Patient Positioning (Performance)

Guidelines:

• Goals of patient positioning:
  • Providing exposure of the surgical site
  • Maintaining patient’s comfort and privacy
  • Providing access to intravenous lines and monitoring equipment
  • Allowing for optimal ventilation by maintaining a patent airway and avoiding constriction or pressure on the chest or abdomen
  • Maintaining circulation and protecting muscles, nerves, and bony prominences, joints, skin, eyes, and vital organs from injury
  • Observing and protecting fingers, toes, and genitals
  • Stabilizing to prevent unintended shifting or movement

Considerations:

• Team Communication
  • Safe positioning is the responsibility of the entire surgical team
  • Briefing, Time-out, Debriefing
  • Clear communication to prevent falls during positioning and transfer
  • Pre-op assessment (mobility, skin integrity, BMI, etc.)
• Positioning
  • Focus on neutral positioning
  • Limit amount of time patient is in Trendelenburg, lithotomy, or prone positioning or variations to reduce risk of injury
  • Secure arms, but be careful not to apply pressure
  • Second time-out for positioning check

Nurse’s role:

• Positioning core elements:
  • Head/neck neutral to prevent brachial plexus injury
  • Reposition patient’s head to decrease scalp pressure
  • Place pillow or padding under the patient’s lumbosacral area
  • Flexing the patient’s knees approximately 5-10 degrees
  • Placing the OR bed safety strap approximately 2 inches above the patient’s knees
  • Placing the patient’s legs parallel without crossing the ankles
  • Protecting the patient’s feet from hyperflexion or hyperextension
  • Tuck arms at sides using a draw sheet
    • Tuck between patient and the OR bed mattress
    • Not so tightly as to become a pressure source
    • Should extend from mid-upper arm to fingertips
  • Secure arms at sides using arm guards
    • Boards are padded and level with OR bed mattress
    • Arms in a palms-up position with neutral alignment of wrists and arms
  • Flex and secure arms across body
  • Extend and secure the arms on arm boards
• Prone Position
  • Elevate head of OR bed 5-10 degrees to help reduce venous congestion in the face, intraocular pressure, and facial edema
  • Head in neutral alignment
  • Avoid horseshoe-shaped head positioners, pressure may cause POVL
  • Place two chest supports from the clavicle to the iliac crest to facilitate chest and abdominal expansion and decrease pressure on the abdomen
  • Verify breasts, genitalia, and abdomen are free from pressure or torsion
  • Padding patient’s knees and placing padding under lower legs to elevate the toes from the bed and prevent pressure on the toes
  • Arms tucked securely, but not tightly, at sides with a draw sheet; securing at sides with arm guards; placing arms on padded arm boards that are parallel to OR bed; placing on padded arm rests with articulated joints.
  • Avoid abducting patient’s arms more than 90 degrees with elbows flexed.

Pitfalls:

• Failure to protect patient and employ the appropriate interventions for patients undergoing surgery may be deemed as negligence or failure to meet the duty of care
• Assumption that the circumstances that caused the injury were under the control of perioperative team members
• Do not use shoulder braces
• Do not position arms above the patient’s head
• Do not position arms at an angle greater than 90 degrees from the patient’s body

Examples:

• What areas of the patient’s body can be under increased pressure while in supine position?
  • Back of head
  • Elbows
  • Scapulae
  • Sacrum
  • Coccyx
  • heels

Linchpins (Key Points):

• Patient positioning is a team effort
• Focus on neutral positioning of head, arms, legs
• Reposition when possible
• Team communication for patient safety