1. PATIENT POSITIONING
SAMI ABU SABET

2. Goals of Proper Positioning
To maintain patient’s 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
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3. Overview
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.
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 musculoskeletal discomfort
Maintenance of individual requirements
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4. Assessment
The team should assess the following prior to positioning of the patient:
Procedure length
Surgeon’s preference of position
Required position for procedure
Anesthesia to be administered
Patient’s risk factors
age, weight, skin condition, mobility/limitations, etc.
Patient’s privacy and medical needs
Basics of anatomy & physiology
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5. Team Responsibilities
Physician:
-Optimal procedural exposure
Anesthesia:
-Physiologic requirements (A-B-C’s)
-Position timing
Nurse:
-Safe transfer using adequate personnel
-Use of adequate padding and positioning aids
-Provide an ongoing assessment
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6. Surgical Positions Variations include:
Trendelenburg.
Reverse trendelenburg.
Fowler’s
Jackknife
High lithotomy
Low lithotomy
Four basic surgical positions include:
Supine
Prone
Lateral
Lithotomy
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7. 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 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 crossing circulation
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8. Supine Disadvantages
Greatest disadvantages are circulation and pressure points
Most Common Nerve Damage:
Brachial Plexus: positioning the arm >90*
Radial and Ulnar: compression against the bed, metal attachments, or when team members lean against the arms during the procedure
Perennial and Tibial: Crossing of feet and plantar flexion of ankles and feet
Vulnerable Bony Prominences:
(due to rubbing and sustained pressure)
Occipital, spine, scapula, Olecranon, Sacrum, Calcaneous
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9. Prone Turning and supported
Face down, resting on the abdomen and chest
Chest rolls & 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
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10. Prone Disadvantages
Greatest disadvantages are to the respiratory and circulatory systems and pressure points
Most Common Nerve Damage:
Brachial, radial, median, ulnar
Vulnerable Bony Prominences:
Temporal, clavicle, iliac
Vulnerable Vessels:
Carotid, aorta, vena cava.
Susceptible to hyperextension of
the joints
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11. Lateral supine prior to turning
Shoulder & hips turned together 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
Sami Abu Sabet

12. Lateral Disadvantages
Greatest disadvantages 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
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13. Trendelenburg
The patient is placed in the supine position while the 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 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
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14. 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
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15. Trendelenburg Disadvantages
Lung volume is decreased
The pressure of the organs against the diaphragm mechanically compresses the heart
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16. Reverse Trendelenburg
The 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
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17. Fowler’s Position (Sitting/Lawnchair/Beachchair)
Patient begins in the supine position
Foot of the bed is lowered slightly, flexing the knees, while the body section is raised to 35 – 45 degrees, thereby becoming a backrest
The entire 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 .
A pillow is placed under the knees.
For cranial procedures, the head is
supported in a head rest .
This position can be used for
shoulder or breast reconstruction
procedures
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18. Jackknife Modification of the prone position
The patient is placed in the prone position on the bed and then inverted in a V position
The hips are over the center break of the 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 bed leg section is
lowered, and the 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
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19. Lithotomy
The patient in the supine position, the legs are raised and abducted to expose the perineal region
The patient’s buttocks are even with the lower break in the bed (to prevent lumbo sacral 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 nervous plexus.
The position must be symmetrical
The perineum should be in line with the longitudinal axis of the bed
The pelvis should be level
The head and trunk should be in a straight line
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20. 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 bed is lowered
It may be necessary to bring the
patient’s buttocks further down to the
edge of the bed break
Coordination with the anesthesia
care provider is necessary to ensure
that the patient’s hands/fingers are
protected from crushing prior to
lowering of the bottom of the bed
section
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21. Low Lithotomy
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 patient’s thighs and trunk is not as acute as for the high lithotomy position
Used in vaginal procedures
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22. Lithotomy Disadvantage
Particular attention needs to be given to the popliteal space behind the knee where the legs rest in the stirrups
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23. 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
Ensure that the patient is adequately secured to the table
One strap placed across the patient’s thighs and the second across the lower legs
Extra care must be taken to ensure that loose skin is protected (ie lithotomy position)
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24. Safety Considerations
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25. Supine Safety Considerations: Risk #1: Risk #2: Safety Consideration:
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 bed
Risk #1:
Pressure points:
occiput;scapulae;thoracic vertebrae;olecranon process;sacrum/coccyx;
calcaneae;knees
Risk #2:
Neural injuries of extremities, brachial plexus, ulna, radial nerves
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26. Prone
Safety Consideration:
Maintain cervical neck alignment
Protection of forehead, eyes, chin
Padded headrest to provide airway
Chest rolls to allow chest movement and decrease abdominal pressure
Breasts and genitalia free from torsion
Padded with pillows
Padded footboard
Risk #1:
Head, eyes, nose
Risk #2:
Chest compression, iliac crest, breast, male genitalia
Risk #3:
Knees
Risk #4:
Feet
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27. Lateral Risk #1: Risk #2: 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
Maintain spinal alignment during turning
Padded support to prevent lateral neck flexion
Risk #1:
Bony prominences and pressure points on dependent side
Risk #2:
Spinal alignment
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28. Documentation
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29. Documentation should include:
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
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
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30. Don’t 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 ½ to 3 hours significantly increase the risk of pressure ulcer formation
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31. Don’t Forget:
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
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32. One last note…
Positioning problems can result in significant injuries and successful lawsuits((دعاوى قضائية.
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