Patient POSITIONING

Positions Variations include: Four basic positions include: Trendelenburg Reverse trendelenburg Fowler’s Jackknife High lithotomy Low lithotomy Four basic positions include: Supine Prone Lateral 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 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 OR bed 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

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

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

Lithotomy Risk #1: Safety Consideration: Risk #2: Risk #3: 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 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.