PATIENT POSITIONINGIN THE OPERATING ROOM

Goals of Proper PositioningTo maintain patients airway and avoid constriction or pressure on the chest cavityTo maintain circulationTo prevent nerve damageTo provide adequate exposure of the operative siteTo provide comfort and safety to the patient

OverviewRN 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 respirationNo interference with circulationNo pressure on peripheral nervesMinimal skin pressureAccessibility to operative siteAccessibility for anesthetic administrationNo undue musculoskeletal discomfortMaintenance of individual requirements

AssessmentThe team should assess the following prior to positioning of the patient:Procedure lengthSurgeons preference of positionRequired position for procedureAnesthesia to be administeredPatients risk factors age, weight, skin condition, mobility/limitations, pre-existing conditions, etc.Patients privacy and medical needsBasics of anatomy & physiology

Team Responsibilities Physician:-Optimal procedural exposureAnesthesia:-Physiologic requirements (A-B-Cs)-Position timingNursing:-Safe transfer using adequate personnel-Use of adequate padding and positioning aids-Provide an ongoing assessment

Surgical PositionsFour basic surgical positions include:SupineProneLateralLithotomy

Variations include:TrendelenburgReverse trendelenburgFowlersJackknifeHigh lithotomyLow lithotomy

SupineMost common with the least amount of harmPlaced on back with legs extended and uncrossed at the anklesArms either on arm boards abducted

Supine Concerns Greatest concerns are circulation and pressure pointsMost 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 procedurePeroneal 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 turningTurning is synchronized and supportedFace down, resting on the abdomen and chestChest 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 levelArms 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 airwayForehead, eyes and chin are protected Padding to bilateral arms and under

kneesPillow 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 ConcernsGreatest concerns are to the respiratory and circulatory systems and pressure pointsMost Common Nerve Damage:Brachial, radial, median, ulnarVulnerable Bony Prominences:Temporal, acromion, clavicle, iliacVulnerable Vessels:Carotid, aorta, vena cava, saphenousSusceptible to hyperextension of

the joints

Lateral Anesthetized supine prior to turning Shoulder & hips turned simultaneously to prevent torsion of the spine & great vesselsLower leg is flexed at the hip; upper leg is straightHead must be in cervical alignment with the spineBreasts and genitalia to be free from torsion and pressureAxillary 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 armPillow 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 pointsMost Common Nerve Damage:Brachial, radial, median, ulnar, peronealVulnerable Bony Prominences:Temporal, acromion, olecranon, iliac, greater trochanterVulnerable Vessels:Carotid, axillary, brachial, aorta,

vena cava, saphenous

TrendelenburgThe 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 pelvisArms are in a comfortable position either at the side or on bilateral arm boardsThe foot of the OR bed is lowered to a desired angleVelcro adhesive MUST be checked prior to placing the patient on the table paddingSurgical 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 positionUsed 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 decreasedThe 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 feetUsed for head and neck proceduresFacilitates exposure, aids in breathing and decreases blood supply to the areaA padded footboard is used to prevent the patient from sliding toward the foot

Fowlers Position (Sitting/Lawnchair/Beachchair) Patient begins in the supine positionFoot of the OR bed is lowered slightly, flexing the knees, while the body section is raised to 35 45 degrees, thereby becoming a backrestThe entire OR bed is tilted slightly with the head end downward (preventing the patient from sliding)Feet rest against a padded footboardArms are crossed loosely over

the abdomen and taped or placed on a pillow on the patients lapA pillow is placed under the knees.For cranial procedures, the head is

supported in a head rest and/or with sterile tongsThis position can be used for

shoulder or breast reconstruction procedures

Jackknife Modification of the prone positionThe patient is placed in the prone position on the OR bed and then inverted in a V positionThe hips are over the center break of the OR bed between the body and leg sectionsChest rolls are placed to raise the chestArms are extended on angled arm boards with the elbows flexed and the palms downA pillow is placed under the ankles to free the feet and toes of

pressureThe 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 bodyUsed in gluteal and anorectal

procedures

Lithotomy With the patient in the supine position, the legs are raised and abducted to expose the perineal regionThe 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 abdomenThe legs and feet are placed in stirrups that support the lower extremitiesStirrups should be placed at an even heightThe legs are raised, positioned, and lowered slowly and simultaneously, with the permission of the anesthesia care providerAdequate padding and support for the legs/feet should eliminate pressure on joints and nervus plexusThe position must be symmetricalThe perineum should be in line with the longitudinal axis of the OR bedThe pelvis should be levelThe head and trunk should be in a straight line

High Lithotomy Frequently used for procedures that requires a vaginal or perineal approachThe patient is in the supine position with legs raised and abducted by stirrupsOnce the feet are positioned in stirrups, the footboard is removed and the bottom section of the OR bed is loweredIt may be necessary to bring the

patients buttocks further down to the edge of the OR bed breakCoordination with the anesthesia

care provider is necessary to ensure that the patients hands/fingers areprotected from crushing prior to lowering of the bottom of the OR bed section

Low Lithotomy All of the positioning techniques used to high lithotomy applyPlaced in supine position with the legs raised and abducted in crutch-like or full lower leg support stirrupsThe angle between the patients thighs and trunk is not as acute as for the high lithotomy positionUsed 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 PatientsSupine:Normal blood flow may be impeded due to compression of vena cava and aorta by abdominal contentsImpairs diaphragmatic movement and reduces lung capacityTrendelenburg:Tolerated less well than supineAdded weight of abdominal contents on the diaphragm may lead to atelectasis and hypoxemiaProne:ProblematicRequires additional support and monitoring of the patient and pressure on the abdomenVentilation may be markedly more difficultLateral:Well toleratedCorrect sizing and placement of axillary roll is importantEnsure that pendulous abdomen does not hang over side of OR bedHead-Up: (Reverse Trendelenburg/Semi-recumbent)Most safeWeight of abdominal contents unloaded from diaphragmUse of well-padded footboard to prevent sliding

Key PointsUse safe body mechanics during transfers and positioning ensure adequate assistance is usedMaintain stretcher/bed in a locked position prior to patient transfers and positioningVerify weight limit on OR table to be usedEnsure that the patient is adequately secured to the OR tableOne strap placed across the patients thighs and the second across the lower legsExtra care must be taken to ensure that loose skin is protected (ie lithotomy position)

Safety Considerations

SupineRisk #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:Padding to heels, elbows, kneesSpine, head alignment with hipsLegs parallel, uncrossed at ankles

Safety Consideration:Arm board at less than 90 degreesHead in neutral positionArm board pads level with OR bed

ProneRisk #1:Head, eyes, nose

Risk #2:Chest compression, iliac crest, breast, male genitalia

Risk #3:Knees

Risk #4:Feet

Safety Consideration:Maintain cervical neck alignmentProtection of forehead, eyes, chinPadded headrest to provide airway

Safety Consideration:Chest rolls to allow chest movement and decrease abdominal pressureBreasts and genitalia free from torsion

Safety Consideration:Padded with pillows

Safety Consideration:Padded footboard

LateralRisk #1:Bony prominences and pressure points on dependent side

Risk #2:Spinal alignment

Safety Consideration:Axillary roll for dependent axillaLower leg flexed at hipUpper leg straight with pillow between legsPadding between knees, ankles and feet

Safety Consideration:Maintain spinal alignment during turningPadded support to prevent lateral neck flexion

Lithotomy

Risk #1:Hip/knee joint injuryLumbar/sacral pressureVascular congestion

Risk #2:Neuropathy of obturator nerves, femoral nerves, common peroneal nerves/ulnar nerves

Risk #3:Restricted diaphragmatic movementPulmonary region

Safety Consideration:Place stirrups at even heightElevate lower legs slowly and simultaneously from stirrups

Safety Consideration:Maintain minimal external hip rotationPad lateral or posterior knees/ankles to prevent pressure and contact with metal surface

Safety Consideration:Keep arms away from chest to facilitate respirationArms on arm boards at less than 90 degree angle or over abdomen

Documentation

Documentation should include:Preoperative assessmentsType and location of positioning and/or padding devicesNames and titles of persons positioning the patientIntra-operative positioning changesPostoperative outcome evaluationDocumentation includes nursing assessments and interventionsDocumenting nursing activities provides an accurate picture of the nursing care provided as well as the outcomes of the care deliveredDocument all of your findings

Dont Forget:Good positioning starts with an assessmentPrevent surgical team members from leaning against patientsArm board pads should be level with table padsCushioning of all pressure points is a priority - the correct use of padding can protect the patientProcedures longer than 2 to 3 hours significantly increase the risk of pressure ulcer formationDuring a longer procedure, you should assist with shifting the patient, adjusting the table, or adding/removing a positioning deviceThe nurse must assess extremities at regular intervals for signs of circulatory compromiseDocumentation of the positioning process should be performed accurately and completely

One last notePositioning problems can result in significant injuries and successful lawsuits.