Positioning the Patient

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

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

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

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

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

• implementing safe practices for positioning patients who are pregnant;

• implementing safe practices for positioning patients with obesity;

• 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 the scope of this document. Guidance for preventing deep vein thrombosis (DVT) is outside the scope of this document. 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 personnel and is the responsibility of all members of the surgical team. The goals of patient positioning include

• providing exposure of the surgical site;

• 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, eyes, 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  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. 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 procedures^2-4 ;

• evaluating the patient’s risk for injury based on an assessment of identified needs and the planned operative or invasive procedure^3,5 ;

• anticipating the surgeon’s requirements for surgical access;

• gathering positioning equipment and devices;

• using positioning equipment and devices correctly;

• verifying device and equipment integrity;

• monitoring the patient during the procedure⁶ ;

• 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.^5,7-10 

Incorrectly positioning a surgical patient can result in serious injury to personnel or the patient.^1,11  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, shoulders, and upper extremities of the team members performing these tasks.¹²  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.^1,13 

Peripheral nerve injuries are a relatively uncommon but important complication of positioning. The cause is often multifactorial; systemic factors, nerve insults, and underlying patient factors make these injuries difficult to predict and prevent.¹⁴  Most positioning injuries are caused by mechanisms that involve compression or stretching,⁵  but peripheral nerve injury may be caused by a combination of local factors (eg, stretching, compression, ischemia, transection) and systemic factors (eg, systemic hypotension, inflammation).^15,16 

Some surgical positions increase the risk for a stretching injury (eg, lateral neck rotation).¹⁶  Compression reduces blood flow and disrupts cellular integrity, resulting in tissue edema, ischemia, and necrosis.^5,16  Compression can occur as a result of the pressure of a nerve against a hard surface or bony prominence.¹⁶  Positioning injuries can affect the skin and soft tissues, joints, ligaments and bones, eyes, nerves, and blood and lymph vessels.¹  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 Loss considers procedures to be prolonged when they exceed an average of 4 hours duration.¹⁷ 

Evidence Review

A medical librarian with a perioperative background conducted a systematic search of the databases Ovid MEDLINE, Ovid Embase, EBSCO CINAHL, and the Cochrane Database of Systematic Reviews. The search was limited to literature published in English from December 2014 through December 2020. At the time of the initial search, weekly alerts were created on the topics included in that search. Results from these alerts were provided to the lead author until June 2021. The lead author 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 adhesive tape, airway obstruction, anoxia, armboard*, arterial pressure, attitude of health personnel, attitude to obesity, beach chair position*, bean bag, bed attachments, bed inj*, bed ulcer, bed sore*, beds, beds and mattresses, brachial plexus injury, brachial plexus neuropathies, Braden Scale, Braden Scale for Predicting Pressure Sore Risk, candy cane stirrups, compartment syndromes, cultural bias, cultural competency, cultural diversity, decubitus inj*, decubitus ulcer, decubitus sore*, delivery of health care, deoxygenation, difference in treatment, discrepancies in treatment, ethnic groups, ethnicity, expectant mothers, foam, Fowler position*, fracture table position*, gel pad, gravid, head-down tilt, health care delivery, health care inequalities, health personnel attitude, healthcare disparities, hemodynamic monitoring, hospital acquired pressure ulcers, hospital acquired skin lesions, hospital associated pressure injury, hypotension, hypovolemia, impaired skin integrity, implicit bias, improvised positioning device, inclined position*, intraocular pressure, intraoperative complications, intraoperative monitoring, jackknife position*, knee-chest position, lateral* position*, leg holders, lithotomy position*, Lloyd-Davies position*, mechanical compression*, minorities, minority groups, minority health, monitoring (intraoperative), monitoring (physiological), morbid obesity, Munro scale, nationality, neuropath*, nerv* entrapment, nerv* injur*, nerv* pals*, nerv* peripheral, nerve compression, nerve compression syndromes, nurses role, nurses scope of practice, nursing assessment, nursing care, nursing role, obesity, obesity (morbid), ocular hypertension, ocular hypotony, ocular tonometry, operating room nursing, operating rooms, operating tables, oximet*, oxygen deficiency, oxygen saturation, patient positioning, people of color, perioperative care, perioperative nursing, peripheral nerve injuries, pillows and cushions, positioner*, positioning device, postoperative complications, pregnancy, pregnant, prejudice, pressure inj*, pressure redistributing padding, pressure sore*, pressure ulcers, prone position, prophylactic dressing, race, race factors, racial disparities, racial factors, ramp, ramped position*, risk assessment, risk factors, race, race factors, racial disparities, racial factors, ramp, ramped position*, risk assessment, risk factors, sciatic neuropathy, scope of nursing practice, Scott Triggers, semi-Fowler* position*, severe obesity, shoulder braces, silk tape, Sims position*, skin color, skin pigmentation, skin tone, staff attitude, static overlays, stirrup*, surgical equipment, surgical nursing, supine position, support device, surgical equipment and supplies, table*, tonometry (ocular), Trendelenburg position*, ulnar nerve compression syndromes, ulnar neuropathies, unequal treatment, vacuum-packed positioning, venous congestion, viscoelastic, visual loss, vital signs, wedge*, weight bias, Wilson frame, wounds and injuries, and yellow fin stirrups.

Included were research and non-research literature in English, complete publications, and publications with dates within the time restriction when available. Excluded were non-peer-reviewed publications and older evidence within the time restriction when more recent evidence was available. Editorials, news items, and other brief items were excluded. Low-quality evidence was excluded when higher-quality evidence was available, and literature outside the time restriction was excluded when literature within the time restriction was available (Figure 1).

Figure 1: Flow Diagram of Literature Search Results

Adapted from Moher D, Liberati A, Tetzlaff J, Ativan DG; The PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA Statement PLoS Med. 2009;6(6):e1000097.

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 lead author and the evidence appraiser reviewed and critically appraised each article using the AORN Research or Non-Research Evidence Appraisal Tools as appropriate. The literature was independently evaluated and appraised according to the strength and quality of the evidence. Each article was then assigned an appraisal score. The appraisal score is noted in brackets after each reference as applicable.

Each recommendation rating is based on a synthesis of the collective evidence, a benefit-harm assessment, and consideration of resource use. The strength of the recommendation was determined using the AORN Evidence Rating Model and the quality and consistency of the evidence supporting a recommendation. The recommendation strength rating is noted in brackets after each recommendation.

Note: The evidence summary table is available at https://aorn.org/guidelines/about-aorn-guidelines/evidence-tables.