Surgical Patient Positioning

ST210Concorde Career College, Portland

PositioningObjectives:

List the basic surgical positions and analyze the use of each

Identify basic positioning aids and describe the use of each

PositioningObjectives:

List the steps for placing the patient in the basic surgical positions and list the potential hazards and safety precautions that relate to each position

Surgical Technology Lecture Series 2000©

Power-Point®

Production Notes

Primary Author - Kevin Frey CST, MA

Coauthor and Executive Editor - Bob Caruthers CST, PhD

Series Editor - Teri Junge, MEd, CSFA, CST, FAST

Table of Contents

General Information Patient Safety Equipment Patient Positions

General Information

Position Determination

General factors Surgical procedure Surgeon’s preference Technique of anesthetic administration

Patient factors Age Size (height and weight) Cardiopulmonary status Preexisting conditions

Responsibilities

Choice of position is made by surgeon and anesthetist

The surgeon will ensure the patient is properly positioned

Safe positioning of the surgical patient is the responsibility of the entire surgical team

Timing of Positioning Patient is not positioned or moved until the

anesthetist indicates it is okay to do so

Factors that influence time of positioning Site of surgical procedure Age and size of patient Type of anesthetic administered Pain associated with moving conscious patient

Patient Safety

Patient Safety

Safety

Properly identify patient Operating table and gurney locked

Mattress secured to operating table Minimum of 2 people assist an awake

patient during transfer Person on “gurney side” helps patient

move to operating table Person on “operating table side”

prevents patient from falling off the narrow table

Safety (continued)

Minimum 4 persons to move unconsciousness, obese, or weak patients Move on the count of three Anesthetist controls timing Anesthetist controls head and neck at all times Lift - do not slide or pull the patient Surgeon is responsible for stabilizing un-

splinted fractures during move

Safety (continued) Anesthetized patient is moved slowly to allow

circulatory system to adjust Body parts not to extend beyond table edges,

rest on metal parts, or unpadded surfaces Body exposure kept to minimum

Prevent hypothermia Maintain patient’s dignity (especially awake

patient)

Safety (continued)

Protect arms Prevent accidental IV removal Avoid hyperextension of arm board

Be sure patient in the supine position has not crossed legs Uncrossed to avoid neurovascular compromise

Safety (continued) Chest rolls are used in

the prone position to facilitate respiration

Protect patient’s fingers and skin at flex points of table

Mayo stand must not rest on patient If table raised during

procedure; Mayo stand must also be raised

Respiratory System Requirements Unhindered

diaphragmatic movement

Patent airway Prevent hypoxia

Some hypoxia may be unavoidable

Facilitate inhalation anesthesia

No constriction about neck or chest

Place arms at sides, on arm boards, not crossed on the chest

Circulatory System Requirements Adequate circulation

required Maintain BP Provide oxygenated

blood to tissue Facilitate venous return, Prevent thrombus

formation Pressure on peripheral

blood vessels avoided Body support and

safety straps not too tight

Peripheral Nervous System Requirements

Avoid prolonged pressure or stretching on peripheral nerves Injury can range from

sensory and motor loss to paralysis

Positioning devices that come in contact with patient must be well padded

Peripheral Nerves (continued)

Frequent sites of injury Divisions of the brachial

plexus Due to extreme positions

of head and arm Ulnar nerve Radial nerve Peroneal nerve

Extremity nerves damaged by compression against bone, stirrups, or operating table

Facial nerve

Musculoskeletal System Requirements

Anesthetized patients lack muscle tone or control

Strain on muscles results in injury Body alignment must be maintained

Soft Tissue Requirements Body weight distributed

unevenly on operating table Weight on bony

prominences can lead to skin ulceration

Tissue folded under skin of obese patient will not receive proper perfusion

Debilitated patients and diabetics are at high risk for decubitus ulcers

Wrinkled sheets and edges of positioning devices under the patient can cause pressure on skin

Patient Access

Anesthetist must be able to Attach monitoring

devices Administer anesthesia Observe patient Maintain access to

airway and IV sites

Equipment

Operating Table

Electric or manual hydraulic

Metal top 3 hinged sections:

head, body, leg Allow patient to be

manipulated; flexed Joints of table referred

to as breaks Flexing the table is

referred to as breaking

Operating Table (continued) Metal crossbar between

two upper sections to elevate kidney area

X-ray penetrable top extends length of table for insertion of X-ray cassette

Rubber; foam mattress adhered with Velcro®

Foot extension board for tall patient; also used with lithotomy position

Operating Table (continued)

Table is manipulated into desired position either by electronic controls or lever-operated hydraulic system

Control set on back, side, foot, or flex

Brake is set to maintain table position

Table Accessories Safety belt (knee strap)

Placed over thighs 2” above knees Circulator should be able to pass fingers between

strap and patient Some straps attached at sides of table; others

fastened in middle Blanket placed on patient between skin and belt

Belt placed over, not under blanket

Table Accessories (continued) Anesthesia screen

Metal bar attaches to head of table to hold drapes off patient’s face

Substitute for IV poles Lift sheet (draw sheet)

Folded sheet placed horizontally across top of sheet on operating table

Can be used in moving patient

Table Accessories (continued) Lift sheet (continued)

Arms can be enclosed in sheet with hands placed palm down or turned inwards toward body

Finger tips must extend beyond edges of sheet Tuck sheet under patient’s sides Do not tuck under sides of mattress

Table Accessories (continued) Arm boards

Support arms Provide access to IV Support arm or hand

where surgical site is located

Hand placed palm up on board to prevent ulnar nerve pressure and abnormal shoulder rotation Exceptions Prone position Upper arm of lateral

position

Table Accessories (continued)

Arm boards (continued) Arm board can be adjusted to different angles Never abduct arm more than 90 degrees from

shoulder Double arm board

Arms positioned one above the other Also called overhead arm support

Table Accessories (continued) Wrist straps

Narrow straps placed around wrists to secure hand and arm to arm board

Hand table (upper extremity table) Slipped under mattress

on one side of table Other end of table

supported by legs Can use 2 arm boards

placed side-by-side; not as effective or safe

Table Accessories (continued)

Shoulder braces Padded concave

supports to prevent patient from slipping off table when using Trendelenburg position

Acromion processes must rest on braces, not muscles or soft tissue near the neck

Table Accessories (continued)

Kidney rests Padded concave

pieces that slide under mattress on kidney elevator

Placed snugly against body to provide stability in kidney position

Table Accessories (continued)

Body (hip) restraint strap A wide belt or tape (preferred) is used Placed over patient’s hips to help secure patient in

lateral position

Table Accessories (continued) Hemorrhoid strap

Benzoin spray 3” wide adhesive tape Strips placed

approximately 4” lateral to surgical site

Use 2 strips per side Spread buttocks when

patient is in Kraske position

Table Accessories (continued)

Stirrups (candy canes) Metal poles placed in

holder on each side of operating table to support legs and feet in lithotomy position

Feet supported by canvas or fabric loops, suspending the legs

Table Accessories (continued)

Metal footboard Foot extension board

placed perpendicular to table to keep patient from slipping off operating table in reverse Trendelenburg

Used to prevent foot drop during extended procedures

Table Accessories (continued) Donut

Ring-shaped foam pad for head Also used to protect pressure points

Bolsters Used to elevate specific part of body Chest roll Axillary roll

Table Accessories (continued) Suction bean bag

Placed on top of operating table

Patient lays on the bean bag

Suction attached to one end of bag

As air is withdrawn the pad hardens and is molded to the patient’s body by the surgical team

Table Accessories (continued)

Suction bean bag (continued) Suction disconnected to release To allow air to reenter, valve is squeezed Excellent positioning device for stabilizing patient

in lateral position

Table Accessories (continued)

Wilson Frame For thoracic spinal

surgery Used to open the

intervertebral spaces

Table Accessories (continued)

Trauma attachments Used for extraction

during procedures such as ORIF, nail or rod insertion, and percutaneous pinning

Table Accessories (Continued) OSI Jackson Table

Modular table system used primarily for spinal procedures

Choice of flat table top or open frame

Carbon construction facilitates fluoroscopy use

Patient Positions

Supine (Dorsal) Position Patient lies on back

If arms at side, supported by draw sheet, palms down

If arms on arm boards, palms up

Legs straight and in line with head and spine

Hips parallel to spine

Supine (continued) Safety belt across thighs 2” above knees Pillows placed under head, under knees,

under lumbar curvature Protect heels from pressure Feet must not be in prolonged plantar flexion

(foot drop)

Supine (continued) Procedures

Anterior surface of body Extremities

Modifications Procedures on face or neck: Place rolled towel

lengthwise along upper boarder of scapula to slightly hyperextend neck and/or lower head section of operating table

Supine (continued)

Modifications (continued) Modified dorsal recumbent (frog leg)

Knees slightly flexed with a pillow under each

Thighs externally rotatedSoles of feet rest on table top

Trendelenburg Position

Supine with head tilted downward Safety belt 2” above

knees Shoulder brace may be

used Lung volume

decreased Heart mechanically

compressed by pressure of organs against diaphragm

Trendelenburg (continued)

Level entire table slowly at end of procedure Procedures

Lower abdomen or pelvis to allow abdominal viscera to fall away from surgical site

Reverse Trendelenburg Position Supine with head

tilted upward Padded foot board

may be necessary Small pillows placed

under knees and lumbar curvature

Donut for the head Safety belt 2” below

the knees Footboard may be

used to retain patient on table

Reverse Trendelenburg (continued) Procedures

Upper abdomen Allows abdominal viscera to fall away from surgical site Examples: gallbladder, biliary tract, splenectomy

Thyroidectomy Facilitates breathing and decreases blood supply to

surgical site

Fowler’s (Sitting) Position Start with patient in the

supine position Buttocks at flex in table Knees over lower break

Foot section lowered slightly to flex knees

Body section raised becoming the “back” of the chair

Arms rest on armboards parallel to operating table Alternative: Secure arms to

large pillow placed on lap

Fowler’s (continued) Safety belt placed 2” above the knees Table tilted slightly head downward Table resembles modified armchair Procedures

Shoulder Nasopharyngeal Facial Breast reconstruction

Lithotomy Position Wrap ankle and foot of

patient with towel, leggings, or cotton boots for padding against canvas loops

Transfer head section to foot end of table to serve as foot extension

Place stirrup on side of table that will not be used for patient transfer

Lithotomy (continued)

Start with the patient in the supine position Arms placed on armboards

Hands not to extend along table where fingers could be crushed in breaks while leg section is lowered or raised

Buttocks resting along break between body and leg section

Place other stirrup Stirrups must be of equal position and at an

appropriate height according to length of patient’s legs

Lithotomy (continued) When anesthetist gives permission, both legs are

raised simultaneously by two persons Support the foot, ankle, and calf Flex the knees and legs; place inside the stirrup

posts Place feet in canvas loops

First loop of canvas around ankle Second loop around sole of foot

Lithotomy (continued) Lower section of mattress is removed Leg section of table is lowered

Lower leg or ankles must not touch any metal part of the stirrup

Buttocks must be even and not extend beyond table edge Extension beyond edge causes strain on

lumbosacral muscles and ligaments due to body weight placed on sacrum

Lithotomy (continued)

Conclusion of surgical procedure Raise leg section Replace mattress When anesthetist gives permission, both legs are

extended, brought together, and lowered slowly and simultaneously by two persons Prevents hypotension as blood reenters legs and leaves

the torso Essential to avoid lower back strain

Reapply safety belt Safety belt not applied when patient is in lithotomy

Lithotomy (continued) Lung compliance is decreased by pressure of

thighs on abdomen Diaphragmatic movement restricted

Procedures Perineal Vaginal Urological Rectal

Prone Position Patient lays on abdomen

(face down) Chest rolls pre-placed on

operating table Extend from clavicles to iliac

crest to facilitate respiration Patient is anesthetized and

intubated in the supine position on the gurney

When anesthetist gives permission, patient is slowly rolled onto abdomen on operating table by team of at least 4 people

Prone (continued) Breasts moved laterally External genitalia toward foot of table Arms

Placed along side of body with palms up or towards side of body Can cause pressure on breasts

Placed on armboards, angled with elbows flexed Palm downward

When moving arm, lower toward floor rotating in an upward in natural movement

Prone (continued) Head turned to one side; use a donut Pillow under anterior of ankles Safety belt above the knees

Procedures Spine Posterior aspect of lower extremity

Kraske (Jackknife) Position Modification of the

prone position Hips over center break

between body and leg sections of operating table

Chest rolls employed Arms on arm boards;

elbows flexed; palms down

Head to the side on donut Pillow under ankles Safety belt below the

knees

Kraske (continued) Leg section lowered; entire table tilted head

downward so hips are elevated above body Return patient to level position slowly Remove safety belt when moving table parts Venous pooling occurs cephalad and caudad Kraske position not tolerated well by patients

Procedures Rectal Pilonidal sinus

Knee-Chest Position Modification of the

prone position Foot extension Table flexed at center

break Leg section at right

angle to operating table Patient kneels on lower

section Knees are flexed at

right angle to body Head turned to side;

placed on donut

Knee-Chest (continued)

Arms placed on pillow near head with elbows flexed

Safety belt above the knees or tape used Pillows placed on foot board and taped into place

Procedures Spine

Lateral Position Anesthesia administered

with the patient in the supine position, then repositioned onto the non-operative side Turned by no fewer than 4

people As patient is turned,

patient’s back drawn to edge of operating table

Arms placed on overhead armboard; lower arm palm up; upper arm slightly flexed with palm down

Lateral (continued) Lower leg flexed at knee Upper leg straight Large pillow placed lengthwise between legs to

prevent pressure on peroneal nerve Safety belt or wide tape placed over hip to provide

stability BP taken from lower arm Small roll under axilla to relieve pressure

Lateral (continued) Shoulders in alignment Head in cervical alignment Supported by pillow between shoulder and neck to

prevent stretching the neck, brachial plexus, aid in maintaining patent airway

Procedures Thorax Kidney Retroperitoneal space

Kidney Position Modification of lateral

position with flank region over kidney elevator Short kidney rest

attached to elevator at patient’s back

Longer rest placed on front below level of iliac crest to prevent pressure on abdominal organs

Table slightly flexed Kidney elevator raised to

increase space between lower ribs and iliac crest

Kidney Position (continued)

Safety strap or wide tape placed after table flexed and elevator raised

Entire table tilted head downward until surgical area is horizontal

For all lateral positions, keep shoulder, hip, knee, and ankle in alignment

Before closure, table is flattened to allow better approximation of tissues

Procedures Kidney