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From Wikipedia, the free encyclopedia Surgical positioning is to facilitate the surgeon's technical approach while balancing risk factors. Surgical techniques have been expanded by the flexibility provided by anesthesia methodology, so that new areas of the body have become accessible and new positions have been developed. All surgical positions carry some degree of position-related risk; these risks are increased in the anesthetized patient, who cannot make the clinician aware of compromised positions. The goal of providing the best surgical exposure is always balanced by the need to minimize the risk to the patient. COMMON INTRAOPERATIVE POSITIONS There are five standard positions (ie, supine, prone, lateral, sitting, lithotomy) commonly used for surgical procedures. Often, these intraoperative positions are modified according to surgeons' preferences, surgical approaches, and patients' physiologic requirements. Supine. When positioned supine (ie, dorsal recumbent), the patient is placed on his or her back on the OR bed. The patient's arms are tucked at the sides with the palms facing inward or extended on padded arm boards with the palms facing upward (Figure 9). The patient's spinal column should be in a straight line with his or her legs parallel to the OR bed. Supine positioning is used for abdominal, cardiac, peripheral vascular, and some orthopedic extremity procedures. Variations of the supine position include * Trendelenburg's position (ie, patient supine with head lowered, feet up), * reverse Trendelenburg's position (ie, patient supine with head up, feet lowered), and * modified supine position on the fracture table (ie, patient supine with one leg extended in traction, one leg placed in stirrup device) (Figure 10). Possible injuries. Pressure points vulnerable to skin breakdown in the supine position include the occiput, scapulae, thoracic vertebrae, olecranon (ie, elbow), sacrum, coccyx, and calcaneous (ie, heel). Pressure injuries to the patient's genitalia may occur after positioning on a fracture table. Neural injuries common with prolonged supine positioning involve the extremities (eg, brachial plexus injury, wrist drop, ulnar neuropathy, foot drop, pudendal nerve injury). Changing the patient's position from supine to Trendelenburg's or reverse Trendelenburg's also may place the patient at risk for shear injuries.(27) Physiologic responses. Supine positioning has less adverse effect on the patient's circulatory system than other surgical positions. The patient's respiratory efforts, however, may be impeded by decreased diaphragmatic movements secondary to pressure from abdominal contents, especially in Trendelenburg's position. Trendelenburg's position may adversely affect the patient's cardiac output because of mechanical compression of the heart and increased venous return from the lower extremities. Prone. When positioned prone, the patient is placed face down on the OR bed. The arms are placed at the patient's side, palms up or extended outward and upward on padded arm boards,
breasts. Possible injuries. one person lifts and supports the shoulders and chest. cheeks). orthopedic. nose. the anesthesia care provider controls the patient's head and neck. A minimum of four surgical team members use a draw sheet to lift and turn the patient onto his or her nonsurgical side (ie. Body rolls are placed anteriorly from the patient's shoulders to the pelvis to lift the chest off the OR bed to ensure adequate lung expansion during respiration. Specialty beds or accessory equipment (eg. eyes. clavicles. adrenalectomy). gastroesophageal. patient bed). He or she places a safety strap across the patient's hip and may apply two-inch adhesive tape across the patient's upper hip and fasten the ends of the tape to the OR bed for stability. lumbar laminectomy. neurosurgery.(28) Physiologic responses. knees. In most thoracotomy procedures. An adequate number of surgical team members is needed to support the patient's body alignment during transfer to the prone position because the patient must be turned as a single unit (ie. kidney. and retroperitoneal procedures. Prone positioning is used for surgical procedures that require access to the cervical. Modifications to the prone position include the jackknife (ie. foot drop. Sims's) is used for surgical procedures involving the upper chest. male genitalia.palms down. or upper areas of the ureter. one person controls the pelvis). and brachial plexus insults. During lateral chest positioning. thoracic. log rolled). lobectomy. reconstructive flap procedures. After the patient is intubated. The circulating nurse may place a bean bag device on the OR bed before the patient is transferred to the OR bed. decreased cardiac index and stroke volume. corneal abrasion. The patient's spinal column should be straight and in parallel alignment to the sides of the OR bed. In the left lateral position. the patient lies on the unaffected side to expose the surgical chest wall or flank. pyelolithotomy. the patient lies on his or her left side with the fight side placed upward. and toes at risk for pressure injuries. Positioning for thoracotomy procedure. lateral decubitis. and proctologic procedures (eg. and conjunctival edema. elbows. nephrectomy. surgical team members must transfer the patient to a prone position quickly to avoid airway compromise. The patient most likely will be anesthetized in the supine position on a transportation vehicle (eg. The circulating nurse places a pillow between the patient's legs and inserts padding under the ankles and feet to maintain proper alignment. ears. Possible neural injuries result from neck hyperextension. the patient's bottom leg is flexed for stability. neck. The circulating nurse ensures all movements are coordinated to prevent spinal injuries. resection. The prone position places the patient's face (ie. Lateral positioning is used for thoracotomy (eg. pyelostomy. alopecia. discectomy). Respiratory excursion can be limited severely unless the patient is positioned in a manner that supports the chest and pelvis while allowing the weight of the abdomen to fall away from the diaphragm. head. In the right lateral position. spinal fusion. iliac crests. and the . Lateral The lateral position (ie. Prone positioning subjects the patient's cardiac and respiratory systems to unique and unfamiliar requirements (eg. laminectomy frames) may be used to customize prone positions for different surgical approaches. the patient lies on his or her right side with the left side placed upward. one person moves the lower extremities. repair of aortic aneurysms). sigmoidoscopy. and retinal ischemia. with elbows flexed to prevent overextension of the shoulders (Figures 11 and 12). Kraske's) used for proctologic procedures (Figure 13) and the knee-chest and kneeling positions used for spinal procedures. lateral recumbent. hemorrhoidectomy. or lumbar spines (eg. renal (eg. The anesthesia care provider anesthetizes the patient in the supine position. Other potential injuries are facial. stretcher. fistula repair). increased systemic and pulmonary vascular resistance).
and maintain alignment of the spine. The circulating nurse ensures the patient's body is in a straight horizontal line from the shoulder to the hip. flexes the elbow. Possible injuries. the back of the OR bed is elevated to a vertical plane. removal of posterior spinal tumors) and posterior and lateral cranial procedures (eg. acromial process. The anesthesia care provider uses a pillow to support and align the patient's head. He or she places one or two pillows between the patient's legs and supports the feet with a pillow. rolled blankets. Possible injuries. back of the knee. pillows. and adhesive tape to maintain the patient in this position.(29) The patient's upper arm usually is placed on a padded overhead brace or an elevated arm board. Additional injuries associated with lateral positioning include corneal abrasions and shear injuries. coccyx. padded arm board. a foot board is placed perpendicular to the bed to support the patient's feet. and positioned in front of the patient on a padded arm board. and the patient is placed over the break in the OR bed. in a semisitting position). posterior fossa craniectomy. which may occur during flexion of the OR bed or initial positioning. The patient's head and back are elevated. modified Fowler's). tibial. a surgical procedure that requires access to a patient's neck or shoulder will require a semisitting position (ie. sandbags. and raised above the head at a 90-degree angle or less. The circulating nurse flexes the lower leg and extends the upper leg. the arms are secured on a pillow across the abdomen. although the legs may be positioned in two other ways: both legs flexed or the upper leg flexed and the lower leg straight. scapulae. Potential neural injuries may occur to the peroneal. ischial tuberosities. medial and lateral condyles. and places the arm on a padded arm board or near the patient's head on the OR bed. surgical team members take care to stabilize the patient's torso. He or she places the patient's upper arm on an elevated. Areas that may be affected by pressure injuries include the patient's occiput (ie. The sitting position usually involves the use of an over-bed frame that attaches to a skull pin fixation device. die knees are flexed. flexed. and maleolus. eye. surgical team members position the patient over the kidney elevator of the OR bed. Positioning for renal procedures. and . flexed slightly at the elbow. transsphenoidal procedures).top leg remains straight. avoid extreme flexion of the head. posterior cervical laminectomy. After the patient is anesthesized. He or she ensures the upper extremities are perpendicular to the patient's shoulder level to prevent shoulder injuries. At all times. "lawn chair" positioning) without the use of a skull pin device or overbed frame (Figure 15). greater trochanter. iliac crest. or suprascapular nerves and the brachial plexus. The circulating nurse may use padded kidney rests. The circulating nurse brings the lower shoulder slightly forward. In the sitting position (ie. and the legs are dependent. occipital and craniotomy procedures. Occasionally. The anesthesia care provider flexes the OR bed to lower the patient's head and legs. so that the area between the twelfth rib and the iliac crest is elevated when the OR bed is flexed and the kidney elevator is raised. ulnar.(30) Sitting. The sitting position is used for posterior cervical spine procedures (eg. The circulating nurse applies a safety strap across the patient's thigh so that the strap does not interfere with the surgical site. Areas susceptible to pressure injuries include the patient's dependent ear. He or she places a small roll or bolster under the lower axilla to facilitate lung expansion with respirations and to prevent compression of the scapula and brachial plexus. The circulating nurse places a small roll at the apex of the patient's scapula to relieve pressure on the dependent arm and allow chest movement with respirations. The upper arm also may be flexed gently at the elbow and brought forward to rest near the patient's head on the OR bed (Figure 14) The lower arm is brought forward slightly. anterior iliac spine. sacral.
The potential for injury to the patient's femoral. Lithotomy. and anterior tibial nerves as a result of inadequate padding and poor body alignment. are least desirable for extended lithotomy procedures. sequential. heels. and the arms are tucked at the sides or placed across the abdomen to prevent the patient's fingers from resting in the bed break (Figure 16). graduated) and attach the sleeves to a power unit before the start of surgery if the patient is to remain in the lithotomy position for more than two hours. The patient's buttocks are even with the lower break in the OR bed to prevent lumbosacral strain. Knee crutch stirrups compress calf muscles and the popliteal fossa more severely than ankle strap stirrups and. obstetric. Air can enter through skull pin sites and through open venous channels and sinuses in the exposed brain. dilatation and curettage. which results in pulmonary congestion and decreased tidal volumes. Hemodynamics are adversely affected by the sitting position.(33) Physiologic responses. deep vein thrombus formations. urologic. posterior tibial. obturator. hemorrhoidectomy. and saphenous nerves during lithotomy positioning is significant. as gravitational forces cause pooling of blood in the patient's lower extremities. and rectal (eg. Depending on the type of stirrup devices used (eg. sciatic. A compartment syndrome (ie. This will decrease blood pooling in calf muscles and prevent deep vein thrombus formations. One advantage of the sitting position is the positive effect on the patient's respiratory system. and behind the knees and lower legs. Lithotomy positioning is used for gynecologic (eg. The circulating nurse should apply antiembolism stockings and pneumatic compression sleeves (eg. Positioning injuries can occur to the patient's supra-scapular. and rectal areas. plantar surfaces of the feet. sigmoidoscopy.(31)" Physiologic responses.(32) Other possible dangers are hand injuries from fingers being trapped in hinges of the OR bed at the lower break point. Another potential sequela of the sitting position is the increased likelihood of air embolism due to negative venous pressure in the patient's head and neck. Blood . He or she also should warn surgical team members not to lean on the inner aspects of the patient's thighs to prevent drastic external hip rotations or flexions.calcaneous. and the sacrum. which can result in foot drop. elbows. Circulatory compromise begins with the gravitational flow of blood from the elevated legs to the splanchnic area during the surgical procedure. boot. Cerebral ischemia and hypotension are common complications found during surgical procedures that require sitting positions. repair of anal fistula) procedures and for radical resections of the groin. Possible injuries. pressure injuries can occur to the patient's ankles. increased internal pressure in the muscle compartment) in calf muscles also develops from lithotomy positions in which stirrup devices cause external pressure and prolong limb compressions. The most common injury is peroneal nerve damage on the lateral aspect of the patient's knee. intermittent. knee crutch). Lung excursion and diaphragmatic activity are facilitated by the unrestricted movement of die thoracic cavity. cervical biopsy). therefore. ulnar. Lithotomy positioning may result in respiratory and circulatory compromises. scapulae. sciatic. peroneal. The extreme flexion of the patient's thighs impairs respiratory function by increasing intraabdominal pressure against the diaphragm. ankle strap. where most of the patient's weight rests. vulva. Pressure injury sites are the patient's occiput. In the lithotomy position. vaginal hysterectomy. The anesthesia care provider and the surgeon monitor the patient for development of an air embolism via Doppler ultrasound readings and central venous line pressures. and nerve injury from severe external rotation or flexion of hip joints. the patient lies supine with his or her legs abducted and elevated in stirrup devices attached to the OR bed. peroneal.
The nurse also questions the patient about the condition of his or her skin. Preoperative patient care. or any other breaks in the skin's integrity. percutaneous nephrostomy catheters. During the preoperative interview and assessment. gastrostomy tubes. tubes. joint prostheses). Gravitational forces return 500 to 800 mL of blood to the patient's legs. or drains may compress against the patient's skin and the OR bed surface and cause pressure injuries. PERIOPERATIVE NURSING CONSIDERATIONS The safe positioning of patients for surgical procedures requires the cooperation of all surgical team members. the preoperative nurse routinely notes the patient's age. . lowering and raising both legs simultaneously prevents possible hip dislocations or lumbar muscle strain. It is used to relax tension of the abdominal muscles. Preexisting health conditions. prescribed medications. or they may be removed or repositioned inadvertently as a consequence of improper positioning. weight.loss may not be detected immediately during surgery because of increased splanchnic blood volume. specifically asking about skin areas that may be visually inaccessible during the interview because of wound dressings or privacy issues. The preoperative nurse also notes the patient's level of consciousness and his or her ability to follow instructions at the time of this assessment. laboratory test results. the free encyclopedia In medicine. and mobility impairments. Slow. presence or absence of peripheral pulses.(34) which depletes the circulating volume and decreases the patient's blood pressure. and to increase comfort during eating and other activities. Impaired skin integrity. abrasions. preexisting medical problems. It is also used in postpartum women to improve uterine drainage. baseline vital signs. Preoperative knowledge of the patient's general state of health also allows the nurse to assess the patient's risk for respiratory or cardiac complications related to surgical positioning. He or she questions the patient about the presence of stomas. In addition. The patient is placed in a semi-upright sitting position (45-60 degrees) and may have knees either bent or straight. Fowler's position From Wikipedia. Implanted devices also may cause pressure injuries if they are compressed against the surfaces of OR beds. Fowler's position is a standard patient position. catheters. External catheters. or implanted devices (eg. the preoperative nurse notes the patient's skin color and temperature and the presence of bruises. During visual skin inspection. ileostomy. Nurses implement appropriate perioperative nursing actions throughout all phases of patients' surgical experiences to prevent and minimize potential complications related to intraoperative surgical positioning. colostomy. pacemakers. range of motion of all extremities. Circulating blood volume may be depleted when the patient's legs are lowered to the OR bed at the end of the surgical procedure and blood is diverted quickly to the patient's peripheral circulation. Notation of the patient's preexisting health conditions and medication history aids the nurse in anticipating medications needed by the anesthesia care provider. skin condition. An abdominal stoma may be at risk for pressure injury from prone positioning and may require extra protection. urostomy. simultaneous positioning of the patient's legs at the beginning and end of the surgical procedure allows the body to adjust to shifting blood volumes. allowing for improved breathing in immobile patients as it alleviates compression of the chest due to gravity.
in contrast to the reverse Trendelenburg position. High Fowler's position is when the patient's head is raised 80-90 degrees. where the body is tilted in the opposite direction. Trendelenburg position From Wikipedia. It is not recommended for the treatment of hypovolaemic shock. Low Fowler's position is when the head of bed is elevated 15-30 degrees. and finally Fowler's which is 45-60 degrees. and Standard Fowlers (also known as simply "Fowler's"). It was named after the German surgeon Friedrich Trendelenburg. high Fowler's. Contents [hide] • • • • 1 Uses 2 See also 3 References 4 External links . whereas Semi-Fowler's position is when the patient's head is elevated 30-45 degrees. the free encyclopedia Old description of the Trendelenburg position.Such a position is maintained during procedures that involve either the nasal or oral passageways as it prevents aspiration during the introduction of feeding tubes and also promotes a slight gravitational pull in peristalsis when swallowing. There are several types of Fowlers positions: low. It allows better access to the pelvic organs as gravity pulls the intestines away from the pelvis. This is a standard position used in abdominal and gynecological surgery. In the Trendelenburg position the body is laid flat on the back (supine position) with the feet higher than the head by 15-30 degrees. semi-.
 "Supine is fine" is a good. Unsourced material may be challenged and removed. in which case they should be positioned on the side. Trendelenburg position is helpful in surgical reduction of an abdominal hernia. the Trendelenburg position is used in waterboarding. A 2005 literature review found the "Literature on the position was scarce. The legs of the patient may be straight or bent. Perhaps because of its effect on breathing difficulty and airway problems. It plays no role in the placement of a femoral central venous line. • • • • • • High Fowlers position From Wikipedia. and seemed to be guided by 'expert opinion. causes the brain to swell. Many experienced divers still believe this position is appropriate. but current scuba first aid professionals no longer advocate elevating the feet higher than the head. lacked strength. The Trendelenburg position is also used when placing a Central Venous Line. the free encyclopedia This article does not cite any references or sources. The Trendelenburg position used to be the standard first aid position for shock. However.'" A 2008 meta-analysis found adverse consequences to the use of the Trendelenburg position and recommended it be avoided. The Trendelenburg position in this case increases regurgitation and airway problems. . increases breathing difficulty.  Trendelenburg position uses gravity to assist in the filling and distension of the upper central veins when placing a central line in the internal jugular or subclavian veins. The patient's upper half of their body is between 60 degrees and 90 degrees in relation to the lower half of their body. The Trendelenburg position was used for injured scuba divers. Uses • People with hypotension (low blood pressure) have historically been placed in the Trendelenburg position in hopes of increasing their cerebral perfusion pressure (the blood pressure to the brain). Please help improve this article by adding citations to reliable sources. and has not been proven to be of any value. or it can be used to help rotate a posterior fetus either during pregnancy or the birth itself. or during the incidence of a prolapsed umbilical cord to take pressure off the cord and get more oxygen to the fetus. It is also used in the placement of an external jugular peripheral line for the same reason. (November 2010) The High Fowler's position is a position in which typically a patient in a hospital is placed when the head of the bed needs to be elevated as high as possible. The Trendelenburg position may be used in childbirth when a woman's cervix is too swollen and won't quite dilate to 10 centimeters. general rule for victims of submersion injuries unless they have fluid in the airway or are breathing. the passive leg raising test is a useful clinical guide to fluid resuscitation and can be used for effective autotransfusion.
etc. grooming. (at times) when a breathing treatment being given to the patient. when the patient is having difficulty breathing. High Fowlers position From Wikipedia. dependent drainage after abdominal surgery. grooming. the free encyclopedia This article does not cite any references or sources. radiology needing to take a specific type of x-ray at the bedside. The patient's upper half of their body is between 60 degrees and 90 degrees in relation to the lower half of their body.Contents [hide] • • • • 1 Purposes 2 See also 3 References 4 External links  Purposes This position is frequently used when feeding a patient (especially one on feeding precautions). etc. radiology needing to take a specific type of x-ray at the bedside. dependent drainage after abdominal surgery. The legs of the patient may be straight or bent. the free encyclopedia . Lithotomy position From Wikipedia. Please help improve this article by adding citations to reliable sources. (at times) when a breathing treatment being given to the patient. when the patient is having difficulty breathing. Unsourced material may be challenged and removed. Contents [hide] • • • • 1 Purposes 2 See also 3 References 4 External links  Purposes This position is frequently used when feeding a patient (especially one on feeding precautions). (November 2010) The High Fowler's position is a position in which typically a patient in a hospital is placed when the head of the bed needs to be elevated as high as possible.
the free encyclopedia (Redirected from Reverse Trendelenburg position) Old description of the Trendelenburg position. positioned above the hips. combined with a greater sensitivity to patient needs have raised awareness of the physical and psychological risks the position may pose for prolonged surgical procedures. talk. most notably. and spread apart through the use of stirrups. childbirth. The lithotomy position involves the positioning of an individual's feet above or at the same level as the hips (often in stirrups). the position is named after the ancient surgical procedure for removing kidney stones. References to the position have been found in some of the oldest known medical documents including versions of the Hippocratic oath (see lithotomy). The position is perhaps most recognizable as the 'often used' position for childbirth: the patient is laid on the back with knees bent. gall stones and bladder stones via the perineum. urology. The position is frequently used and has many obvious benefits from the doctor's perspective. as well as a common position for childbirth in Western nations. New observations and scientific findings. (help. Most notably the position provides good visual and physical access to the perineal region. The position is used for procedures ranging from simple pelvic exams to surgeries and procedures involving. get involved!) (July 2009) The lithotomy position is a medical term referring to a common position for surgical procedures and medical examinations involving the pelvis and lower abdomen. . Please help improve this article by checking for inaccuracies. Trendelenburg position From Wikipedia.This article may contain inappropriate or misinterpreted citations that do not verify the text. but not limited to reproductive organs. and. and gastrointestinal systems. with the perineum positioned at the edge of an examination table. pelvic examinations.
It was named after the German surgeon Friedrich Trendelenburg. lacked strength.In the Trendelenburg position the body is laid flat on the back (supine position) with the feet higher than the head by 15-30 degrees. However. It allows better access to the pelvic organs as gravity pulls the intestines away from the pelvis. It is not recommended for the treatment of hypovolaemic shock.  Trendelenburg position uses gravity to assist in the filling and distension of • • • • • • . in contrast to the reverse Trendelenburg position. The Trendelenburg position was used for injured scuba divers. increases breathing difficulty. the passive leg raising test is a useful clinical guide to fluid resuscitation and can be used for effective autotransfusion. A 2005 literature review found the "Literature on the position was scarce. Trendelenburg position is helpful in surgical reduction of an abdominal hernia. where the body is tilted in the opposite direction. and seemed to be guided by 'expert opinion. or it can be used to help rotate a posterior fetus either during pregnancy or the birth itself. or during the incidence of a prolapsed umbilical cord to take pressure off the cord and get more oxygen to the fetus.'" A 2008 meta-analysis found adverse consequences to the use of the Trendelenburg position and recommended it be avoided. causes the brain to swell. but current scuba first aid professionals no longer advocate elevating the feet higher than the head. The Trendelenburg position used to be the standard first aid position for shock. general rule for victims of submersion injuries unless they have fluid in the airway or are breathing. The Trendelenburg position is also used when placing a Central Venous Line. the Trendelenburg position is used in waterboarding. Contents [hide] • • • • 1 Uses 2 See also 3 References 4 External links  Uses • People with hypotension (low blood pressure) have historically been placed in the Trendelenburg position in hopes of increasing their cerebral perfusion pressure (the blood pressure to the brain). Many experienced divers still believe this position is appropriate. This is a standard position used in abdominal and gynecological surgery. The Trendelenburg position in this case increases regurgitation and airway problems. Perhaps because of its effect on breathing difficulty and airway problems. The Trendelenburg position may be used in childbirth when a woman's cervix is too swollen and won't quite dilate to 10 centimeters. "Supine is fine" is a good. and has not been proven to be of any value. in which case they should be positioned on the side.
Post partum perineal examination 2. Patient's right lower extremity is flexed at the hip. provides stability. 6. A study claims that people solve anagrams significantly faster when supine than when standing. 2. resting against bed surface or a pillow. as opposed to the prone position.  Detailed description The position is described as follows: 1. Patient's left lower extremity is straightened 3. Common uses 1. Sims' position From Wikipedia. Patient lies on their left side. The bent knee. 7.the upper central veins when placing a central line in the internal jugular or subclavian veins. It plays no role in the placement of a femoral central venous line. A man lying in the supine position /ˈsuːpaɪn/) is a position of the body: lying down with the face up. named after James Marion Sims is usually used for rectal examination. treatments and enemas. 8. The supine position ( . It is performed by having a patient lie on their left side. When used in surgical procedures. 5. sometimes with the hands behind the head or neck. From Wikipedia. thoracic and pericardial regions. the dorsal side is down. and the ventral side is up. as well as the head.Supine position 3. the free encyclopedia The Sims' position. Using terms defined in the anatomical position. it allows access to the peritoneal. the free encyclopedia 4. and right hip and knee bent. It is also used in the placement of an external jugular peripheral line for the same reason. and the leg is flexed at the knee. left hip and lower extremity straight. neck and extremities. which is face down.