PATIENT POSITIONING

IN THE
OPERATING ROOM
 Goals of Proper Positioning
• To maintain patient’s airway
and avoid constriction or
pressure on the chest
cavity
• To maintain circulation
• To prevent nerve damage
• To provide adequate
exposure of the operative
site
• To provide comfort and
safety to the patient
 Overview
• RN must be aware of the anatomic and
physiologic changes associated with
anesthesia, patient positioning, and the
procedure.
• The following criteria should be met to
prevent injury from pressure, obstruction, or
stretching:
– No interference with respiration
– No interference with circulation
– No pressure on peripheral nerves
– Minimal skin pressure
– Accessibility to operative site
– Accessibility for anesthetic administration
– No undue musculoskeletal discomfort
– Maintenance of individual requirements
 Assessment
• The team should assess the following prior to
positioning of the patient:
– Procedure length
– Surgeon’s preference of position
– Required position for procedure
– Anesthesia to be administered
– Patient’s risk factors
• age, weight, skin condition, mobility/limitations,
pre-existing conditions, etc.
– Patient’s privacy and medical needs
– Basics of anatomy & physiology
 Team Responsibilities
Physician:
-Optimal procedural exposure
Anesthesia:
-Physiologic requirements (A-B-C’s)
-Position timing
Nursing:
-Safe transfer using adequate
personnel
-Use of adequate padding and
positioning aids
-Provide an ongoing assessment
 Surgical Positions
• Four basic • Variations include:
surgical positions – Trendelenburg
include: – Reverse
– Supine trendelenburg
– Prone – Fowler’s
– Lateral – Jackknife
– Lithotomy – 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
• Vulnerable Bony Prominences:
(due to rubbing and sustained pressure)
– Occiput, spine, scapula, Olecranon, Sacrum,
Calcaneous
 Prone
• Anesthetized supine, usually on the stretcher, prior to turning
• Turning is synchronized and supported
• Face down, resting on the abdomen and chest
• Chest rolls x2 placed lengthwise under the axilla and along the sides of
the chest from the clavicle to iliac crests (to raise the weight of the body
off of the abdomen and thorax)
• One roll is placed at the iliac or pelvic level
• Arms lie at the sides or over head on arm boards (must lower arms slowly
to the ground then bring them up in an arc to place on arm boards)
• Head is face down and turned to one side with accessible airway
• Forehead, eyes and chin are protected
• Padding to bilateral arms and under
knees
• Pillow placed under bilateral feet
(for maintenance of foot extension)
• Female breasts and male genitalia must
be free from pressure and torsion
• Safety strap placed 2” above knees
 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
 Fowler’s 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 patient’s 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 patient’s 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
patient’s buttocks further down to the
edge of the OR bed break
• Coordination with the anesthesia
care provider is necessary to ensure
that the patient’s 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 patient’s 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
 Effects of Positioning - Obese Patients
• Supine:
– Normal blood flow may be impeded due to compression of vena cava
and aorta by abdominal contents
– Impairs diaphragmatic movement and reduces lung capacity
• Trendelenburg:
– Tolerated less well than supine
– Added weight of abdominal contents on the diaphragm may lead to
atelectasis and hypoxemia
• 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
• Head-Up: (Reverse Trendelenburg/Semi-recumbent)
– 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 patient’s 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: Safety
Considerations:
• Pressure points: • Padding to heels, elbows,
– occiput;scapulae;thoracic knees
vertebrae;olecranon • Spine, head alignment with
process;sacrum/coccyx; hips
calcaneae;knees • Legs parallel, uncrossed at
ankles
Risk #2: Safety
• Neural injuries of Consideration:
extremities, brachial • Arm board at less than 90
degrees
plexus, ulna, radial nerves
• Head in neutral position
• Arm board pads level with
OR bed
 Prone
Risk #1: Safety Consideration:
– Maintain cervical neck
– Head, eyes, nose alignment
– Protection of forehead,
eyes, chin
– Padded headrest to provide
airway
Safety Consideration:
Risk #2: – Chest rolls to allow chest
– Chest compression, movement and decrease
iliac crest, breast, abdominal pressure
male genitalia – Breasts and genitalia free
from torsion
Risk #3: Safety Consideration:
– Padded with pillows
– Knees
Safety Consideration:
Risk #4:
– Padded footboard
– Feet
 Lateral
Risk #1: Safety Consideration:
– Bony prominences and – Axillary roll for
pressure points on dependent axilla
dependent side – Lower leg flexed at hip
– Upper leg straight with
pillow between legs
– Padding between knees,
ankles and feet
Risk #2: Safety Consideration:
– Spinal alignment – Maintain spinal alignment
during turning
– Padded support to
prevent lateral neck
flexion
 Lithotomy
Risk #1: Safety Consideration:
– Place stirrups at even height
– Hip/knee joint injury
– Elevate lower legs slowly and
– Lumbar/sacral pressure simultaneously from stirrups
– Vascular congestion
Safety Consideration:
Risk #2: – Maintain minimal external hip
– Neuropathy of obturator rotation
nerves, femoral nerves, – Pad lateral or posterior
common peroneal knees/ankles to prevent
nerves/ulnar nerves pressure and contact with
metal surface
Risk #3: Safety Consideration:
– Restricted diaphragmatic – Keep arms away from chest
movement to facilitate respiration
– Pulmonary region – Arms on arm boards at less
than 90 degree angle or over
abdomen
Documentation
• Documentation should include:
– Preoperative assessments
– Type and location of positioning and/or
padding devices
– Names and titles of persons positioning
the patient
– Intra-operative positioning changes
– Postoperative outcome evaluation
• Documentation includes nursing
assessments and interventions
• Documenting nursing activities
provides an accurate picture of the
nursing care provided as well as the
outcomes of the care delivered
• Document all of your findings
 Don’t Forget:
• Good positioning starts with an assessment
• Prevent surgical team members from leaning against patients
• Arm board pads should be level with table pads
• Cushioning of all pressure points is a priority - the correct use of
padding can protect the patient
• Procedures longer than 2 ½ to 3 hours significantly increase the
risk of pressure ulcer formation
• During a longer procedure, you should assist with shifting the
patient, adjusting the table, or adding/removing a positioning
device
• The nurse must assess extremities at regular intervals for signs
of circulatory compromise
• Documentation of the positioning process should be performed
accurately and completely
 One last note…
Positioning problems can result in
significant injuries and
successful lawsuits.