Patient Positioning (Performance) for Certified Perioperative Nurse (CNOR)

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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

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Transcript

References

Armstrong M. & Moore, R.A. (2022). Anatomy, Patient Positioning. StatPearls [Internet].
https://www.ncbi.nlm.nih.gov/books/NBK513320/
Association of periOperative Registered Nurses (AORN): Guideline Essentials (website), 2022, https://www.aorn.org/guidelines-resources/guidelines-for-perioperative-practice/guideline-essentials
Rothrock, J. (2019). Alexander’s Care of the Patient in Surgery (16th ed.). Elsevier Health Sciences.
Spruce, L. (2021). Positioning the patient. AORN Journal, 114(1), 75-83. http://doi.org/10.1002/aorn.13442