prep, dressing, draping the patient

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POSITIONING, PREPPING ANDDRAPING THE PATIENT


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Preliminary Considerations

Positioning for a surgical procedure isimportant to the patients outcome.

Proper positioning facilitates preoperativeskin preparation and appropriate drapingwith sterile drapes.


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Positioning requires a detailed knowledge of

anatomy and physiologic principles, asfamiliarity with the necessary equipment.

Safety is a prime consideration.


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Factors:

Age

Weight

Cardiopulmonary status

Pre-existing disease


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Pre-op patients should be assessed:

For alteration in skin integrity

Joint mobility

Vascular prosthesis


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Main Objective for Positioning

Optimize surgical site exposure for thesurgeon

Minimize risk for adverse physiologic effects

Facilitate physiologic monitoring by theanesthesia

Promote safety and security for the patient


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Responsibility for Patient

Positioning

Surgeon selects surgical position in

consultation with the anesthesia provider

Circulator or first assistant responsible for

placing the patient in a surgical position


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In essence, patient positioning is a sharedresponsibility among all team members.

The anesthesia provider has the final word onpositioning when the patients physiologicstatus and monitoring are in questioning.


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Factors that influence the time at

which the patient is positioned

Site of the surgical procedure

Age and size of the patient

Technique of anesthesia administration If the patient is conscious

Pain on moving

*The patient is not moved, positioned, orprepped until the anesthesia provider indicatesit is safe to do so.


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Preparation for Positioning

1. Review the proposed position by referring tothe position book and the surgeonspreference card in comparison with thescheduled procedure.

2. Ask the surgeon for guidance and assistanceif unsure how to position the patient.

3. Check the working parts of the operatingbed before bringing the patient into theroom.


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4. Assemble and check all table attachments andprotective pads anticipated for surgicalprocedure

5. Review the plan of care for unique needs of thepatient.


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Body Areas that need Padding

during PositioningSupine Position:

Occiput

Heels

Elbows

Sacrum


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Prone or Other Face Down Position

Anterior Knees of kneeling patient Face (particularly the forehead) and

Ears

Dorsum of foot to protect toes

Genitalia and breast


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Lateral Position

Face and Ears Medial Knees

Axilla

Ankles and feet

Arms


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Safety Measures

1. The patient is properly identified beforebeing transferred to the operating bed, andthe surgical site is affirmed according tofacility policy.

2. The patient is assessed for mobility status.

3. The operating bed and transport vehicle are

securely locked in position, with themattress stabilized during transfer to andfrom the operating bed.


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4. Two persons should assist an awake patientwith the transfer by positioning themselves

on each side of the patient transfer path.5. Adequate assistance in lifting unconscious,

anesthetized, obese, or weak patients is

necessary to prevent injury.6. The anesthesia provider guards the head of

the anesthetized patient at all times andsupports it during movement.

7. The physician assumes responsibility forprotecting unsplinted fracture duringmovement.


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8. The anesthetized patient is not movedwithout permission of the anesthesia

provider.9. The anesthetized patient is moved slowly and

gently to allow circulatory system to adjust

and to control the body during movement.10. No body part should extend beyond the

edges of the operating bed or contact metalparts or unpadded surfaces.

11. Body exposure should be minimal to preventhypothermia and preserve dignity.


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12. Movement & positioning should notobstruct or dislodge catheters, IV infusion

tubing, oxygen cannulas and monitors.13. The armboard is protected to avoid

hyperextending the arm or dislodging the IV

cannula.14. When patient is supine, the ankles and legs

must not be crossed.

15. When patient is prone, the thorax is relievedof pressure by using chest rolls to facilitatechest expansion with respiration.


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16. When patient is positioned lateral, a pillow isplaced lengthwise between the legs to preventpressure over bony prominences, blood vesselsand nerves. This also relieves pressure on thesuperior hip.

17. During articulation of the operating bed, the

patient is protected from crash injury at the flexpoints of the operating bed.

18. When the bed is elevated, the patients feet &

protuberant parts are protected from compressionof over-bed tables, mayo stands & frames.

19. Surfaces should not create pressure on body parts


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Anatomic and Physiologic

Considerations

1. Respiratory Considerations

*Unhindered diaphragmatic movement and apatent airway are essential for maintainingrespiratory function, preventing hypoxia, andfacilitating induction by inhalation.

*Chest excursion is a concern, becauseinspiration expands chest anteriorly.


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Considerations

Some hypoxia is always present in horizontalposition.

There should be no constriction around theneck or chest.

Patients arms must be on the sides notcrossed on the chest


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2. Circulatory Considerations

*Adequate arterial circulation is necessary formaintaining blood pressure, perfusing tissueswith oxygen, facilitating venous return, andpreventing thrombus prevention.

Occlusion and pressure on the peripheral bloodvessels are avoided.

Body restraints must not be fasten too tightly. Some drugs can cause constriction or dilatation

of blood vessels.


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3. Peripheral Nerve Consideration

*Prolonged pressure on or stretching of the

peripheral nerves can result in injuries that rangefrom sensory and motor loss to paralysis andwasting.

Most common sites of injuries: Brachial plexus

Ulnar

Radial Peroneal

Facial nerve


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4. Musculoskeletal Considerations When turning a patient, always keep the spine in

alignment by grasping the shoulder girdle andhip in a rolling fashion

Do not turn or elevate a patient by grasping onthe hip and twisting the spine


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5. Soft Tissue Consideration

*Body weight is distributed unevenly when thepatient lies on the operating bed. Weight that isconcentrated over bony prominence can causeskin ulcers and deep tissue injury. These areas

should be protected from constant pressureagainst hard surfaces.

*Wrinkled sheet and the edges of a positioningor other device under the patient can cause

pressure on the skin.Consideration:

Gel pads are preferred


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6. Accessibility of the Surgical Site

The surgical procedure & patient considerationdetermine the position in which the patient is

placed.

*To minimize trauma and operating time, the

surgeon must have adequate exposure of thesurgical site.


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7. Accessibility for Anesthetic Administration

*The anesthesia provider should be able toattach monitoring electrodes, administer theanesthetic and observe its effects, and maintain

IV access. *The patients airway is of prime concern and

must be patent and accessible at all times.

8. Individual Positioning Consideration


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Complications caused by

positioning

Hemodynamic instability by orthostatic

position Poor ventilation by thoracic compression

Peripheral nerve injury

Tissue damage Ischemia of hair-bearing scalps


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Pressure necrosis

Digit amputation in table bends

Blindness from optic nerve ischemia

Corneal abrasions

Venous emboli Vertebral Injury

Panic attacks and feeling of claustrophobia

in awake patient


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Equipments for Positioning

Operating Bed mostly consist of rectangulartops measuring 79 89 inches long by 20 -24inches wide

Hinged Sections: Head

Body

Leg


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Special Equipments and Bed

Attachments

Safety belts (thigh strap) to restrain legmovements during surgical procedure


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Anesthesia Screen a metal bar attaches

to the head of the operating bed andholds the drapes from the patients face


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Lift Sheet (Draw Sheet) a double-layer sheetplaced horizontally across the top of a clean

sheet on the operating bed

Armboard used to support the arm if IV fluid is

being infused, if the armor hand is the site of the

surgical procedure, if

the arm at the side wouldinterfere with access

to the surgical area


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Double armboard supports both arm

with one directly above the other n

lateral position


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Wrist or Arm strap narrow strap placedaround the wrist to secure the arms to thearmboard


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Upper Extremity Table for surgical procedureon an arm or hand; used in lieu of armboard

Shoulder Bridge (thyroid Elevator) headsection is temporarily removed and a metal bar

is slipped under a mattress between the headand the body section


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Shoulder Braces or Support placed

in metal clamps on the side of the

operating bed and slipped in from theedge of the bed


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Lateral Positioner (kidney rest)

concave metal pieces with grooved

notches at the base and placed underthe mattress on the body elevator

flexion of the operating bed.


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Body (hip) Restraint Strap helps to

hold the patient securely in a lateral

position


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Positioning for anal procedures with adhesivetape

- Patient is placed on prone position


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Adjustable arched spinal frame

consists of two padded arches mounted

on a frame that is attached to theoperating bed

Wilson spine frame


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Andrews spine frame


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Four-poster spine frame


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Stirrups supports the legs in the lithotomy

position


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Additional Types of Stirrups

Urologic Stirrups

Stirrups used for abdominal or perinealand obstetric procedures

Allen-style stirrups


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Headrests used with supine, prone,

sitting or lateral position


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Accessories

Donut (ring-shaped rubber) used during

procedures on the head or face to keepthe surgical area in a horizontal plane

Bolsters used to elevate specific parts of

the body


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Pressure Minimizing Matress minimizepressure on bony prominence, peripheral

blood vessels, and nerves during aprolonged procedure

Surgical Vacuum Positioning System soft pads filled with tiny beads are placedunder body parts to be supported.Vacuum is created inside the pad causingthe beads to press together


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Surgical positions

1. Supine (Dorsal) Position

- Patient lies flat on the back with arms securedat the side with the lift sheet and the palmsextend along the side of the body.


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Modifications:

Procedure on the face or neck

Shoulder or anterolateral procedures

Dorsal recumbent position

Modified dorsal recumbent

Arm extension

T d l b P iti


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2. Trendelenburgs Position

- Patient lies on his/her back in the supine position with kneesover the lower break of operating bed. The foot of operating

bed is lowered to the desired angle.- Used for procedures in the lower abdomen or pelvis when it

is desirable to tilt the abdominal viscera away from pelvicarea for better exposure.


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3. Reverse Trendelenburgs Position

- The patient lies in supine position and mattress

is adjusted adjusted so the surgical area is overthe elevator bridge on the operating bed

This position is used for thyroidectomy to

facilitate breathing and to decrease bloodsupply to the surgical site.

- It is also used for laparoscopic gallbladder,

biliary tract, or stomach procedures.

-


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4 Fowlers Position


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4. Fowlers Position

- The patient lies on his or her back with the

buttocks at the flex in the operating bed and theknees over the lower break, the foot of the bedlower slightly while the body section is raised 45degrees.

- May be used for shoulder, nasopharyngeal, facialand breast reconstruction procedure.


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Sitting Positionpatient is in fowlers positionexcept that the torso is in upright position.

- used on occasion for someotorhinologic ad neurosurgical procedure.

Beach Chair or Modified Sitting Position

- The patient is supine with the back and legsslightly elevated. The entire spine is slightlycontoured.


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5. Lithotomy Position

- Used for perineal, vaginal, endourologic, andrectal procedures

- The patients buttocks rest along the breakbetween the body and leg sections of the

operating bed


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Commonly Used Lithotomy

Position Low Lithotomy Standard Lithotomy

Hemi (Split) Lithotomy High Lithotomy

Exagerated Lithotomy

Tilted Low Lithotomy


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6. Prone Position

Patient is placed on abdomen. Chest rolls

are placed under axillae and sides of chestto level of the iliac crest to facilitaterespiration.

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prep, dressing, draping the patient