Intraoperative Positioning
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Outline
Overview
- Purpose
- Optimal exposure/access of surgical site
- Patient safety
- Maintain proper body alignment
- Secure patient
- Without circulation compromise
- Ensure access
- IV
- Airway
- Monitoring devices
- Position selection
- Surgeon preference
- Collaborate with anesthesia team
- Surgeon preference
Nursing Points
General
- Common surgical positions
- Supine
- Most common
- Back to OR table
- Procedures examples
- Abdominal
- Head/neck
- Podiatry
- Hand
- Cardiac
- Plastics
- Neuro
- Laparoscopic
- Prone
- Stomach to OR table
- Procedure examples
- Back
- Neck
- Lateral
- Side-lying position
- Right lateral
- Patient lies with right side down
- Left lateral
- Patient lies with left side down
- Right lateral
- Procedure examples
- Side needs exposed
- Good for patients who
- Can’t be prone/supine
- Side-lying position
- Trendelenburg
- Supine with
- Head/torso lowered
- Legs elevated
- Procedure examples
- Gynecological
- Abdominal
- Genitourinary
- Laparoscopic
- Robotic
- Supine with
- Reverse trendelenburg
- Supine with
- Head/torso elevated
- Legs lowered
- Procedure examples
- Head
- Neck
- Gynecological
- Abdominal
- Laparoscopic
- Supine with
- Lithotomy
- Supine with legs raised
- Stirrups
- Procedures used for
- Gynecological
- Anal
- Genitourinary
- Supine with legs raised
- Jackknife
- Prone with
- Head and legs lowered
- Buttocks elevated
- Procedures used for
- Anal
- Prone with
- Supine
Assessment
- Patient assessment before positioning
- Areas of discomfort
- Injuries
- Age
- Height
- Weight
- Skin issues
- Physical issues
- Mobility
- Surgical history
- Extension/rotation issues
- Areas of discomfort
- Documentation
- Skin issues
- Prior to positioning
- Positioning devices used
- Position of patient
- Extremities
- Skin issues
Therapeutic Management
- Positioning devices
- Gel rolls
- Prone position
- Axillary rolls
- Lateral position
- Padding/Pillows
- Bony prominences
- Patient comfort
- Pressure points
- Lateral position
- Footroll
- Prone position
- Under ankles
- Elevate toes off bed
- Foot board
- Reverse trendelenburg
- Headrests
- Prone
- Supine
- Beanbag
- Trendelenburg
- Stirrups
- Lithotomy
- Safety strap
- 2 inches above knee
- All procedures
- Arm boards
- Arms secured
- Gel rolls
- Positioning concerns
- Length of procedure
- Greater than 2 hours
- Risk of pressure related injuries
- Greater than 2 hours
- Lithotomy
- Length of procedure
- Lower extremity nerve injuries
- Trendelenburg
- Shearing
- Sliding towards head
- Shearing
- Trendelenburg
-
-
- Reverse trendelenburg
- Shearing
- Sliding towards feet
- Shearing
- Prone
- Pressure points
- Face
- Breasts
- Male genitalia
- Knees
- Tongue swelling
- Intubation concerns
- Dislodged endotracheal tube
- Pressure points
- Lateral
- Alignment issues
-
Nursing Concepts
- Comfort
- Safety
- Tissue/skin integrity
Patient Education
- Teach patient
- Tell perioperative staff
- Injuries
- Aches/pains
- Circulation issues
- Skin issues
- Remove jewelry
- Body piercings
- Can cause trauma when positioning
- Body piercings
- Ask questions!
- Tell perioperative staff
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Transcript
Hey guys today I am going to talk to you about intraoperative positioning!
So whats the big deal about intraoperative positioning? Well positioning in the OR is critical to the success of the surgery! Appropriate positioning ensures that the surgeon and staff have optimal exposure of the surgical site. Because of this sometimes we have to put our patients in positions that may not be so natural. So the surgeon is going to pick the position of the patient but will often times collaborate with anesthesia because remember we are a team! With this in mind it is super important for the perioperative team to keep the patient safe with positioning because it can create some issues if not performed properly! So we do this by making sure the patient has proper body alignment, their airway is accessible, and of course we are trying to help the patient so we always want to prevent any positioning injuries! Remember the patient is under anesthesia and is unable to tell you if something feels uncomfortable so you must be their advocate!
Ok let’s look at some intraoperative positions! Here we have the supine position which is the most common and used for a ton of surgical procedures. In the supine position the patient’s back will be against the OR table. So many procedures are done in this position but a few are abdominal procedures, head and neck, cardiac, laparoscopic, and podiatry.
Here we have the prone position where the patient’s stomach is against the OR table. This procedure is a little more difficult as once the patient is under anesthesia they need to be flipped into this position and then protected appropriately. I’ll talk about some of the positioning devices we use to protect our patients in an upcoming slide! We use this position a lot too often times for back procedures.
Ok guys here we have the lateral position or the side-lying position. I just want to make sure you understand that if a surgeon tells you the patient needs to be in the right lateral position this means that the patient’s right side will be down and vice versa for the left lateral. This position is used anytime we need the side of the patient exposed or even for hip procedures. Guys also this procedure is used if the patient is not under general anesthesia and maybe just local or moderate sedation and they maybe can’t tolerate lying supine or prone.
Ok guys this position you see here in this slide is called trendelenburg! I hear surgeons ask for this position on a daily basis so yes it’s a common one! With trendelenburg the head and torso are lowered with the legs elevated. Obviously the patient needs to be secured adequately and we will talk about that a little later! Common procedures that may incorporate trendelenburg are gyne and urology procedures.
Ok guys this position is called reverse trendelenburg and as you can see the patient is in a supine position but now their head and torso are elveated with their feet lowered. Once again the patient needs to be appropriately secured to the OR table. We use this position for head, neck, laparoscopic, and robotic procedures.
Guys here we have the lithotomy position which no one likes! In this position the patient is supine with their legs raised and they are typically in some form of stirrup. We use this position for gyne procedures, urology procedures, and even anal procedures like a hemorrhoidectomy. So guys if a patient can’t handle the prone position and they are in need of some type of anal surgery, the surgeon may request this position.
Ok this position is called the jackknife! The patient is prone but the OR table is manipulated so that the head and legs are lowered but the buttocks are elevated. So guys this is super important…make sure your OR table is functioning as expected before bringing your patient into the OR. Guys we predominately use this position for hemorrhoid surgery or anything in this region.
Ok guys so what should be assessed before we bring our patient into the OR in reference to positioning? We want to make sure our patient tells us if they have any areas of discomfort that we need to pay special attention to. Also we want to be sure we ask about any mobility or range of motion issues or even surgical history. A person who has had neck surgery or shoulder replacement may not have the mobility that we would expect and we do not want to cause any issues to our patient. Also guys its super important to know if our patients have any skin issues, pressure ulcers, breakdown, etc. so we pay extra close attention to these areas. Finally age, height, and weight all play a role in the positioning of patients as elderly patients have thinner skin and less muscle mass so bony prominences may need extra padding. Also some OR table do have weight limits so be sure to know these guidelines at your facility!
So documentation is super important with positioning. Be sure to document any skin issues that were revealed prior to positioning. Be sure to document not only the position your patient is in for the procedure but also the position of all extremities. It is also critical to document the positioning devices used to prevent any injury in your patient.
So I know I have mentioned positioning devices so here is a list of positioning devices that help to protect our patients from injury and tissue trauma. let’s talk about them a little closer! Guys gel rolls are exactly like they sound they are soft, jelly like devices that are placed under a patients chest when they are in the prone position to allow for chest expansion. We use axillary rolls a lot when the patient is in the lateral position to maintain proper alignment of the patient. A beanbag is used with the trendelenburg position to keep the patient in a secure position to prevent sliding. I use padding and pillows a ton! Whether it’s around the patients heals, elbows, knees, or pillows under the knees or between the knees to keep the patient comfortable and protect those bony areas is super important! The last thing we want is for our patients surgery to be successful but now they have a pressure ulcer! Ok guys in this picture we can see the patient is in the reverse trendelenburg position. We want to secure them appropriately and prevent any sliding and we can do this with the help of a footboard seen here! Stirrups are used with our patients in the lithotomy position and guys I would say that patients complain postop the most about this position. So when you are placing your patient’s legs in stirrups use care that the hips are aligned appropriately. A lot of facilities will do inservices on proper positioning so guys check into that! And finally super common and used everyday are armboards. Armboards help to keep your patient’s arms to be aligned to prevent any nerve injuries from occurring. Guys where I work the circulating nurse and the anesthesia team work very closely to make sure our patient is in a position that is as safe as can be!
Ok so guys I’m sure because you’ve seen some of the pictures of positions, there can be some concerns when it comes to positioning. So an injury can occur with any length of procedure but the risk of pressure related injuries can increase with procedures that are over 2 hours. Also guys nerve injuries of the lower extremities are of concern with our patients who are in lithotomy so keep that in mind. Shearing is of concern with our positions that tilt the patient like trendelenburg and reverse trendelenburg. And when our patients are prone there is a lot of pressure on certain body parts like the face, breasts, and male genitalia. So when we place our patients prone be sure you are making sure all body parts are in the correct place and padded adequately. And guys don’t be surprised if your patient’s tongue is swollen after being prone because the pressure on the face can cause this. Also guys we want to pay special attention to the airway when the patient is prone because now as you can imagine the tube is not in the best of places!
So what should we teach our patients that relates to positioning? We want to encourage our patients to inform the staff if they have any pains, mobility, or skin issues. We also want them to remove jewelry including body jewelry as these can cause trauma to the patient when positioning them. And of course encourage your patient to ask any questions they may have!
Ok guys so proper intraoperative positioning ensures that the patient is safe and comfortable during the surgery and also as protects tissue and skin integrity. Remember your patient is under anesthesia so you as the perioperative nurse must be sure to pay close attention to protecting your patient when positioning. Be sure to check out our lessons on general anesthesia, local anesthesia, and moderate sedation for more information!
Ok guys let’s look at the key points here. The purpose of intraoperative positioning is to provide exposure of the surgical site which is chosen by the surgeon. We padding and positioning devices to protect the patient and protect from nerve issues and maintain proper body alignment. The supine position is back to the OR table, prone position is stomach to OR table, and lateral position is side lying. Trendelenburg position is when the head and torso are lowered and the feet are elevated. In reverse trendelenburg the head is elevated and a footboard prevents sliding. Lithotomy is typically used for gyne procedures with legs in stirrups, in the jackknife position the buttocks are higher than the body. Encourage patients to report aches, extension, skin and mobility issues. They should always remove jewelry and of course ask questions!
Okay guys I hope you enjoyed this lesson on intraoperative positioning! Make sure you check out all the resources attached to this lesson, as well as the rest of the lessons in this course. Now, go out and be your best self today. And, as always, happy nursing!
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