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Introduction

The Guideline for Positioning the Patient has been approved by the AORN Guidelines Advisory Board. It was presented as a proposed guideline for comments by members and others. The guideline is effective May 1, 2017. The recommendations in the guideline are intended to be achievable and represent what is believed to be an optimal level of practice. Policies and procedures will reflect variations in practice settings and/or clinical situations that determine the degree to which the guideline can be implemented. AORN recognizes the many diverse settings in which perioperative nurses practice; therefore, this guideline is adaptable to all areas where operative or other invasive procedures may be performed.

Purpose

This document provides guidance to perioperative team members for positioning patients undergoing operative and other invasive procedures in the perioperative practice setting. Guidance is provided for

  • demonstrating respect and privacy during patient positioning;

  • conducting preoperative and postoperative nursing assessments specific to patient positioning;

  • identifying, selecting, maintaining, and using positioning equipment and devices;

  • selecting and using pressure-redistributing support surfaces and prophylactic dressings to prevent pressure injury;

  • using neurophysiological monitoring to identify and prevent potential positioning injuries;

  • implementing safe practices for positioning patients in the supine, Trendelenburg, reverse Trendelenburg, lithotomy, sitting and semi-sitting, lateral, and prone positions and modifications of these positions;

  • implementing safe practices for positioning patients who are pregnant or obese;

  • documenting patient positioning and positioning-related activities;

  • planning education and verifying competency of personnel responsible for patient positioning;

  • developing policies and procedures related to patient positioning; and

  • implementing quality improvement programs related to patient positioning.

A discussion of positions or devices used for anesthesia administration, positions for cardiopulmonary resuscitation (CPR), and positions that are preferred or modified for specific procedures are outside the scope of this document. Recommendations for patient moving and handling, transport, transfer, and fall prevention are also outside of the scope of this document. Guidance for preventing deep vein thrombosis (DVT) is outside of the scope of this document; however, because some mechanical methods of DVT prophylaxis are inherently associated with patient positioning, guidance is provided relative to the use of mechanical DVT prophylaxis in combination with specific positions. Guidance related to positioning for robotic procedures is included with the relevant recommendation. There are a vast variety of surgical positions and of positioning equipment and devices, and it would not be possible to address them all in this document; therefore, the information in this guideline is limited to the most commonly used positions and positioning equipment and devices.

Positioning patients is one of the most important tasks performed by perioperative personnel1,2  and is the responsibility of all members of the surgical team.2-5  The goals of patient positioning include

  • providing exposure of the surgical site6 ;

  • maintaining the patient’s comfort and privacy;

  • providing access to intravenous (IV) 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, bony prominences, joints, skin, and vital organs from injury;

  • observing and protecting fingers, toes, and genitals; and

  • stabilizing the patient to prevent unintended shifting or movement.

Positioning the patient is a team effort that includes the perioperative registered nurse (RN), the anesthesia professional, the surgeon, and other perioperative personnel (eg, first assistants, assistive personnel).1,5,7-9  As patient advocates, perioperative team members are responsible for maintaining the patient’s autonomy, dignity, and privacy and for representing the patient’s interests throughout the procedure.10  Some elements of patient positioning are core to anesthesia practice; therefore, the ability of the perioperative team to support the activities of the anesthesia professional is essential. All perioperative team members involved in positioning activities are responsible for

  • understanding the physiologic changes that occur during operative and other invasive procedures9,11-14 ;

  • evaluating the patient’s risk for injury based on an assessment of identified needs and the planned operative or invasive procedure9,13 ;

  • anticipating the surgeon’s requirements for surgical access;

  • gathering positioning equipment and devices;

  • using positioning equipment and devices correctly;

  • monitoring the patient during the procedure1 ;

  • applying principles of body mechanics and ergonomics during patient positioning;

  • respecting the patient’s individual positioning limitations; and

  • implementing interventions to provide for the patient’s comfort and safety and to protect the patient’s circulatory, respiratory, musculoskeletal, neurological, and integumentary structures.2,3,5,13,15 

Incorrectly positioning a surgical patient can result in serious injury to both personnel and the patient.1,4  Performing patient positioning requires the application of lifting, pushing, or pulling forces and therefore presents a high risk for musculoskeletal injury to the lower back and shoulders of the team members performing these tasks.16  Because of the effects of sedation, regional anesthesia, or general anesthesia, patients lack normal perception and protective reflexes and are thus at increased risk for positioning injury.4,17 

Most positioning injuries are caused by mechanisms involving compression or stretching.13  Stretching leads to nerve compression and ischemic changes from reduced blood flow.13  Some surgical positions increase the risk for a stretching injury (eg, lateral neck rotation).13  Compression reduces blood flow and disrupts cellular integrity, resulting in tissue edema, ischemia, and necrosis.13  Positioning injuries can affect the skin and soft tissues, joints, ligaments and bones, eyes, nerves, and blood and lymph vessels.4  A positioning injury can be temporary or permanent, and the effects of the injury can range from minor inconvenience to long-term functional restriction, secondary morbidity, or even death.4,14 

Many positioning injuries are associated with prolonged procedures. The definition of a prolonged procedure is subjective, and the literature does not conclusively define a time parameter for prolonged surgery. The American Society of Anesthesiologists (ASA) Task Force on Perioperative Visual Loss18  considers procedures to be prolonged when they exceed an average of 6.5 hours duration (range 2 hours to 12 hours).

Failing to provide appropriate positioning interventions for individuals undergoing operative or other invasive procedures may be deemed negligence or a failure to meet the duty of care owed to the patient.19  When there is a positioning injury, the doctrine of res ipsa loquitur (ie, the thing speaks for itself) may be applicable.11  Under this doctrine, there is an assumption that the event that caused the injury was under the control of the defendant (eg, surgeon, anesthesia professional, perioperative RN) and would not have occurred if proper care had been provided to the plaintiff (ie, patient).11  The potential for a patient injury and for litigation underscores the importance of implementing positioning interventions to prevent nerve and tissue damage and thoroughly and accurately documenting the care provided.11,12 

Evidence Review

A medical librarian conducted a systematic literature search of the databases Ovid MEDLINE®, EBSCO CINAHL®, Scopus®, and the Ovid Cochrane Database of Systematic Reviews. The search was limited to literature published in English from 2008 through February 2016. At the time of the initial search, weekly alerts were created for the topics included in that search. Results from these alerts were provided to the lead author until September 2016. The lead author requested a supplementary search on eye protection and requested additional articles that either did not fit the original search criteria or were discovered during the evidence appraisal process. The lead author and the medical librarian also identified relevant guidelines from government agencies, professional organizations, and standards-setting bodies.

Search terms included positioning, positioning injury, compression injury, shear, friction, pressure, interface pressure, pressure ulcers, pressure reducing, pressure relieving, positioning surfaces, support surfaces, positioning equipment, positioning devices, safety straps, OR table, OR bed, OR mattress, alternating pressure mattresses, procedure table, padding, foam, gel, viscoelastic, supine, Fowler/Semi-Fowler/beach chair, lithotomy, lateral, prone, Trendelenburg/reverse Trendelenburg, jack-knife/Kraske, and robotic. Other subject headings and keywords were included to address specific positioning devices, alternative terms for positions, patient-monitoring indicators, and risk assessment.

Excluded were non-peer-reviewed publications and low-quality evidence when higher-quality evidence was available. In total, 1,013 research and non-research sources of evidence were identified for possible inclusion, and of these, 529 are cited in the guideline (Figure 1).

Figure 1.
Flow Diagram of Literature Search Results

Flow Diagram of Literature Search Results

Included articles were independently evaluated and critically appraised according to the strength and quality of the evidence. Articles identified in the search were provided to the project team for evaluation. The team consisted of the lead author and one evidence appraiser. The articles were reviewed and critically appraised using the AORN Research or Non-Research Evidence Appraisal Tools as appropriate. Each article was then assigned an appraisal score. The appraisal score is noted in brackets after each reference as applicable.

The collective evidence supporting each intervention within a specific recommendation was summarized, and the AORN Evidence Rating Model was used to rate the strength of the evidence. Factors considered in review of the collective evidence were the quality of the evidence, the quantity of similar evidence on a given topic, and the consistency of the evidence supporting a recommendation. The evidence rating is noted in brackets after each intervention.

 

Note: The evidence summary table is available at http://www.aorn.org/evidencetables/.

 

Editor’s note: Ovid MEDLINE is a registered trademark of the US National Library of Medicine’s Medical Literature Analysis and Retrieval System, Bethesda, MD. CINAHL, Cumulative Index to Nursing and Allied Health Literature, is a registered trademark of EBSCO Industries, Birmingham, AL. Scopus is a registered trademark of Elsevier B.V., Amsterdam, The Netherlands.

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