• 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

• 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
– Maintenance of individual requirements

• 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, pre-existing conditions, etc.
– Patient’s privacy and medical needs
– Basics of anatomy & physiology

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

• Four basic surgical positions include:
– Supine
– Prone
– Lateral
– Lithotomy
• Variations include:
– Trendelenburg
– Reverse trendelenburg
– Fowler’s
– Jackknife
– High lithotomy
– Low lithotomy

• 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

• 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

• 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

• 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

• 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

• 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

• 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

• 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

(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

• 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

• 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

• 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

• 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

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

• 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)

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

Risk #3:
– Knees
Risk #4:
– Feet
Risk #1:
– Head, eyes, nose
Risk #2:
– Chest compression, iliac crest, breast, male genitalia
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

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

Risk #1:
– Hip/knee joint injury
– Lumbar/sacral pressure
– Vascular congestion
Risk #2:
– Neuropathy of obturator nerves, femoral nerves, common peroneal nerves/ulnar nerves
Risk #3:
– Restricted diaphragmatic movement
– Pulmonary region
Safety Consideration:
– Place stirrups at even height
– Elevate lower legs slowly and simultaneously from stirrups
Safety Consideration: hip rotation
– Pad lateral or posterior knees/ankles to prevent pressure and contact with metal surface
Safety Consideration:
– Keep arms away from chest to facilitate respiration
– Arms on arm boards at less than 90 degree angle or over abdomen

• 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

• 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