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Positioning in the

Perioperative Setting

Presented by

ALLEN LEUNG, RN, PYNEH

24-03-2012

Objective

• The goals of the operative positioning

• Anatomic consideration for positioning

• Guidelines for safe positioning

• Various kind of positioning device

• Common positions for operation

Goals

• Provide optimum exposure and access to the

surgical site.

• Provide access for the administration of the

anaesthesia and patient’s monitioring.

• Maintain patient normal phsiological function

including breathing and circulation.

• Prevent patient from injuries and post- operative

discomfort.

Anatomic consideration for positioning

• Respiratory Consideration ▫ Hindered diaphragmatic and chest movement

• Circulatory Consideration ▫ Thrombus formation

▫ Occlusion of peripheral blood vessels

• Peripheral Nerve Consideration ▫ Common sites: brachial plexus, ulnar and radial nerves

▫ Prolonged pressure on or stretching

• Musculoskeletal Consideration ▫ Strain of muscle and hyperextend of the joint

• Soft tissue Consideration ▫ Skin pressure ulcers and deep tissue injury over bone

prominences

Pressure ulcer

• Pressure over 32mmHg reduces capillary flow predisposes the patient to pressure injury

This pictorial shows the pressure map of a 185 lb male resting on a foam OR table mattress while in the supine position

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Pressure ulcer Guidelines for safe positioning

• Prepare operation table accessories and lock it securely before

positioning

• Move the patient only after the anaesthesia care team gives approval

• Guard and support the patient’s head at all times by the anaesthesia care

team during movement

• Move the patient slowly and gently

• Provide adequate numbers of personnel for the safe movement of the

patient

• Prevent hyperextension of arm (90-degree) and legs crossed

• Watch out for endotracheal tubes, IV lines, drains, urinary catheter and

etc to prevent kinking and pulling them out

• Prevent the patient to touch any exposed table parts or hang over sides

Positioning Device – operating Table

Characteristics:

•Stable

•Easily maneuverable

•Highly adjustable

•Adaptable

•Comfortable

•Radiolucent

Operating Table Accessories

Body (Hip) Restraint strap

• Place the strap over the patient’s hips to secure the patient in the lateral position

Anaesthesia Screen

• Hold the drapes from the patient’s face/IV access

• Separate the nonsterile from sterile area

Armboards • Support the arms

Operating Table Accessories

Headrest

• Hold the head securely

Skull clamp • Three-point fixing the patient’s head for neurosurgery or cervical spine operation

Operating Table Accessories

Shoulder Braces • support the shoulders to prevent the patient

from slipping, such as in the Tendelenburg’s position

Side and Lumbar supports

• Support lumbar vertebral in lateral position

Foot Support • Support the feet in reverse Trendelenburg’s position

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Stirrups

• Support the legs and feet in the lithotomy position

Operating Table Accessories

Adjustable Arched Spinal Frame • Adjust the spinal frame arch for spinal surgery

Gas spring

assisted stirrups

Knee crutches

Candy cane or

sling stirrups

Perineal Post

• Prevent injury during traction against the perineal region

Traction Boot

• Secure a leg to a traction boot for applying the traction

Operating Table Accessories

Head table • Support the operative arm

Different types of padding / postioner Supine Position

Supine Position

• Patient on back with face toward ceiling

• Legs uncrossed

• Position arms at sides or on armboards, turn the palms towards the patient or turn the palms up

• Prevent to hyperextend both arms more than 90o

• Place safety belts 2” above the knees and both arms, and not so tight as to impeded circulation

• Place paddings under head and heels

• Place a small pillow under calves supporting the full length of the lower legs

• Apply anti-embolism stockings if necessary

• For the pregnant patient, a wedge should be placed under patient’s right side to shift the uterus to the left and relieve compression on the aorta and vena cava

Supine Position

Use for : • Administration of general anesthesia • Anterior Chest surgery e.g. Open heart surgery • Surgery on face, neck, or mouth • Most surgery on extremities Vulnerable Anatomy: • Occiput, Scapulae, Olecranon (elbows) , Thoracic Vertebrae, Lumbar area,

Sacrum & Coccyx, Calcaneus (Heels)

Potential Injuries: •Lumbar strains •Nerve injury: Brachial plexus Radial nerve Ulnar nerve •Skin damage

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Supine Position

Trendelenburg Position

Use for:

• Lower abdominal surgery

• Insertion of central catheter

Reverse Trendelenburg Position

Use for:

• Face and Neck surgery

Lateral Position

Lateral Position • Patient begins in supine position • Turn shoulders and hips simultanously – operative side up • Place their back on the edge of the operation table • Maintain spinal alignment • Flex lower leg at knee and hip, keep upper leg straight or

slight flexed • Place pillow to separate two legs • Place and secure lower arm on an armboard, and upper arm

on an overbed arm support/gutter or pillow with elbow slightly flexed and upward, but not more than 90-degree

• Place paddings under head, ankle, knee, hip and axilla • Place safety belt across hips, and pelvic and sacral supports to

hold the patient in position • Place the short kidney rest against the back, & a large kidney

rest against the abdominal wall with padding • Place lower margin of rib cage just level with the break point

Lateral Position

Potential injuries: Nerve injury: Brachial plexus Radial nerve Ulnar nerve Peroneal nerve Use for : •Kidney surgery •Hips surgery •Thoracic surgery • Feet

Vulnerable Anatomy: • Dependent side of face and ear • Dependent shoulder • Arms • Dependent axilla • Dependent hip • Legs • Dependent knee • Ankles

Lithotomy Position Lithotomy Position

• Patient begins in supine position

• Lift both legs with knees together simultaneously into stirrups or leg holders

• Avoid forcing the legs

• Avoid hyperflexion of the hips

• Place arms on armboards or over chest

• Do not extend patient’s buttock over the break in the operation table

• Place paddings under head and stirrups

• Lower both legs slowly and simultaneously

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Lithotomy Position Potential injuries:

• Lumbosacral muscles

• Femoral and obturator nerves

• Saphenous vessels and nerves

• Peroneal nerve

Use for:

• Perineal approach surgery

e.g. obstetrics and gynaelogical operation, genitourinary operation,

• A-P resection, etc

Vulnerable Anatomy: • Occiput • Shoulders • Scapulae • Hips • Sacrum & Coccyx • Calcaneus (Heels) • Lateral aspect of the legs

Prone Position

Prone Position

• Begin in supine position

• Log-roll the patient into the prone position

• Provide pillows &/or laminectomy frame to support the chest, abdomen, pelvis & both legs

• Maintain head and cervical alignment

• Rest the head on a pillow or a head ring to prevent the pressure on eyes, ears & cheeks

• Avoid compressions on female breasts or male genitalia

• Position arms either at patient’s sides with palms turned inward or upward, or position both arms on armboards with the elbows flexed and the palms down

• Allow toes to extend over the end of the bed or raise off the bed with padding under the shins

• Secure safety belt 2” above knees

Prone Position

Potential injuries: • Skin breakdown • Interfere respiration and

circulation • Eye or ear damage

• Nerve damage: Brachial plexus

• Damage to breasts or genitals

Use for : • Surgery on the back or spine

• Surgery on the back of the legs

Vulnerable Anatomy: • Forehead, eyes, ear, and chin • Anterior shoulders • Breasts • Iliac crests • Genitalia • Knees • Shins • Dorsum of the feet • Toes

Sitting / Fowler’s Position Sitting / Fowler’s Position

• Flex the operation table and lower one foot section at least 45-degree

• Elevate the back section and tilt the table chassis in steep Trendelenburg

• Flex and secure arms across the abdomen

• Place pillow on patient’s lap and paddings under heels

• Place safety belt across thighs

• Stabilize patient’s head with a head holder, mainly for neurosurgery

• Wedge a small sandbag or support under the medial border of the scapula to push the shoulder forward

• Flex the neck away from the shoulder, resting the head on a head ring

• Avoid to flex the neck excessively

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Sitting / Fowler’s Position Potential injuries:

• Eye or neck injury

• Sciatic nerve

Use for:

Neurosurgical surgery

Otorhinologic surgery

Shoulder surgery

Vulnerable Anatomy:

• Occiput

• Scapulae

• Ischial Tuberosities

• Back of Knees

• Calcaneus (Heels)

Orthopedic Fracture Table Position

Orthopedic Fracture Table Position

• Place the patient in supine position with the pelvis stabilized

• Place padding on genitalia area and under head

• Protect the feet and ankles by a well-padded bootlike devices

• Rotate and pull operated leg into traction

• Place both hands onto the patient’s chest,

• OR, place and secure one arm on an armboard, and another arm on overbed arm support with elbow slightly flexed and upward, or ipsilateral arm across the patient’s chest

Potential injuries: • Pudendal nerves

Use for: • Hip fracture surgery e.g DHS,

IMNS Vulnerable Anatomy:

• Occiput • Scapulae

• Olecranon (elbows) • Sacrum & Coccyx • Perineum

• Contralateral calf • Calcaneus (Heels) (within

traction boots)

Role of the Perioperative Nurse

• Patient Advocate

• Patient Assessment:

▫ History, Pre- existing condition, expected surgical procedure

• Planning Care:

▫ Required equipment and setting

▫ Number of person needed

• Implementation:

▫ Transportation > Transfer > Positioning > Transfer

▫ DIGNITY of patient

• Evaluation:

▫ Thorough, once- over check

• Documentation

Case 1 Case1

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Case 1 Case 2

Case 2 Case 3

Case 4

Thank You !!