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Patient Positioning 2 1
Patient Positioning 2 1
IN THE
OPERATING ROOM
Overview
Assessment
The team should assess the following prior to
positioning of the patient:
Procedure length
Surgeons preference of position
Required position for procedure
Anesthesia to be administered
Patients risk factors
age, weight, skin condition, mobility/limitations,
pre-existing conditions, etc.
Patients privacy and medical needs
Basics of anatomy & physiology
Team Responsibilities
Physician:
Surgical Positions
Four basic
surgical positions
include:
Supine
Prone
Lateral
Lithotomy
Variations include:
Trendelenburg
Reverse
trendelenburg
Fowlers
Jackknife
High lithotomy
Low lithotomy
Supine
Most common with the least amount of harm
Placed on back with legs extended and uncrossed at the ankles
Arms either on arm boards abducted <90* with palms up or
tucked (not touching metal or constricted)
Spinal column should be in alignment with legs parallel to the OR
bed
Head in line with the spine and the face is upward
Hips are parallel to the spine
Padding is placed under the head, arms, and heels with a pillow
placed under the knees
Safety belt placed 2 above the knees while not impeding
circulation
Supine Concerns
Greatest concerns are circulation and pressure
points
Most Common Nerve Damage:
Brachial Plexus: positioning the arm >90*
Radial and Ulnar: compression against the OR bed,
metal attachments, or when team members lean
against the arms during the procedure
Peroneal and Tibial: Crossing of feet and plantar
flexion of ankles and feet
Prone
Prone Concerns
Greatest concerns are to the
respiratory and circulatory systems and
pressure points
Most Common Nerve Damage:
Brachial, radial, median, ulnar
Vulnerable Bony Prominences:
Temporal, acromion, clavicle, iliac
Vulnerable Vessels:
Carotid, aorta, vena cava, saphenous
Susceptible to hyperextension of
the joints
Lateral
Anesthetized supine prior to turning
Shoulder & hips turned simultaneously to prevent torsion of the
spine & great vessels
Lower leg is flexed at the hip; upper leg is straight
Head must be in cervical alignment with the spine
Breasts and genitalia to be free from torsion and pressure
Axillary roll placed to the axillary area of the downside arm (to
protect brachial plexus)
Padding placed under lower leg, to ankle and foot of upper leg,
and to lower arm (palm up) and upper arm
Pillow placed lengthwise between
legs and between arms (if lateral
arm holder is not used)
Stabilize patient with safety
strap and silk tape, if needed
Lateral Concerns
Greatest concerns are respiratory,
circulatory, and pressure points
Most Common Nerve Damage:
Brachial, radial, median, ulnar, peroneal
Vulnerable Bony Prominences:
Temporal, acromion, olecranon, iliac,
greater trochanter
Vulnerable Vessels:
Carotid, axillary, brachial, aorta,
vena cava, saphenous
Trendelenburg
The patient is placed in the supine position while the
OR bed is modified to a head-down tilt of 35 to 45
degrees resulting in the head being lower than the
pelvis
Arms are in a comfortable position either at the
side or on bilateral arm boards
The foot of the OR bed is lowered to a desired angle
Velcro adhesive MUST be checked prior to placing
the patient on the table padding
Surgical tape may be indicated to assure the table
padding is fixed to the table to prevent pad slippage
Trendelenburg
In addition to a safety strap, strips of 3 tape may be
used to assist with holding the patient in the proper
position
Used for procedures in the lower abdomen or pelvis
Enables the abdominal viscera to be moved away
from the pelvic area for better exposure
Trendelenburg
Concerns
Lung volume is decreased
The pressure of the organs against
the diaphragm mechanically
compresses the heart
Reverse Trendelenburg
The entire OR bed is tilted so the head is higher than
the feet
Used for head and neck procedures
Facilitates exposure, aids in breathing and decreases
blood supply to the area
A padded footboard is used to prevent the patient
from sliding toward the foot
Fowlers Position
(Sitting/Lawnchair/Beachchair)
Patient begins in the supine position
Foot of the OR bed is lowered slightly, flexing the knees, while the
body section is raised to 35 45 degrees, thereby becoming a
backrest
The entire OR bed is tilted slightly with the head end downward
(preventing the patient from sliding)
Feet rest against a padded footboard
Arms are crossed loosely over
the abdomen and taped or placed on
a pillow on the patients lap
A pillow is placed under the knees.
For cranial procedures, the head is
supported in a head rest and/or
with sterile tongs
This position can be used for
shoulder or breast reconstruction
procedures
Jackknife
Modification of the prone position
The patient is placed in the prone position on the OR bed and then
inverted in a V position
The hips are over the center break of the OR bed between the body
and leg sections
Chest rolls are placed to raise the chest
Arms are extended on angled arm boards with the elbows flexed and
the palms down
A pillow is placed under the ankles to free the feet and toes of
pressure
The OR bed leg section is
lowered, and the OR bed is
flexed at a 90 degree angle
so that the hips are elevated
above the rest of the body
Used in gluteal and anorectal
procedures
Lithotomy
With the patient in the supine position, the legs are raised and
abducted to expose the perineal region
The patients buttocks are even with the lower break in the OR
bed (to prevent lumbosacral strain)
The arms are placed on padded arm boards, tucked at the sides,
or placed across the abdomen
The legs and feet are placed in stirrups that support the lower
extremities
Stirrups should be placed at an even height
The legs are raised, positioned, and lowered slowly and
simultaneously, with the permission of the anesthesia care
provider
Adequate padding and support for the legs/feet should eliminate
pressure on joints and nervus plexus
The position must be symmetrical
The perineum should be in line with the longitudinal axis of the
OR bed
The pelvis should be level
The head and trunk should be in a straight line
High Lithotomy
Frequently used for procedures that requires a vaginal or
perineal approach
The patient is in the supine position with legs raised and
abducted by stirrups
Once the feet are positioned in stirrups, the footboard is
removed and the bottom section of the OR bed is lowered
It may be necessary to bring the
patients buttocks further down to the
edge of the OR bed break
Coordination with the anesthesia
care provider is necessary to ensure
that the patients hands/fingers are
protected from crushing prior to
lowering of the bottom of the OR bed
section
Low Lithotomy
All of the positioning techniques used to high
lithotomy apply
Placed in supine position with the legs raised and
abducted in crutch-like or full lower leg support
stirrups
The angle between the patients thighs and trunk is
not as acute as for the high lithotomy position
Used in vaginal procedures
Lithotomy Concerns
Particular attention needs to be
given to the popliteal space behind
the knee where the legs rest in the
stirrups
Trendelenburg:
Prone:
Problematic
Requires additional support and monitoring of the patient and
pressure on the abdomen
Ventilation may be markedly more difficult
Lateral:
Well tolerated
Correct sizing and placement of axillary roll is important
Ensure that pendulous abdomen does not hang over side of OR bed
Most safe
Weight of abdominal contents unloaded from diaphragm
Use of well-padded footboard to prevent sliding
Key Points
Use safe body mechanics during transfers and
positioning ensure adequate assistance is
used
Maintain stretcher/bed in a locked position
prior to patient transfers and positioning
Verify weight limit on OR table to be used
Ensure that the patient is adequately secured
to the OR table
One strap placed across the patients thighs
and the second across the lower legs
Extra care must be taken to ensure that loose
skin is protected (ie lithotomy position)
Safety
Considerations
Supine
Risk #1:
Pressure points:
occiput;scapulae;thoracic
vertebrae;olecranon
process;sacrum/coccyx;
calcaneae;knees
Risk #2:
Neural injuries of
extremities, brachial
plexus, ulna, radial nerves
Safety
Considerations:
Safety
Consideration:
Prone
Risk #1:
Risk #2:
Chest compression,
iliac crest, breast,
male genitalia
Risk #3:
Knees
Risk #4:
Feet
Safety Consideration:
Maintain cervical neck
alignment
Protection of forehead,
eyes, chin
Padded headrest to provide
airway
Safety Consideration:
Safety Consideration:
Padded with pillows
Safety Consideration:
Padded footboard
Lateral
Risk #1:
Risk #2:
Spinal alignment
Safety Consideration:
Axillary roll for
dependent axilla
Lower leg flexed at hip
Upper leg straight with
pillow between legs
Padding between knees,
ankles and feet
Safety Consideration:
Maintain spinal alignment
during turning
Padded support to
prevent lateral neck
flexion
Lithotomy
Risk #1:
Safety Consideration:
Risk #2:
Safety Consideration:
Risk #3:
Safety Consideration:
Restricted diaphragmatic
movement
Pulmonary region
Documentation
Dont Forget: