Patient
POSITIONING
Positions
• Four basic
positions include:
– Supine
– Prone
– Lateral
– Lithotomy
• Variations include:
– Trendelenburg
– Reverse
trendelenburg
– Fowler’s
– 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 bed
• 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
Prone
• 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
• One roll is placed at the iliac or pelvic level
• Arms lie at the sides or over head on arm boards
• Head is face down and turned to one side with accessible airway
• Padding to bilateral feet, arms and knees
• Safety strap placed 2” above knees
Lateral
• 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
• Axillary roll placed to the axillary area of the downside arm
• 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
• Stabilize patient with safety
strap and silk tape, if needed
Trendelenburg
• The patient is placed in the supine position while the
bed is modified to a head-down tilt of 35 to 45
degrees, the head being lower than the pelvis
• In addition to a safety strap, strips of 3” tape may be
used to assist with holding the patient in the position
• Used for procedures in the lower abdomen or pelvis
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
Fowler’s Position
(Sitting/Lawnchair/Beachchair)
• Foot of the bed is lowered, flexing the knees, while the body
section is raised to 35 – 45 degree
• Feet rest against a padded footboard
• Arms are crossed loosely over
the abdomen and placed on
a pillow on the patient’s 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
Jackknife
• Modification of the prone position
• The patient is placed in the prone position on the bed and then
inverted in a V position
• 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
• Used in gluteal and anorectal
procedures
Lithotomy
• With the patient in the supine position, the legs are raised and
abducted to expose the perineal region
• The legs and feet are placed in stirrups that support the lower
extremities
• Stirrups should be placed at an even height
• Adequate padding and support for the legs/feet should eliminate
pressure on joints and nervus plexus
• The position must be symmetrical
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
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
Safety
Considerations
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 or bed to be
used
• Ensure that the patient is adequately secured
to the OR table or bed to be used
• 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)
Supine
Risk #1:
• Pressure points:
– occiput;scapulae;thoracic
vertebrae;olecranon
process;sacrum/coccyx;
calcaneaus;knees
Risk #2:
• Neural injuries of
extremities, brachial
plexus, ulna, radial nerves
Safety
Considerations:
• 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:
– Chest compression,
iliac crest, breast,
male genitalia
Risk #3:
– Knees
Risk #4:
– Feet
Safety Consideration:
– Maintain cervical neck
alignment
– Protection of forehead,
eyes, chin
– Padded headrest to provide
airway
Safety Consideration:
– Chest rolls to allow chest
movement and decrease
abdominal pressure
– Breasts and genitalia free
from torsion
Safety Consideration:
– Padded with pillows
Safety Consideration:
– Padded footboard
Lateral
Risk #1:
– Bony prominences and
pressure points on
dependent side
Risk #2:
– Spinal alignment
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
Lithotomy
Risk #1:
Safety Consideration:
Risk #2:
Safety Consideration:
Risk #3:
Safety Consideration:
– Hip/knee joint injury
– Lumbar/sacral pressure
– Vascular congestion
– Neuropathy of obturator
nerves, femoral nerves,
common peroneal
nerves/ulnar nerves
– Restricted diaphragmatic
movement
– Pulmonary region
– Place stirrups at even height
– Elevate lower legs slowly and
simultaneously from stirrups
– Maintain minimal external
hip rotation
– Pad lateral or posterior
knees/ankles to prevent
pressure and contact with
metal surface
– 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:
– 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
Don’t Forget:
• Good positioning starts with an assessment
• Prevent team members from leaning against patients
• 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
• 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.