PATIENT POSITIONING IN THE OPERATING ROOM

Goals of Proper Positioning

To maintain patients 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

 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

Overview

Maintenance of individual requirements

Assessment
The team should assess the following prior to positioning of the patient:
Procedure length Surgeons preference of position Required position for procedure Anesthesia to be administered Patients risk factors age, weight, skin condition, mobility/limitations, pre-existing conditions, etc. Patients privacy and medical needs Basics of anatomy & physiology

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

Surgical Positions
Four basic surgical positions include: Supine Prone Lateral Lithotomy Variations include: Trendelenburg Reverse trendelenburg Fowlers Jackknife 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

 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

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

Fowlers Position
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 patients 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

(Sitting/Lawnchair/Beachchair)

 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

Jackknife

Lithotomy
With the patient in the supine position, the legs are raised and abducted to expose the perineal region The 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 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 patients buttocks further down to the edge of the OR bed break Coordination with the anesthesia care provider is necessary to ensure that the patients hands/fingers are protected from crushing prior to lowering of the bottom of the OR bed section

 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 patients thighs and trunk is not as acute as for the high lithotomy position Used in vaginal procedures

Low Lithotomy

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 Tolerated less well than supine Added weight of abdominal contents on the diaphragm may lead to atelectasis and hypoxemia Problematic Requires additional support and monitoring of the patient and pressure on the abdomen Ventilation may be markedly more difficult Well tolerated Correct sizing and placement of axillary roll is important Ensure that pendulous abdomen does not hang over side of OR bed Most safe Weight of abdominal contents unloaded from diaphragm Use of well-padded footboard to prevent sliding

Trendelenburg:

Prone:

Lateral:

Head-Up: (Reverse Trendelenburg/Semi-recumbent)

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 patients 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:
Pressure points:
occiput;scapulae;thoracic vertebrae;olecranon process;sacrum/coccyx; calcaneae;knees

Safety Considerations:

Risk #2:
Neural injuries of extremities, brachial plexus, ulna, radial nerves

Padding to heels, elbows, knees Spine, head alignment with hips Legs parallel, uncrossed at ankles

Safety Consideration:

Arm board at less than 90 degrees Head in neutral position Arm board pads level with OR bed

Prone
Risk #1:

Head, eyes, nose

Risk #2:

Safety Consideration: Maintain cervical neck alignment Protection of forehead, eyes, chin Padded headrest to provide airway Safety Consideration:

Chest compression, iliac crest, breast, male genitalia Knees

Feet

Risk #3:

Risk #4:

Safety Consideration: Padded with pillows Safety Consideration: Padded footboard

Chest rolls to allow chest movement and decrease abdominal pressure Breasts and genitalia free from torsion

Lateral
Risk #1:
Bony prominences and pressure points on dependent side Safety Consideration: Axillary roll for dependent axilla Lower leg flexed at hip Upper leg straight with pillow between legs Padding between knees, ankles and feet Safety Consideration: Maintain spinal alignment during turning Padded support to prevent lateral neck flexion

Risk #2:

Spinal alignment

Lithotomy
Risk #1: Safety Consideration: Safety Consideration:
Maintain minimal external hip rotation Pad lateral or posterior knees/ankles to prevent pressure and contact with metal surface

Risk #2:

Hip/knee joint injury Lumbar/sacral pressure Vascular congestion

Neuropathy of obturator nerves, femoral nerves, common peroneal nerves/ulnar nerves

Place stirrups at even height Elevate lower legs slowly and simultaneously from stirrups

Risk #3:

Restricted diaphragmatic movement Pulmonary region

Safety Consideration:

Keep arms away from chest to facilitate respiration Arms on arm boards at less than 90 degree angle or over abdomen

Documentation

 Documentation should include:

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

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

Dont 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 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.