1. Patient
POSITIONING

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. Safety Considerations

14. 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)

15. 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

16. 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

17. 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

18. 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

19. Documentation

20. 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

21. 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

22. One last note…
Positioning problems can result in significant injuries and successful lawsuits.