and to ensure that no pressure points exist for the duration of the surgery. Caring for a patient who is morbidly obese and who requires surgery in the lithotomy position can be especially challenging, and the possibility of injury to the patient or staff members should be considered. A case study involving the care of a patient who weighed almost 600 lb undergoing surgery in the lithotomy position demonstrates ways to provide safe care for this type of challenging patient.

Key words: lithotomy position, morbidly obese patients, alternate stirrup use

Positioning a patient plays a major part in the successful outcome of any surgery.¹ Nurses routinely place patients' legs into different types of stirrups when the lithotomy position is required. This position presents challenges with any patient; complications can range from staff member injuries (eg, muscle strain, backache) to serious patient complications (eg, nerve palsy, compartment syndrome).¹, ² The patient who is underweight, debilitated, disabled, elderly, or obese, however, can present additional challenges.¹

The average weight of patients is increasing, and according to the National Health and Nutrition Examination Survey, 34% of US adults could be classified as obese in 2006.³ Morbid obesity is defined as a body mass index greater than 40 kg/m².⁴ Often, standard equipment is not adequate to provide safe care for larger patients. Medical equipment manufacturers have developed new and larger table attachments and equipment (eg, lifts, moving devices) to assist in the care of patients who are morbidly obese; however, in some instances, innovation is required on the part of a multidisciplinary perioperative team to provide safe care.

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The Lithotomy Position 

The lithotomy position is used to allow maximum surgical exposure in vaginal, rectal, and urologic procedures. There are four levels of the lithotomy position ranging from low lithotomy, which places a patient's legs at approximately a 35-degree angle to his or her recumbent torso, to the exaggerated lithotomy position with the patient's legs at more than a 90-degree angle.⁵ Patient leg abduction should be limited to the degree needed for adequate surgical exposure to avoid stress on the patient's hip joints and prevent compromise of lower extremity circulation.⁶ Physiologic responses, including musculoskeletal, cutaneous and neurologic, and respiratory and hemodynamic responses occur when the patient's legs are elevated into lithotomy stirrups; perioperative team members must take these issues into consideration when caring for patients undergoing surgery that requires the lithotomy position.¹, ⁵, ⁷

Potential Musculoskeletal Complications 

Injuries to the patient's hips and knees can result from lithotomy positioning. Abductor muscles and hip capsule joint problems can develop if the patient's legs are stretched or the patient remains in the lithotomy position for an extended period. The patient's fingers, if tucked at his or her sides, are in danger of injury when the bottom of the OR bed is raised or lowered.⁵

Potential Cutaneous and Neurologic Complications 

Soft tissue problems can result from incorrect handling or positioning by health care providers and can include injuries to the patient's femoral, cutaneous, sciatic, and obturator nerves. Pressure points from inadequate padding and positioning may cause tissue damage. Shearing force from changes in position can damage skin tissue, especially in patients who are older, debilitated, or obese. Proper patient-moving techniques should be used to prevent shearing forces.

Potential Respiratory and Hemodynamic Complications 

Respiratory complications can occur because the patient's abdominal organs shift when the patient's legs are raised and placed in stirrups. This increases pressure on the diaphragm and can result in respiratory compromise.⁵ Raising or lowering the patient's legs too rapidly can result in fluid volume shifts that affect blood pressure. When team members lower the patient's legs after the procedure, fluid volume deficits can quickly become more obvious, making the patient's hemodynamic status unstable and complicating the anesthesia care provider's management of the patient.⁵

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General Nursing Care for Patients Who Are Morbidly Obese 

Patients who are morbidly obese present special challenges to all members of the perioperative team. These patients can experience any of the common positioning problems that place any patient at risk; however, morbid obesity increases a patient's risk of additional complications that must be considered in the plan of care (Table 1).⁸ Nursing interventions to prevent problems include ensuring that sequential compression stockings fit to prevent constriction and monitoring the patient's clothing and bed linen to prevent constriction and prevent the patient from lying on bunched or wrinkled material that could cause tissue damage. Drapes must be large enough to cover the patient and provide a sterile field. Instruments must be large enough to provide adequate exposure and allow the surgeon to perform the planned procedure, which may require special bariatric instrument sets.

TABLE 1. Nursing Care Plan for Patients Who Are Morbidly Obese

SaO₂ = arterial oxygen saturation.

Potential Musculoskeletal Complications 

As a result of the patient's size and potential mobility difficulties, routine care may be more complicated and require the help of additional support personnel to avoid injury to the patient or staff members.¹, ⁵, ⁷ There is an increased risk of injuring the patient's joints, muscles, nerves, and soft tissues when lifting and moving the patient because of his or her size, and the inability of health care providers to clearly see the patient's anatomic markers (eg, joints) can make safe knee and hip flexion difficult to determine.¹, ⁵, ⁷ Overabduction can occur because of the size and weight of the patient's thighs and the need to create adequate space in which the surgeon and staff members can work.¹, ⁵, ⁷ For example, the nurse should have additional personnel support the patient's legs and prevent overabduction when placing the patient in the frog leg position during insertion of an indwelling urinary catheter.

Potential Anesthetic Complications 

Patients who are morbidly obese present significant challenges for the anesthesia care provider. Often, these patients experience medication problems as a result of altered absorption and increased storage of medications in their excess fat. Cardiovascular and respiratory concerns may include increased cardiac afterload, decreased oxygen supply, and a respiratory system taxed by increased fat metabolism.⁹ Additional chest weight, abdominal pressure, and the presence of coexisting conditions unrelated to the procedure (eg, hiatal hernia, sleep apnea) increase the patient's respiratory workload. The patient's chest weight and abdominal pressure also increase the patient's risk of aspiration and its serious consequences.⁹ Intubating a patient who is morbidly obese can be difficult because of limited cervical neck movement, reduced oxygen reserves, and increased oxygen consumption.⁹ Anesthesia care providers may have difficulty seeing the vocal cords because of limited neck movement and fat deposits that can obstruct the airway. As a result of these complications, intubating the patient while he or she is awake may be necessary.⁹ The anesthesia care provider may require special head positioning and support aids such as an airway management head cradle and an elevation wedge specifically designed to assist with induction and head support during procedures on patients who are obese. Emergency response carts also should be in the room in the event of a difficult intubation or other emergency. The patient also may require appropriately sized blood pressure cuffs.

Potential Cardiovascular Complications 

Cardiac conditions that often present in patients who are morbidly obese may include hypertension, diabetes, bradycardia or tachycardia, and slow cardiac conduction and ischemia. As a complicating factor, the electrocardiogram conduction signal may be distorted as a result of excess chest fat. Furthermore, patients who are obese have an increased incidence of deep vein thrombosis, and superficial veins may be difficult to access for IV placement.⁹

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Placing the Patient Who is Morbidly Obese in the Lithotomy Position 

“Obese patients are more prone to difficulty with positioning and positioning injuries during surgery because of the strain excessive weight places on their musculoskeletal and nervous systems.”^9(p45) Patients who are obese also may present with existing areas of skin damage that need to be assessed and taken into consideration during positioning.

It is imperative that the perioperative nurse has a preoperative discussion with the surgeon and the anesthesia care provider about plans and needs for the surgery. The circulating nurse should perform a careful preoperative assessment of the patient to identify cardiac, vascular, or neurologic conditions that could affect the patient's safety or care during surgery. Additionally, the nurse should identify any issues that might adversely affect the patient when he or she is placed in the lithotomy position, such as

The nurse should note any concerns in the patient's medical record and convey these concerns to the surgical team.

Assembling additional staff members to help during moving and positioning also prevents injuries to staff members. A verbal walk-through of the planned move and positioning needs can help reduce injuries. Depending on the patient's status and the surgical exposure needs, team members may need to experiment with positioning with a volunteer staff member standing in for the patient.

The RN in charge of the patient should act as the person in charge of the move to reduce confusion and prevent injury to the patient or staff members. Before taking the patient into the OR, the nurse should ensure that all positioning equipment (eg, heavy-duty stirrups, gel pads, pillows) is available, is in position, and has been checked for function and safety. Transporting patients who are obese may necessitate the use of special assistance devices or carts.

Equipment (eg, OR bed, stirrups, arm boards) must support the patient's weight and fit the extremities to avoid causing injury. When caring for patients who are morbidly obese, the surgical team must modify many aspects of routine care to deal with the patient's larger size and weight. A bariatric OR bed is needed that can support the patient's weight and provide additional width. Typical bariatric beds are capable of supporting up to 1,000 lb and are extra wide, and the mattresses are well constructed to help prevent full compression of the mattress. Other equipment considerations include providing appropriately sized arm boards and safety belts for the bed. Devices to support the extremities (eg, slings) may be needed.

Bariatric stirrups should hold up to an 800-lb patient, but stirrups manufactured for bariatric beds must be assessed for each patient. For instance, although the stirrup could support the weight of the patient's leg, the sides of the boot may be too narrow to accommodate the size and circumference of the leg without creating pressure. Perioperative team members may have to improvise stirrups to accommodate the patient without causing problems. Methods to improvise should not be undertaken that would contradict the manufacturer's instructions for use or negate the product warranty, however.

Different types of stirrups are available for the lithotomy position, but candy-cane shaped, knee-crutch, and boot-type stirrups are used most often. Instructions for use from the manufacturer and AORN positioning recommendations should always be followed during use of positioning aids, including stirrups.¹ Candy-cane shaped stirrups provide good exposure of the surgical site, are easy to use, and allow room for the team to work. Knee-crutch stirrups are commonly used during cystoscopy procedures, which tend to be shorter in duration. Boot-type stirrups are often used during procedures in which the patient is awake (eg, local anesthesia, monitored anesthesia care) because they allow the patient's legs to be in a lower, more comfortable position and can be raised if necessary. Use of each type of stirrup has the potential to cause problems (eg, nerve or pressure injuries, overrotation).

Candy-Cane Shaped Stirrups 

These stirrups look similar to a cane and are attached to the side of the OR bed (Figure 1). After attaching the stirrups to the bed, perioperative personnel can rotate them to change the angle at which the stirrups hold the legs. The patient's foot is secured in a double sling made of cotton webbing and suspended from the end of the cane by a fastener. Injury can occur if the patient's legs are allowed to relax and extend outward to rest on the cane bar.² Pressure from the cane bar on the lateral aspect of the calf or knee can result in footdrop or nerve injury to the leg. Although padding can be placed between the cane bar and the patient's leg, pressure injury can still occur. The patient's hips can be externally overrotated when in these stirrups to a point of hyperabduction,² which can cause sciatic and obturator nerve injury and injury to the patient's hip and knee joints and leg muscles. Gel boots and wide straps can pad and reduce pressure to the ankle and foot. The patient's leg weight and the duration of the procedure can increase the potential for further injury to the distal sural and plantar nerves.

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• Figure 1. 

  Candy-cane shaped stirrups.

Knee-Crutch Stirrups 

These stirrups resemble the top of a walking crutch (Figure 2). The nurse places the patient's leg over the crutch and positions the leg so it is resting over the supporting arch. All weight is resting on the knee, which can put undue pressure on the popliteal space. Knee-crutch stirrups also have the potential to cause injury to the posterior and the common peroneal nerves and the popliteal artery because they place pressure on the popliteal fossae and may not evenly distribute pressure.²

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• Figure 2. 

  Knee-crutch stirrups.

Boot-Type Stirrups 

These stirrups resemble boots attached to the sides of the OR bed and give more support to the entire leg (Figure 3). They are commonly used for procedures in which the patient is receiving local anesthesia or monitored anesthesia care as well as during pelviscopy procedures. The support that boot-type stirrups provide reduces the potential for nerve and pressure injury because pressure is evenly distributed to the leg and foot; however, the same types of injuries that occur with other stirrups can occur when these stirrups are used. Boot-type stirrups are attached to the bed at the level of the patient's hip socket and reduce stress on the hip joint. It is important to remember that these stirrups may appear easier to use, but incorrect placement of the bed attachment bracket can cause stress injury to the patient's hip.

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• Figure 3. 

  Boot-type stirrups.

General Concerns With Any Type of Stirrup 

In general, stirrups are secured on the OR bed rails at the level of the patient's hip socket, with the patient's buttocks at the end of the break in the bed. The nurse can adjust the height of the boot or foot location to match the patient's leg size. To prevent shearing injuries, care should be taken to use transfer devices to lift, not slide or pull, the patient if repositioning the patient to the break in the bed is necessary. When placing a normal-weight patient into the lithotomy position, two team members lift, slightly externally rotate, and flex the patient's legs and raise them together while holding the feet and supporting the calves close to the knee joints. When the leg is at an appropriate level, the team members place the patient's feet in the stirrups. If using candy-cane shaped stirrups, staff members should place the gel boots or straps on the patient before raising the legs. This decreases the difficulty of getting the foot into the strap while holding the leg, which then provides safer lifting of the leg to the stirrup attachment. Several staff members may be needed to lift each leg if the patient is morbidly obese, or pneumatic slings may be required to position the patient's legs; no one person should attempt to lift the extremity alone. Abduction of the patient's legs should be limited to the degree needed for good surgical exposure, and the position should not allow either leg to hyperrotate or hyperextend. The nurse should gently secure the patient's arms on padded arm boards at less than a 90-degree angle and ensure that the patient's hands, if placed at the sides of the OR bed, are clear of the breaks in the bed to prevent injury when the bottom of the bed is lowered.²

The circulating nurse should assess the patient thoroughly after the team has completed positioning. He or she should check the patient for alignment, possible pressure points and potential sites of injury (eg, sacrum, arms, hands), and other potential problems (eg, respiratory or circulatory compromise as a result of leg positioning) and make any necessary adjustments. The nurse also should check the patient's position

Procedural time should be kept to a minimum. AORN's “Recommended practices for positioning the patient in the perioperative practice setting” suggests that the perioperative team should consider repositioning the patient if the procedure lasts longer than four hours.¹ The circulating nurse should then document all positioning and the names of the staff members involved as well as all equipment and padding used.

Before moving any lower extremity into or out of stirrups, team members should alert the anesthesia care provider. When the anesthesia care provider is ready, team members should remove the patient's legs from the stirrups simultaneously and slowly to minimize lumbosacral strain on the patient. If possible, staff members should bring the patient's legs together simultaneously and then lower the patient's legs to the bed surface one at a time to prevent rapid or unexpected circulatory changes.^1(p339) Before the patient is transferred to the postanesthesia care unit, the circulating nurse should carefully assess the patient for skin, nerve, or pressure injury.

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Case Study 

Two weeks before a scheduled surgery, perioperative team members were notified of a lithotomy procedure to be performed on a patient weighing approximately 600 lb. Previously, a physician had attempted to perform an examination with this patient under anesthesia, and staff members had been unable to position the patient or support her legs in a way that would work for the surgeon and be safe for the patient and staff members. Stability, positioning, and padding needs could not be met, so the examination had been cancelled. After talking with this physician, the surgical team members determined that stirrups available at the facility, even the ones used for bariatric surgery patients, would not fit this patient. The gynecology coordinator, circulating nurse, scrub person, and facility safety officer met in advance of the procedure to

The gynecology coordinator contacted the facility's stirrup vendor to see whether any currently manufactured stirrups would work for a patient of this size. The vendor was not able to find any stirrup that would support this patient despite checking with several other manufacturers. The vendor suggested that some ORs used padded Mayo stands or bedside tables to support the patient's legs, but the team decided that these pieces of OR furniture were not intended for that use and therefore the team could not ensure the patient's safety. The gynecology coordinator discussed options with the facility safety officer and had the idea of using two patient lifts, one for each leg. These lifts are capable of supporting 450 lb each, so team members decided that if the lifts met the team's positioning needs, they would provide a safe way to support this patient's legs.

Practice Session 

The team members set up a mock OR that included a special bed used for bariatric procedures to develop and perfect a modified lithotomy position. A team member placed a full-length inflatable patient transfer device on the OR bed. This inflatable pad is placed under the patient and buckled in place (Figure 4). When the device is inflated, team members can more easily move the patient to the OR bed with little effort and safely place the patient in position on the bed. They then deflate the pad and leave it in place for use in moving the patient to the transfer cart and later to the patient bed. Both reusable and disposable pads are available.

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• Figure 4. 

  Inflated patient transfer pad used to transfer patients from the OR bed to the transfer cart and then to the patient's postoperative bed.

Team members positioned lifts at either side of the bed in the mock OR setup (Figure 5). After the safety officer answered team members' questions about how the lifts functioned and the team members had a chance to work with the lifts to become familiar with them, the team members locked the lifts in place and one team member volunteered to be positioned using the lifts (Figure 6). Team members assessed their colleague for positioning problems or pressure points while she was on the bariatric bed and in the slings and experimented with different padding options. The team chose to use thick gel pads to cover any surface that would come into contact with the patient on the bed. Team members placed pillows in the slings to reduce their concave shape and to support the patient's knees and covered the pillows with gel pads extending beyond the sling edges to reduce calf pressure. Team members used wide, thick, egg-crate foam pads to further protect the patient's ankles. Special care was planned to pad and protect the folds and rolls of tissue present on the patient's legs where necessary.

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• Figure 5. 

  Mock OR setup with pneumatic lifts in place at the sides of the bed.

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• Figure 6. 

  Perioperative nurse volunteer in position in the pneumatic lift stirrups.

During induction before positioning, the patient would be placed in a supine position. The team planned to secure two long, wide safety belts together to cover the patient's thigh area and use a second set over the patient's calves. They planned to use two padded, extra-wide arm boards with gel pads and wide arm straps to secure the patient's arms.

Additionally, the anesthesia care provider planned to use the airway management head cradle and elevation wedge to prevent an increase in abdominal and thoracic pressure when the patient was in the supine position (Figure 7). Both the wedge and the head cradle would be left in place throughout the procedure to assist in anesthesia care. Team members anticipated that this patient might experience a difficult induction and intubation and made sure that the emergency cart for difficult airways was in the room and that a circulating nurse would be present to assist the anesthesia care provider during induction.

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• Figure 7. 

  Airway management head cradle and elevation wedge.

Finally, the team planned to provide thermoregulation assistance. Warm blankets would be placed over the patient and a temperature-regulating blanket would be placed over the patient's chest.

Preoperative Phase 

On the day of surgery, the preoperative nurse reviewed the patient's chart in the holding area and admitted the patient. The nurse reviewed the patient's history and interviewed the patient about her allergies, previous surgeries, NPO status, and problems that would affect perioperative care and then answered the patient's questions. The nurse verified the intended surgery with the patient and the surgical consent. The nurse noted that the surgeon had explained to the patient, and documented on the informed consent, that a somewhat “experimental” positioning device that was not specifically designed for the lithotomy position would be used to facilitate positioning of the patient for the procedure and that there might be additional risks associated with the equipment used in this manner. The patient acknowledged her understanding and accepted the risks.

The nurse ensured that an inflatable patient transfer pad was placed on the bariatric stretcher before the patient got onto the stretcher, after which the nurse placed extra-large sequential compression device (SCD) leggings on the patient. The anesthesia care provider started an IV line, and the nurse administered the prescribed antibiotics. All concerns about the patient were communicated to the anesthesia care provider and the surgeon. The nurse explained to the patient how she would be moved to the OR bed, and when the patient was cleared to go to the OR, perioperative team members transferred her to the OR.

Intraoperative Phase 

In the OR, a team member inflated the patient transfer pad and the five-member team and the anesthesia care provider moved the patient to the OR bed, ensuring that she was properly positioned on the chest wedge support. After connecting the SCD leggings to the unit and securing the safety belts, the circulating nurse asked the patient if she was comfortable and made adjustments accordingly. The circulating nurse placed an upper-body temperature-regulating blanket on the patient and then assisted the anesthesia care provider with induction. The emergency cart was not needed because the induction went smoothly. After induction, the anesthesia care provider inserted additional IV lines and an arterial line.

Team members used the inflatable patient transfer pad to move the patient into a lower position on the bed and then deflated it and tucked the ends through the table break to prevent soiling of the mat during the surgery. Team members moved the leg lifts with pillows and gel pads into position on either side of the OR bed and locked them in place (Figure 8). As a result of the patient's large size, team members lifted both legs and then placed each of the patient's legs into the slings separately while the slings were at table height, ensuring that hip rotation was appropriate to avoid patient injury. Three people were needed to lift each of the patient's legs, bend the legs at the knee, and place them in the slings. After both legs were in the slings (Figure 9) and the patient's hands were checked for safe positioning to prevent her fingers from being trapped by the bed as it was repositioned, a team member dropped the end of the bed to prepare for the procedure. Team members placed enough padding around the patient's ankles and lower legs on top of the SCDs to redistribute pressure and then carefully adjusted the height of the lifts to an appropriate height for the procedure.

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• Figure 8. 

  Patient positioned on the bariatric OR bed. The safety straps have been temporarily removed so the patient's legs can be positioned in the pneumatic lifts. Elements in this photo do not necessarily comply with AORN standards and recommended practices.

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• Figure 9. 

  Patient in the lithotomy position in pneumatic lifts. The nurse ensures that no part of the lift frame or other part of the bed is in contact with the patient's legs. Elements in this photo do not necessarily comply with AORN standards and recommended practices.

The circulating nurse assessed the patient's position for potential pressure areas and made adjustments as needed; however, the patient's size made finding bony landmarks difficult and ruled out the use of graduated compression stockings. The nurse monitored the patient's legs throughout the procedure.

The scrub person, surgeon, and surgical assistants placed the drapes for the surgical field. Extra drapes were needed to adequately cover the lifts. After draping the surgical field, the surgeon began the surgical procedure. One limitation that team members noted was that space at the end of the bed to perform the surgery was unavoidably limited by the sling size and placement. The circulating nurse provided team members with extra steps so team members could participate as needed (eg, retracting surgical tissue) without leaning on the patient or inadvertently moving the patient's legs.

The procedure lasted 90 minutes and was uneventful. After the procedure was completed, the team members carefully lowered the slings and moved the patient's legs from the slings back onto the bed surface. The circulating nurse assessed the patient for positioning injuries and did not observe any. The patient's skin appeared to be in the same condition as it had been on arrival in the OR. Team members reinflated the patient transfer pad to move the patient back onto the bariatric cart and transferred her to the postanesthesia care unit without incident. The patient recovered well and was discharged to home the next day.

Postoperative Phase 

A postanesthesia care unit nurse called the patient 48 hours after surgery. The patient reported that she had not noted any positioning injuries, which indicates that the preoperative anticipation and planning contributed to the patient's positive outcome. The surgeon informed the team members that the patient's recovery had been uneventful and that the patient was pleased with the results of the surgery.

Evaluation 

After the surgery, the team members discussed their success and identified opportunities for improving this modified positioning protocol. In caring for this patient, team members discovered that

In reviewing the modified equipment used in positioning the patient for this procedure and the patient's surgical outcomes, the team members determined that use of patient slings was a safe alternative to stirrups when caring for this patient who was morbidly obese and required surgery in the lithotomy position.

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Continued Success 

Team members have since participated in additional procedures requiring this method of leg support and experienced the same success. Team members have discussed patient needs with the facility stirrup vendor and have evaluated the use of newer slings that also would provide safe support to patients who cannot be cared for with standard equipment. This learning experience required team members to combine creativity and perioperative knowledge to provide the type of care that all patients deserve.

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Examination. Continuing Education Program 

Perioperative Care of the Morbidly Obese Patient in the Lithotomy Position 

PURPOSE/GOAL

To educate perioperative nurses about perioperative care of patients who are morbidly obese and undergoing surgery in the lithotomy position.

OBJECTIVES

The Examination and Learner Evaluation are printed here for your convenience. To receive continuing education credit, you must complete the Examination and Learner Evaluation online at http://www.aorn.org/CE.

Questions 

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Learner Evaluation. Continuing Education Program 

Perioperative Care of the Morbidly Obese Patient in the Lithotomy Position 

This evaluation is used to determine the extent to which this continuing education program met your learning needs. Rate the items as described below.

Objectives 

To what extent were the following objectives of this continuing education program achieved?

Content 

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References 

1. Recommended practices for positioning the patient in the perioperative practice setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010;p. 327–350
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2. Graling PR, Colvin DB. The lithotomy position in colon surgery: postoperative complications. AORN J. 1992;55(4):1029–1039
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3. Centers for Disease Control and Prevention. FastStats: obesity and overweight. http://www.cdc.gov/nchs/fastats/overwt.htmAccessed May 14, 2010
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4. US Department of Health and Human Services. Weight-Control Information Network. Statistics related to overweight and obesity. http://win.niddk.nih.gov/statisticsAccessed May 14, 2010
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5. AORN bariatric surgery guideline. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010;p. 481–499
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6. Heizenroth PA. Positioning the patient for surgery. In:  Rothrock JC editors. Alexander's Care of the Patient in Surgery. 13th ed.. Philadelphia, PA: Mosby; 2008;p. 130–157
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7. AORN guidance statement: Safe patient handling and movement in the perioperative setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010;p. 673–695
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8. Petersen C. Positioning injury. In: Perioperative Nursing Data Set: The Perioperative Nursing Vocabulary. 3rd ed.. Denver, CO: AORN, Inc; 2010;p. 178–184
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9. Ide P, Farber ES, Lautz D. Perioperative nursing care of the bariatric surgical patient. AORN J. 2008;88(1):30–58
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   • Abstract
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