PATIENT POSITIONING
IN THE
OPERATING ROOM
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
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,
or stretching:
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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
– Maintenance of individual requirements
Assessment
• The team should assess the following prior to
positioning of the patient:
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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,
pre-existing conditions, etc.
– Patient’s privacy and medical needs
– Basics of anatomy & physiology
Team Responsibilities
Physician:
-Optimal procedural exposure
Anesthesia:
-Physiologic requirements (A-B-C’s)
-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
– 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 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
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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
Lateral
• 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 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
Fowler’s Position
(Sitting/Lawnchair/Beachchair)
• 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 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 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
Lithotomy
• With 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 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
patient’s buttocks further down to the
edge of the OR 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 OR bed
section
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
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
• Trendelenburg:
– Tolerated less well than supine
– Added weight of abdominal contents on the diaphragm may lead to
atelectasis and hypoxemia
• Prone:
– Problematic
– Requires additional support and monitoring of the patient and
pressure on the abdomen
– Ventilation may be markedly more difficult
• Lateral:
– Well tolerated
– Correct sizing and placement of axillary roll is important
– Ensure that pendulous abdomen does not hang over side of OR bed
• Head-Up: (Reverse Trendelenburg/Semi-recumbent)
– Most safe
– Weight of abdominal contents unloaded from diaphragm
– Use of well-padded footboard to prevent sliding
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 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)
Safety
Considerations
Supine
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
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:
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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
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.