Patient Positioning in OR

8/11/2019 Patient Positioning in OR

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POSITIONING IN

OPERATING THEATRE


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To determine the different positioning inoperating theatre

To give examples of procedures that

corresponds to the surgical position To know the nursing precautions and

potential complications of each surgical

positioning

OBJECTIVES


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SURGICAL POSITIONING


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The patient lies flaton his back The arms may be

placed beside the body, on an armboardor supported acrossthe chest by liftingup the gown which acts as sling

Most common Operative position, such as inLaparotomy, certain Gynecological and Orthopedic

cases

SUPINE OR DORSAL POSITION

SUPINE/DORSAL POSITION


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NURSING PRECAUTIONS POTENTIAL COMPLICATIONS

Head not Hyperextended Backache resulted fromunsupported lumbosacralcurvatureTo ensure that arms arenot abducted < 90 Paralysis of arm and hand dueto over abduction

Armboard is paddedHand in prone position

Radial or Ulnar nerve palsy dueto arm or elbow hanging ortight strapping

Arms do not overlap orhang over table edge

Patient protected frommetal contact Continuous pressure on thecalves may caused venous stasis

resulting thrombosis which canlead to Pulmonary Embolisms

Bony prominences are protected (occiput, scapulae,thoracic vertebrae, olecranaon,

sacrum and coccyx, calcaneus)


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PRONE POSITION

The patient lying with abdomen on table surface

Arms are placed above the head Pillows are placed under the shoulders, hips and feet Access for all surgeries involving posterior back

(cervical spine, back, rectal area and dorsal extremities)

PRONE POSITION


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Pillow or towel undershoulders and hipfacilitate chest expansion,reduce abdominal

pressure and venous

oozing at operation site

Lower neck and upper back pain resulting fromhyperextension of headRadial and ulnar nerve palsydue to arm restrainer

Hypotension resulted from pressure on inferior vena cavaand pooling of blood in lowerlimbs

Head not hyperextended, placed on side and keptsupportedPressure point are well

protected with pad (cheek,ear, acromion process,breast, genitalia, patella,dorsum of feet, toes)

Shoulder dislocation during arm positioningBrachial plexus injury due toover extension of arm < 90


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Patient lying in supine position with kneesover lower break of

the table Head tilted down to 15 or according to the surgeon

preferences

Arms may placed on the chest or armboard Common position for laparoscopic surgeries in pelvic or

lower abdominal region Using of shoulder or knee braces may benefit patient

from sliding

TRENDELENBURG POSITION

TRENDELENBURG POSITION


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Head not hyperextended and armnot abducted beyond 90

A 30 Trendelenburg position may causedchanges in blood pressure,cerebral edema, congestionof face and neck

Hands on padded armboards aresupinated

Arms not overlap the table edge or

hang over A too steep position mayresult in cyanosis due toalteration on diaphragmaticextension and lung

expansion

Patient is protected from metalcontact

Bony prominences are well

protected (occiput, scapulae,thoracic vertebrae, olecranon,

sacrum and coccyx and calcaneus)Shearing of skin mayoccurred during

positioningReturning leg first to reversevenous stasis


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REVERSE TRENDELEBURGPOSITION

Patient in supine position with arms by sides or on armboard

Table tilted to 5-10 raising the head

A sand bag may used below the neck and the shoulder blade for extension ofneck (RUSS TECHNIQUE)

The head stabilized by head ring Position often used for head and neck surgery to reduce

venous congestion To prevent stomach regurgitation during induction of

anaesthesia

REVERSETRENDELENBURG POSITION


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Head not hyperextended and arm notabducted beyond 90

Backache may result fromunsupported lumbosacral

curvatureHands on padded armboards aresupinated Paralysis may occurred due

to over abduction of armArms not overlap the table edge orhang over

Ulnar and radial palsy due toelbow or arm hanging overthe table or tight restraint

Patient is protected from metal contact

Bony prominences are well protected(occiput, scapulae, thoracic vertebrae,olecranon, sacrum and coccyx andcalcaneus)

Pulmonary embolisms as a

result of venous stasisCardiovascular overloadeddue to quick return

Anti embolic stocking may be used to prevent blood pooling

Skin shearing due to slidingdown

Foot bracket may used to preventsliding


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LITHOTOMY POSITION

Patient lies in supine position with buttocksat the lower break of

the table Lithotomy stirrups placed

in position level with patient ischial spine

Arms placed over the chest or on an armboard Legs are lifted together upwards and outwards and feet

placed in knee crutch or candy cane Common position for Urology, Gynecology, perineal or

rectal operations

LITHOTOMY POSITION


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Two person required to raisedthe legs simultaneously bygrasping the sole and otherhand supporting the calf

Severe backache caused by toohigh stirrups

Calf holder may resulted peroneal or femoral obturatornerve damageStirrups bars must be checked

and secure before use and itsheight must be similar and notsuspend the patient weight

Osteoarthritis or stiff hips dueto rough handling

Too quick of lowering the legsmay cause hypotensionThe buttock must be even with

the edge of bed to preventlumbosacral strain Femoral nerve damage due toacutely flexed thighsAnti embolic stocking may

used to promote venous return

Bony prominences protectedHip dislocation or fracture as aresult faulty stirrups


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TYPES OF STIRRUPS AND ITSHAZARDS

KNEE CRUTCH Pressure on peroneal nerveresulting footdrop andneuropathies

CANDY CANE Pressure on distalsural and

plantar nerves which cancause neuropathies of thefoot

Hyperabduction may

exaggerated flexion andstretch sciatic nerve BOOTH TYPE

May produce support moreevenly and reduce localized

pressure

KNEE CRUTCH

BOOTH TYPE

CANDY CANE


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Patient lying with one

side facing operativeside uppermost

The legs flexed to 90 and a pillow is placedin between

Upper arm rested onelevated arm rest and the other remains flexed on thetable or armboard

A roll bags may used below the hip/kidney to increasedexposure of iliac region

Position is maintained by use of sandbags or bracesattached to the side of bed

Head supported on a pillow

LATERAL OR KIDNEY POSITION

LATERAL/KIDNEY POSITION


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If table break is used, it must be correctly level with iliaccrest to prevent alteration inrespiration and severe post-operative backache

If the kidney rest raised toomuch, the lungs will not expand

adequately which will result incyanosis and hypotension

Injuries to brachial plexus,median, radial and ulnar nerves

can occur if upper arm is notsupported

Ensure ear is not trappedwhen supporting the headArms are supported withadequate padding to prevent

pressure necrosis

If the head is not supportedadequately, brachial plexus can

get stretchedPerineal nerve damage mayresulted from compression onthe down knee against hardsurface

Bony prominences are fully protected (ribs, iliac crest, greatertrochanter, medial and lateral femoralepicondyles, Tibial condyles, Malleous)


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NEUROSURGICAL POSITION

The patient may lyingin a supine position,

prone or lateral The head is positioned

either on soft ring or a

spiked head rest The head of the table may be tilted a little tofacilitate venous drainage and to reduce CSF

pressure in the brain

NEUROSURGICAL POSITION


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Ensure patient is fullyanaesthetized before

Similar complicationsas for prone and supine

positions positioning or insertion or headspike

Development of skin pressure over the ear,cheek or face if usinghead ring for severalhours (supine)

Eye are well covered and fully protected by pads

Position of spike must not harm patients ears and eyes

Face is protected from pressure

when in prone position Sciatic nerve damagemay result due to long

pressure on the dorsum

of the foots

Arms are in good anatomicalalignments

Bony prominences is protectedwhilst in all position


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Patient positioned insupine with the pelvisstabilized against well

padded vertical perineal post

Traction of operative leg is achieved either by boot-shaped cuff or devices with restraining straps

Un affected leg may be rested on well padded,elevated leg holder

Common position for ORIF of hip or closed femoralnailing

FRACTURE TABLE POSITION

FRACTURE TABLE POSITION


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Patient usually brought intotheatre with hospital bed and

traction applied

Pressure due to perineal post may injured genital

structureEnsure patient is anaesthetized

before transfer onto OT tableFecal incontinence andloss of perineal sensationmay occurred as a result of

pressure injury to perinealand pudendal nerve

Operating table are andattachments are ready accordingto surgeon preferences orstandard manual Tight strap may resulted

peroneal or femoralobturator nerve damageresulting in foot drop

Cautions and extra care regardingshear force injuries,musculoskeletal and nervoussystem during transfer

Bony prominences protected


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Patient lying into prone position

Both legs are abducted

and flexed togetherat right angles

Knees flexed and hipelevated

Head, shoulders and chest rest directly on the table Arms are placed above the head Primary position for sigmoidoscopies and laminectomy

procedure

KNEE-CHEST POSITION

KNEE-CHEST POSITION


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Legs moved together to prevent back strain

Lower neck and upper back pain due to hyperextended head

Arms gently lift up to prevent dislocation

Ulnar or radial nerve palsies asa result tight arm restrainer

Head is not hyperextended

and placed to the side on a pillow

Hypotension due to pressure on

inferior vena cava and poolingof blood at lower extremities

Bony prominences arewell protected (cheek, ear,

forehead, nose, eyes,acromion process, breast[women], genitalia, patella,dorsum of feet, toes)

Shoulder dislocation or brachial plexus injury when placing thearms

Patient may fall from table if bracket are not secure and fail

to support patients weight


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The patient positioned insupine with the upper body

part is flexed to 45 or 90

and the knees slightlyflexed and legs lowered

Arms may be placed overthe laps or armboard

A footrest is used to preventfootdrop and head spike to stabilized head

Useful position for craniotomies, shoulder or

breast reconstruction and ENTS

SEMI- FOWLERS AND FOWLERSPOSITION

SEMI- FOWLERS ANDFOWLERS POSITION


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The cervical, thoracic andlumbar section of spine must

be aligned once positionestablished

Orthostatic hypotension dueto blood pooling at lower

extremitiesRisk of venous thrombosisand embolisms as a result ofimpended venous return

Extra padding are requiresover bony prominences(coccyx, ischial tuberosities,calcaneus, elbows, knees and

scapulae)

High risk of development ofskin pressure over affected

bony prominences

The use of anti-embolismstocking may necessary toassist venous return

Alteration on chestmovement due to restrictionfrom rested arms or tight

straps

Reposition after surgery must

be done gently and slowly


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JACKNIFE POSITION

A modification of prone

position Patient hips are supported

on a pillow and the table

are flexed at 90 angle,raising the hips and lowering head and body

A straps used over the thigh to prevent shearing andsliding

The head, face, shoulders, chest and feet are supported bysoft pads or rolls to prevent bony pressure

Common position for hemorrhoidectomy or pilonidal

sinus procedures

JACKKNIFE POSITION(KRASKES)



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Pillow or towel under shouldersand hip facilitate chestexpansion and reducedabdominal pressure

Lower neck and upper back painresulting from hyperextensionof head

Injury to genitalia due to pressureAnti-embolisms stocking aid

venous return Radial and ulnar nerve palsy

due to arm restrainerHead not hyperextended, placedon side and kept supported Hypotension resulted from pooling of blood in lower limbsPressure point are well

protected with pad (cheek, ear,

acromion process, breast, genitalia, patella, dorsum of feet, toes)

Shoulder dislocation during arm

positioningBrachial plexus injury due toover extension of arm < 90

Patient turn using log-roll

technique end of procedure


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L iz Sparks an RN in Oklahoma

City, concludes, Its not allabout technique. Its aboutknowledge. I f you know whatcauses complications and how toprevent them, you wil l be more

likely to keep patient posi tioningin mind as something you shouldroutinely monitor.


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THANK YOU

Documents

Patient Positioning in OR