Surgical Patient Positioning ST210 Concorde Career College, Portland

Positioning Objectives:  List the basic surgical positions and analyze the use of each  Identify basic positioning aids and describe the use of each

Positioning Objectives:  List the steps for placing the patient in the basic surgical positions and list the potential hazards and safety precautions that relate to each position

Surgical Technology Lecture Series 2000© Power-Point®

Production Notes Primary Author - Kevin Frey CST, MA Coauthor and Executive Editor - Bob Caruthers CST, PhD Series Editor - Teri Junge, MEd, CSFA, CST, FAST

Table of Contents  General Information  Patient Safety  Equipment  Patient Positions

General Information

Position Determination  General factors  Surgical procedure  Surgeon’s preference  Technique of anesthetic administration  Patient factors  Age  Size (height and weight)  Cardiopulmonary status  Preexisting conditions

Responsibilities  Choice of position is made by surgeon and anesthetist  The responsibility for ensuring the patient is properly positioned belongs to the surgeon

Timing of Positioning  Patient is not positioned or moved until the anesthetist indicates it is okay to do so  Factors that influence time of positioning  Site of surgical procedure  Age and size of patient  Type of anesthetic administered  Pain associated with moving conscious patient

Patient Safety

Safety  Properly identify patient  Operating table and gurney locked  Mattress secured to operating table  Minimum of 2 people assist an awake patient during transfer  Person on “gurney side” helps patient move to operating table  Person on “operating table side” prevents patient from falling off the narrow table

Safety (continued)  Minimum 4 persons to move unconsciousness, obese, or weak patients  Move on the count of three  Anesthetist controls timing  Anesthetist controls head and neck at all times  Lift - do not slide or pull the patient  Surgeon is responsible for stabilizing un-splinted fractures during move

Safety (continued)  Anesthetized patient is moved slowly to allow circulatory system to adjust  Body parts not to extend beyond table edges, rest on metal parts, or unpadded surfaces  Body exposure kept to minimum  Prevent hypothermia  Maintain patient’s dignity (especially awake patient)

Safety (continued)  Protect arms  Prevent accidental IV removal  Avoid hyperextension of arm board  Be sure patient in the supine position has not crossed legs  Uncrossed to avoid neurovascular compromise

Safety (continued)  Chest rolls are used in the prone position to facilitate respiration  Protect patient’s fingers and skin at flex points of table  Mayo stand must not rest on patient  If table raised during procedure; Mayo stand must also be raised

Respiratory System Requirements  Unhindered diaphragmatic movement  Patent airway  Prevent hypoxia  Some hypoxia may be unavoidable  Facilitate inhalation anesthesia  No constriction about neck or chest  Place arms at sides, on arm boards, not crossed on the chest

Circulatory System Requirements  Adequate circulation required  Maintain BP  Provide oxygenated blood to tissue  Facilitate venous return,  Prevent thrombus formation  Pressure on peripheral blood vessels avoided  Body support and safety straps not too tight

Peripheral Nervous System Requirements  Avoid prolonged pressure or stretching on peripheral nerves  Injury can range from sensory and motor loss to paralysis  Positioning devices that come in contact with patient must be well padded

Peripheral Nerves (continued)  Frequent sites of injury  Divisions of the brachial plexus  Due to extreme positions of head and arm  Ulnar nerve  Radial nerve  Peroneal nerve  Extremity nerves damaged by compression against bone, stirrups, or operating table  Facial nerve

Musculoskeletal System Requirements  Anesthetized patients lack muscle tone or control  Strain on muscles results in injury  Body alignment must be maintained

Soft Tissue Requirements  Body weight distributed unevenly on operating table  Weight on bony prominences can lead to skin ulceration  Tissue folded under skin of obese patient will not receive proper perfusion  Debilitated patients and diabetics are at high risk for decubitus ulcers  Wrinkled sheets and edges of positioning devices under the patient can cause pressure on skin

Patient Access  Anesthetist must be able to  Attach monitoring devices  Administer anesthesia  Observe patient  Maintain access to airway and IV sites

Equipment

Operating Table  Electric or manual hydraulic  Metal top  3 hinged sections: head, body, leg  Allow patient to be manipulated; flexed  Joints of table referred to as breaks  Flexing the table is referred to as breaking

Operating Table (continued)  Metal crossbar between two upper sections to elevate kidney area  X-ray penetrable top extends length of table for insertion of X-ray cassette  Rubber; foam mattress adhered with Velcro®  Foot extension board for tall patient; also used with lithotomy position

Operating Table (continued)  Table is manipulated into desired position either by electronic controls or lever-operated hydraulic system  Control set on back, side, foot, or flex  Brake is set to maintain table position

Table Accessories  Safety belt (knee strap)  Placed over thighs 2” above knees  Circulator should be able to pass fingers between strap and patient  Some straps attached at sides of table; others fastened in middle  Blanket placed on patient between skin and belt  Belt placed over, not under blanket

Table Accessories (continued)  Anesthesia screen  Metal bar attaches to head of table to hold drapes off patient’s face  Substitute for IV poles  Lift sheet (draw sheet)  Folded sheet placed horizontally across top of sheet on operating table  Can be used in moving patient

Table Accessories (continued)  Lift sheet (continued)  Arms can be enclosed in sheet with hands placed palm down or turned inwards toward body  Finger tips must extend beyond edges of sheet  Tuck sheet under patient’s sides  Do not tuck under sides of mattress

Table Accessories (continued)  Arm boards  Support arms  Provide access to IV  Support arm or hand where surgical site is located  Hand placed palm up on board to prevent ulnar nerve pressure and abnormal shoulder rotation Exceptions  Prone position  Upper arm of lateral position

Table Accessories (continued)  Arm boards (continued)  Arm board can be adjusted to different angles  Never abduct arm more than 90 degrees from shoulder  Double arm board  Arms positioned one above the other  Also called overhead arm support

Table Accessories (continued)  Wrist straps  Narrow straps placed around wrists to secure hand and arm to arm board  Hand table (upper extremity table)  Slipped under mattress on one side of table  Other end of table supported by legs  Can use 2 arm boards placed side-by-side; not as effective or safe

Table Accessories (continued)  Shoulder braces  Padded concave supports to prevent patient from slipping off table when using Trendelenburg position  Acromion processes must rest on braces, not muscles or soft tissue near the neck

Table Accessories (continued)  Kidney rests  Padded concave pieces that slide under mattress on kidney elevator  Placed snugly against body to provide stability in kidney position

Table Accessories (continued)  Body (hip) restraint strap  A wide belt or tape (preferred) is used  Placed over patient’s hips to help secure patient in lateral position

Table Accessories (continued)  Hemorrhoid strap  Benzoin spray  3” wide adhesive tape  Strips placed approximately 4” lateral to surgical site  Use 2 strips per side  Spread buttocks when patient is in Kraske position

Table Accessories (continued)  Stirrups (candy canes)  Metal poles placed in holder on each side of operating table to support legs and feet in lithotomy position  Feet supported by canvas or fabric loops, suspending the legs

Table Accessories (continued)  Metal footboard  Foot extension board placed perpendicular to table to keep patient from slipping off operating table in reverse Trendelenburg  Used to prevent foot drop during extended procedures

Table Accessories (continued)  Donut  Ring-shaped foam pad for head  Also used to protect pressure points  Bolsters  Used to elevate specific part of body  Chest roll  Axillary roll

Table Accessories (continued)  Suction bean bag  Placed on top of operating table  Patient lays on the bean bag  Suction attached to one end of bag  As air is withdrawn the pad hardens and is molded to the patient’s body by the surgical team

Table Accessories (continued)  Suction bean bag (continued)  Suction disconnected to release  To allow air to reenter, valve is squeezed  Excellent positioning device for stabilizing patient in lateral position

Patient Positions

Supine (Dorsal) Position  Patient lies on back  If arms at side, supported by draw sheet, palms down  If arms on arm boards, palms up  Legs straight and in line with head and spine  Hips parallel to spine

Supine (continued)  Safety belt across thighs 2” above knees  Pillows placed under head, under knees, under lumbar curvature  Protect heels from pressure  Feet must not be in prolonged plantar flexion (foot drop)

Supine (continued)  Procedures  Anterior surface of body  Extremities  Modifications  Procedures on face or neck: Place rolled towel lengthwise along upper boarder of scapula to slightly hyperextend neck and/or lower head section of operating table

Supine (continued)  Modifications (continued)  Modified dorsal recumbent (frog leg)  Knees slightly flexed with a pillow under each  Thighs externally rotated  Soles of feet rest on table top

Trendelenburg Position  Supine with head tilted downward  Safety belt 2” above knees  Shoulder brace may be used  Lung volume decreased  Heart mechanically compressed by pressure of organs against diaphragm

Trendelenburg (continued)  Level entire table slowly at end of procedure  Procedures  Lower abdomen or pelvis to allow abdominal viscera to fall away from surgical site

Reverse Trendelenburg Position  Supine with head tilted upward  Padded foot board may be necessary  Small pillows placed under knees and lumbar curvature  Donut for the head  Safety belt 2” below the knees  Footboard may be used to retain patient on table

Reverse Trendelenburg (continued)  Procedures  Upper abdomen  Allows abdominal viscera to fall away from surgical site  Examples: gallbladder, biliary tract, splenectomy  Thyroidectomy  Facilitates breathing and decreases blood supply to surgical site

Fowler’s (Sitting) Position  Start with patient in the supine position  Buttocks at flex in table  Knees over lower break  Foot section lowered slightly to flex knees  Body section raised becoming the “back” of the chair  Arms rest on armboards parallel to operating table  Alternative: Secure arms to large pillow placed on lap

Fowler’s (continued)  Safety belt placed 2” above the knees  Table tilted slightly head downward  Table resembles modified armchair  Procedures  Shoulder  Nasopharyngeal  Facial  Breast reconstruction

Lithotomy Position  Wrap ankle and foot of patient with towel, leggings, or cotton boots for padding against canvas loops  Transfer head section to foot end of table to serve as foot extension  Place stirrup on side of table that will not be used for patient transfer

Lithotomy (continued)  Start with the patient in the supine position  Arms placed on armboards  Hands not to extend along table where fingers could be crushed in breaks while leg section is lowered or raised  Buttocks resting along break between body and leg section  Place other stirrup  Stirrups must be of equal position and at an appropriate height according to length of patient’s legs

Lithotomy (continued)  When anesthetist gives permission, both legs are raised simultaneously by two persons  Support the foot, ankle, and calf  Flex the knees and legs; place inside the stirrup posts  Place feet in canvas loops  First loop of canvas around ankle  Second loop around sole of foot

Lithotomy (continued)  Lower section of mattress is removed  Leg section of table is lowered  Lower leg or ankles must not touch any metal part of the stirrup  Buttocks must be even and not extend beyond table edge  Extension beyond edge causes strain on lumbosacral muscles and ligaments due to body weight placed on sacrum

Lithotomy (continued)  Conclusion of surgical procedure  Raise leg section  Replace mattress  When anesthetist gives permission, both legs are extended, brought together, and lowered slowly and simultaneously by two persons  Prevents hypotension as blood reenters legs and leaves the torso  Essential to avoid lower back strain  Reapply safety belt  Safety belt not applied when patient is in lithotomy

Lithotomy (continued)  Lung compliance is decreased by pressure of thighs on abdomen  Diaphragmatic movement restricted  Procedures  Perineal  Vaginal  Urological  Rectal

Prone Position  Patient lays on abdomen (face down)  Chest rolls pre-placed on operating table  Extend from clavicles to iliac crest to facilitate respiration  Patient is anesthetized and intubated in the supine position on the gurney  When anesthetist gives permission, patient is slowly rolled onto abdomen on operating table by team of at least 4 people

Prone (continued)  Breasts moved laterally  External genitalia toward foot of table  Arms  Placed along side of body with palms up or towards side of body  Can cause pressure on breasts  Placed on armboards, angled with elbows flexed  Palm downward  When moving arm, lower toward floor rotating in an upward in natural movement

Prone (continued)  Head turned to one side; use a donut  Pillow under anterior of ankles  Safety belt above the knees  Procedures  Spine  Posterior aspect of lower extremity

Kraske (Jackknife) Position  Modification of the prone position  Hips over center break between body and leg sections of operating table  Chest rolls employed  Arms on arm boards; elbows flexed; palms down  Head to the side on donut  Pillow under ankles  Safety belt below the knees

Kraske (continued)  Leg section lowered; entire table tilted head downward so hips are elevated above body  Return patient to level position slowly  Remove safety belt when moving table parts  Venous pooling occurs cephalad and caudad  Kraske position not tolerated well by patients  Procedures  Rectal  Pilonidal sinus

Knee-Chest Position  Modification of the prone position  Foot extension  Table flexed at center break  Leg section at right angle to operating table  Patient kneels on lower section  Knees are flexed at right angle to body  Head turned to side; placed on donut

Knee-Chest (continued)  Arms placed on pillow near head with elbows flexed  Safety belt above the knees or tape used  Pillows placed on foot board and taped into place  Procedures  Spine

Lateral Position  Anesthesia administered with the patient in the supine position, then repositioned onto the non-operative side  Turned by no fewer than 4 people  As patient is turned, patient’s back drawn to edge of operating table  Arms placed on overhead armboard; lower arm palm up; upper arm slightly flexed with palm down

Lateral (continued)  Lower leg flexed at knee  Upper leg straight  Large pillow placed lengthwise between legs to prevent pressure on peroneal nerve  Safety belt or wide tape placed over hip to provide stability  BP taken from lower arm  Small roll under axilla to relieve pressure

Lateral (continued)  Shoulders in alignment  Head in cervical alignment  Supported by pillow between shoulder and neck to prevent stretching the neck, brachial plexus, aid in maintaining patent airway  Procedures  Thorax  Kidney  Retroperitoneal space

Kidney Position  Modification of lateral position with flank region over kidney elevator  Short kidney rest attached to elevator at patient’s back  Longer rest placed on front below level of iliac crest to prevent pressure on abdominal organs  Table slightly flexed  Kidney elevator raised to increase space between lower ribs and iliac crest

Positions  Safety strap or wide tape placed after table flexed and elevator raised  Entire table tilted head downward until surgical area is horizontal  All lateral positions, shoulder, hip, knee, ankle in alignment  Before closure, table is flattened to allow better approximation of tissues  Procedures  Kidney