2.7.

Surgical Positions
The perioperative Registered Nurse is responsible for:

PRACTICE RATIONALE

2.7.1 Applying knowledge of the various surgical
positions and the impact of the positions on
the circulatory, respiratory, musculoskeletal
and neurological body systems; and being a
patient advocate throughout the positioning
process.
The position should be consistent with proper
anatomical alignment and physiological
functioning in order to promote the safety and
comfort of the patient during surgery.
Under general anesthesia, patients are unable to
indicate when there is a problem.

2.7.2 Assessing the patient's positioning needs To promote patient safety and comfort.
prior to transferring the patient to the OR
bed. The assessment shall include patient
and intra-operative factors.

Patient factors include, but are not

limited to:
- age, height and weight;
- skin condition;
- nutritional status;
- pre-existing conditions (vascular,
respiratory, circulatory, neurological,
and immunocompromised); and
- physical/mobility limits (i.e., range
of motion, implants, prostheses, etc).
Intra-operative factors include, but are not
limited to:
- type of anesthesia;
- length of surgery; and
- position required.

2.7.3 Confirming adequate staff are available and The circulating perioperative Registered Nurse
trained for transferring patients to and from monitors safety of the patient at all times. Transfer
the OR bed. The OR bed and stretcher/bed/ devices assist in protecting staff and patients from
wheelchair shall be locked in place. injury.
Transfer devices are recommended for
patients with a mobility deficit including
but not limited to patients post general
anesthesia;

2.7.4 Confirming that the patient is not left Protection from potential injury is essential.
unattended on the OR bed;

2.7.5 Confirming that a safety strap is applied Safety measures help prevent injury.
prior to induction;

2.7.6 Confirming that arm boards are secure on

 PRACTICE RATIONALE

the OR bed prior to induction. Each arm

board should have a security device for Padding the elbow reduces the risk of ulnar nerve
hand/wrist to prevent the arm from falling damage. Additional padding may not be required;
off the arm board during the procedure. follow bed manufactures’ recommendations.
Ulnar nerve padding shall be used under the
arm before the security device is employed;
- the arm board shall not be extended Brachial plexus damage may result from
greater than a 90º angle. hyperextension of the arm over 90º.
- The height of the arm board mattress
should align with the OR bed mattress;

2.7.7 Being aware of the function and use of the Properly functioning equipment and devices
OR bed and accessories. Following contribute to patient safety and assist in providing
equipment manufacturer’s instructions. adequate exposure of the surgical site.
Selection criteria for positioning equipment
and devices include but are not limited to:
- availability in a variety of
appropriate shapes and sizes;
- ability to allow normal capillary
interface pressure;
- resistance to moisture
and microorganisms;
- fire resistance;
- non-allergenic to the patient;
- ease of use;
- durable material and design;
- radiolucency;
- easily cleaned and disinfected (if not
disposable);
- easily stored, handled, and
retrieved; and
- cost effectiveness.
2.7.8 Having available the appropriate OR table Firm and stable devices help distribute pressure
and positioning equipment and devices evenly and decrease the potential for injury.
which are in proper working order prior to Patient safety may be compromised if
positioning the patient for surgery; appropriate equipment not used.

2.7.9 Collaborating with the anesthesiologist and Surgical positioning of the patient is a shared
the surgeon when positioning the patient for responsibility. Maintaining the patient's correct body
surgery; alignment and supporting extremities and joints
decreases the potential for injury during transfer and
positioning. (AORN, 2010)
2.7.10 Confirming safety precautions related to
positioning in the supine position have been
implemented. Measures include but not
limited to:
- elbows are padded and placed either
comfortably at the side with the palm
facing the thigh and secured using a
sheet or an arm support; or on an arm
 PRACTICE RATIONALE

board and secured; and

- feet/legs are not crossed This prevents circulatory impairment that could
result in pressure sores or nerve damage
2.7.11 Confirming safety precautions related to
positioning the patient in lithotomy position
are implemented. Measures include but not
limited to:
- Stirrups shall be securely attached to the
bed at a uniform height;
- legs shall be raised/lowered
simultaneously in a slow Prevents muscle strain.
controlled manner (with 2 people); Maintains hemodynamic status.
padding shall be applied to any part of
the leg or foot which comes in contact Injury to the peroneal nerve can occur.
with the stirrups. Legs should not come
in contact with the post of stirrups;
- verify position of hands/fingers as foot Fingers can become pinched by the hinged section of
of OR bed is manipulated both at the the OR bed during movement of the bottom section
beginning and end of the procedure; of the bed.
- scrubbed personnel shall not lean on
the patients legs/thighs; and
- hips shall not extend beyond the end of Avoids muscle strain.
the OR bed.

2.7.12 Confirming safety precautions related to

positioning the patient in prone position
are implemented. Measures include but
not limited to:
- sufficient staff shall be available to
safely turn a patient into the prone Reduces risk of injury for both patient and staff.
position allowing cervical and general
body alignment to be maintained;
- padded head rest shall be used; Reduces direct pressure on the eyes. Allows
- arms shall be tucked at the side or access for airway management.
placed on arm boards(less than
90 degrees);
- prone positioning devices(i.e. bolsters)
shall allow for chest movement and not Respiratory function may be affected.
apply pressure to the abdomen; and
- feet shall be supported so the toes
can hang freely.

2.7.13 Confirming safety precautions related to

positioning the patient in lateral position
are implemented. Measures include but not
limited to:
- sufficient staff shall be available to
safely turn a patient into the lateral
position allowing general body
alignment to be maintained;
- anesthesia controls the patient’s head Maintains alignment of cervical and thoracic spine.
 PRACTICE RATIONALE

and neck as the patient is turned

maintaining the airway;
- the head is placed on a pillow or donut
positioning device;
- for kidney procedures, the iliac crest is
positioned just below the break in the
- OR bed;
- the lower leg is flexed with Protects peroneal nerve from damage.
knee padded;
- the upper leg is straight and placed on Maintains alignment
pillow(s);
- the upper arm should be placed on an arm
board or pillows, and secured; depending
on the procedure being done,
- the lower shoulder should be Reduces pressure on the brachial plexus and can
slightly forward, with a roll just facilitate chest expansion.
posterior to axilla; and
- positioning devices such as vac
mattresses, peg boards, etc. should be
padded wherever they come in
contact with the patient.

2.7.14 Confirming safety precautions related to

positioning the patient in Trendelenburg
position are implemented. Measures include
but not limited to:
- knees should be positioned over The foot of the bed may be adjusted to maintain
the break in the OR bed; position.
- shoulder braces should only be used if High risk of injury to brachial plexus.
absolutely necessary, and must be
well padded if used;
- after positioning, ensure there is no
pressure on the feet by the mayo or
over bed table; and
- movement into and out of Trendelenburg position increases intrathoracic and
trendelenburg should be done slowly to intracranial pressure.
allow respiratory and circulatory
systems to adjust to changes.

2.7.15 Confirming safety precautions related to

positioning the patient in reverse
Trendelenburg position are implemented.
Measures include but not limited to:
- padded foot board may be used; and
- sequential compression Reduces venous stasis.
stockings/devices may be used

2.7.16 Confirming safety precautions related to

positioning the patient in sitting or semi-
sitting position are implemented. Measures
include but not limited to:
 PRACTICE RATIONALE

- arms should always be supported;

- all pressure points shall be padded with These points are supporting the weight of
special attention to the ischial upper body.
tuberosities and sacrum;
- the patient shall be secured to the table
which is providing support to the upper
torso with a strap or tape;
- the head shall be supported with a head Maintains alignment and eliminates movement
rest such as a cranial headrest; and during surgery.
- sequential compression devices Reduces venous stasis.
should be used.

2.7.17 Implementing measures, which reduce the

risk of injury to the patient or the healthcare
team when positioning morbidly obese
patients. Measures include but not limited
to:
- confirming that positioning equipment
as well as the OR table is designed to
be safely used with morbidly obese
patients. Table extensions may be
required depending on the patient’s
size. Thicker mattress may be needed to
provide adequate support, extra wide,
extra long safety straps;
- all OR tables should be labeled with
maximum weight restrictions; and
- an adequate number of staff to
safely position patient,

2.7.18 Limiting exposure of patient's body during Maintaining the dignity and privacy of the patient
positioning. is important, and covering also assists in preventing
loss of body temperature.

2.7.19 In collaboration with anesthesiologist and
surgeon, evaluate the patient's body
alignment and tissue integrity after
positioning. The evaluation should include
but not be limited to the following systems:
- Respiratory;
- Circulatory;
- Neurological;
- Musculoskeletal; and
- Integumentary.
After repositioning or any movement of
the patient, OR bed, or devices the patient
should be re-assessed for body alignment
and assessment of pressure points by the
surgical team.
Respiratory function can be decreased by mechanical
restriction of the rib cage. Circulatory function is
influenced by anesthetic agents and surgical
techniques that may result in vasodilatation,
hypertension, decreased cardiac output, and
inhibition of normal compensatory mechanisms.
Nerve and muscle trauma result from stretching or
compression when upper extremities are abducted at
greater than 90 degrees to the body, hips are placed in
excessive external rotation, and/or the head and neck
is hyper-flexed or hyper-extended. Skin injury is a
function of unrelieved pressure, duration of the
pressure, and the location of the pressure on the body
surface. Both high pressure for a short duration and
low pressure for extended duration are risk factors.
Other extrinsic factors for skin injury are shear forces
and friction. (AORN, 2010, p. 343)
 PRACTICE RATIONALE

2.7.20 Documentation including but not limited to: Documentation provides an accurate picture of the
- preoperative assessment; patient's status and surgical position during surgery.
- type of position and any changes
of position;
- type and location of
positioning/padding devices;
- postoperative assessment; and
- healthcare team members involved in
positioning the patient.

2.7.21 Actively participating in the healthcare Awareness reduces risk.

facility’s, Falls Prevention program.

REFERENCES

Association of PeriOperative Registered Nurses. (2010). Recommended practices for positioning the patient in
the perioperative practice setting. Perioperative Standards and Recommended Practices. Denver: Author

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