Preoperative Assessment

  • Conduct an assessment of the factors related to the surgery:

    • - type of procedure

    • - estimated length of the procedure

    • - ability of the patient to tolerate the anticipated position

    • - amount of surgical exposure required

    • - anesthesia professional's access to the patient

    • - procedural position and positioning devices required

  • Conduct a pressure injury risk assessment that includes:

    • - age

    • - nutritional status

    • - laboratory test values

    • - comorbidities affecting tissue perfusion

    • - skin condition

    • - ASA physical status classification

    • - body mass index

    • - peripheral pulses

  • Assess patient-specific risk for positioning injury:

    • - critical devices (eg, catheters, drains)

    • - jewelry or body piercings

    • - braided hair, hair accessories, or hair extensions

    • - superficial implants (eg, dermal, iris)

    • - implanted devices (eg, pacemaker, chemotherapy port)

    • - prosthetics or corrective devices

Patient assessment is a critical responsibility to help prevent injury related to patient positioning. Identifying a patient's risk for positioning injury and developing a plan of care is necessary for implementing preventive interventions.

Surfaces and Devices

  • Determine equipment and devices to be used based on the planned procedure, surgeon's preferences, and risk factors.

  • Confirm the availability of required positioning equipment when the procedure is scheduled.

  • Use positioning equipment and devices that have the weight and size capacities necessary for safe movement of the patient.

  • Verify the cleanliness, surface integrity, and correct function of positioning equipment, devices, and support surfaces before use.

  • Use equipment and devices designed for positioning in accordance with the manufacturer's instructions for use.

  • Position the patient on a surface that is smooth and wrinkle-free.

  • Position the patient on surfaces that redistribute pressure.

  • Place positioning devices beneath the patient and not beneath the mattress or overlay.

  • Use additional pressure-redistributing padding to support the patient and redistribute pressure from bony prominences and other pressure points.

  • Apply prophylactic dressings to bony prominences (eg, heels, sacrum) or other areas subjected to pressure, friction, and shear.

  • Do not position the patient on a warming blanket.

  • Do not use towels, sheets, or blankets as positioning devices.

Patients and health care workers are at risk for injury if positioning equipment and devices and support surfaces are not used correctly. Patients should be positioned on surfaces that reduce the potential for pressure injury.

General Positioning Practices

  • Have an adequate number of personnel, devices, and equipment available during positioning activities to ensure patient and personnel safety.

  • Respect the patient's dignity and privacy during positioning.

  • Maintain the patient's head and neck in a neutral position without extreme lateral rotation.

  • Position the patient's head to reduce scalp pressure during the procedure.

  • Protect the patient's eyes.

  • Make sure the patient's neck is not hyperextended for prolonged periods.

  • Verify the patient's body is in physiologic alignment.

  • Prevent the patient's body from contacting metal portions of the OR bed.

  • Monitor the position of the patient's hands, fingers, feet, and toes during positioning, including when changes are made to the configuration of the OR bed.

  • Apply monitoring devices in a way that allows the device to function effectively without nerve, tissue, or circulatory compression.

  • Verify placement, tightness, and security of safety restraints after positioning or repositioning.

  • Assess the patient's pulses after securing safety straps to verify adequate perfusion.

  • Confirm the correct patient position and positioning equipment during the time out.

  • Monitor the patient's position during the procedure.

  • Use intraoperative neurophysiological monitoring to identify potential positioning injuries.

  • Implement repositioning interventions to redistribute pressure, if possible.

Surgical patients are at increased risk for injury caused by compression or stretching of tissues during positioning. The patient who is sedated or anesthetized may not be able to communicate or sense numbness, tingling, tissue temperature changes, or mobility limitations.

Supine Position

  • Position the patient's arms as determined by the needs of the surgical team and the physical limitations of the patient: tucked at the sides with a draw sheet, secured at the sides with arm guards, flexed and secured across the body, or extended and secured on padded arm boards.

  • When tucking and securing the patient's arms with a draw sheet:

    • - place the arms in a neutral position with the palms facing the body

    • - do not hyperextend the elbows

    • - pull the draw sheet up between the patient's body and arm, place it over the arm, and tuck it between the patient and the OR bed mattress

    • - ensure the draw sheet extends from above the patient's elbow to the fingertips

    • - ensure the draw sheet is tight enough to secure the arm but not so tight that it creates a pressure source

  • When extending and securing the patient's arms on arm boards:

    • - place the arm boards level with the OR bed mattress

    • - abduct the arms less than 90 degrees

    • - position the arms with the palms facing up

    • - maintain the arms and wrists in neutral alignment

    • - do not position the arms above the head

  • Flex the patient's knees approximately 5 to 10 degrees.

  • Place the safety strap approximately 2 inches above the patient's knees.

  • Elevate the patient's heels off the underlying surface.

  • Redistribute pressure on the heels by using a heel-suspension device or by elevating the patient's calves with a pressure-redistributing surface.

  • Protect the patient's feet from hyperflexion and hyperextension.

The supine position is the most frequently used position for surgical procedures. This position causes extra pressure on the skin over the occiput, scapulae, olecranon processes, sacrum, coccyx, and calcaneum.

Trendelenburg and Reverse Trendelenburg Position

  • When positioning the patient in the Trendelenburg position:

    • - tuck the patient's arms at his or her sides

    • - minimize the degree of Trendelenburg as much as possible

    • - implement measures to prevent the patient from sliding on the OR bed

    • - do not use shoulder braces, if possible

    • - do not use circumferential wrist restraints

  • Keep the patient in the Trendelenburg position for the shortest time possible.

  • Reposition the patient into the supine or reverse Trendelenburg position at established intervals, if possible.

  • Do not use the Trendelenburg position for patients who are extremely obese.

  • When positioning the patient in the reverse Trendelenburg position:

    • - use a padded foot board to prevent the patient from sliding and reduce the potential for injury to the peroneal and tibial nerves from foot or ankle flexion

    • - monitor the patient's feet and implement corrective actions as indicated

The Trendelenburg position moves the patient's abdominal viscera cephalad to improve surgical access to the pelvic organs. This position causes redistribution of the blood supply from the lower extremities to the central and pulmonary circulation, decreases limb perfusion, and decreases venous return from the head. The reverse Trendelenburg position improves drainage of body fluids away from the surgical site. This position causes venous pooling in the lower body that can result in hypotension.

Lithotomy Position

  • Position the patient's buttocks even with the lower break of the bed in a manner that securely supports the sacrum on the bed surface.

  • Protect the patient's hands and fingers from injury when the foot of the OR bed is raised, lowered, or reattached.

  • Do not place the safety restraint over the patient's chest or abdomen.

  • Position the patient's hips in a manner that prevents excessive flexion, rotation, or abduction.

  • Place the leg holders at an even height.

  • Slowly and simultaneously place the patient's legs into the leg holders (minimum of one person per leg).

  • Support the patient's leg over the largest possible surface area of the leg.

  • Place the patient's heels in the lowest position possible.

  • Do not allow the patient's legs to rest against the leg holder posts.

  • Keep the patient in the lithotomy position for the shortest time possible.

  • Reposition the patient at established intervals, if possible.

  • Before lowering the patient's legs to the bed surface, remove the legs from the leg holders slowly and bring them together simultaneously (a minimum of one person per leg).

The lithotomy position provides surgical exposure for vaginal, rectal, and urologic procedures. Modifications of the lithotomy position include low, standard, high, hemi, and exaggerated, depending on how high the legs and pelvis are elevated for the procedure. Raising the patient's legs shifts to the blood from the legs to the central circulation, increasing cardiac output and venous return. Increased pressure on the diaphragm can cause respiratory compromise.

Sitting or Semi-Sitting Position

  • Minimize the degree of patient head elevation as much as possible.

  • Maintain the patient's head in a neutral position without excessive flexion, extension, or rotation.

  • Flex and secure the patient's arms or nonoperative arm across the body.

  • Pad the patient's buttocks.

  • Flex the patient's knees 30 degrees.

  • Prevent the patient's abdominal pannus from resting on the thighs, if possible.

  • Verify placement and security of the safety restraint across the patient's thighs.

  • Be prepared to detect and implement interventions to manage a venous air embolism.

The sitting and semi-sitting positions are used for access to the shoulder, posterior cervical spine, or posterior or lateral head. Complications that may arise from these positions include venous air embolism, hemodymamic instability, pneumocephalus, quadriplegia, and compressive peripheral neuropathy.

Lateral Position

  • Place a head positioner or pillow under the patient's head.

  • Assess and monitor the patient's dependent ear after positioning.

  • Support and secure the patient's arms on two level and parallel arm boards, with one arm on each arm board, and both arms abducted less than 90 degrees.

  • Place an axillary roll under the patient's dependent thorax, distal to the axillary fold, at the level of the seventh to ninth rib.

  • Verify the patient's bilateral radial pulses after placement of the axillary roll.

  • Maintain the patient's physiologic spinal alignment.

  • Place a safety restraint across the patient's hips.

  • Flex the patient's dependent leg at the hip and knee.

  • Position the patient's upper leg straight and support it with pillows between the legs.

  • Minimize the degree of bed flexion and the duration of kidney rest elevation as much as possible.

  • When using kidney braces, place the longer brace anterior against the iliac crest and the shorter brace posterior against the lumbar back.

  • Keep the patient in the lateral position for the shortest time possible.

  • Reposition the patient at established intervals, if possible.

The lateral position is used for orthopedic procedures involving the hip and for kidney and thoracic procedures. A patient in this position is at risk for injury from pressure on vulnerable points on the dependent side (ie, ear, acromion process, olecranon, iliac crest, greater trochanter, lateral knee, malleolus).

Prone Position

  • Position the patient's head in a neutral position, without excessive flexion, extension, or rotation.

  • Use a face positioner when the patient's head is positioned in the midline.

  • Monitor the position of the patient's face.

  • Prevent direct pressure on the patient's eyes.

  • Position the patient's arms as determined by the needs of the surgical team and the physical limitations of the patient: tucked at the sides with a draw sheet, secured at the sides with arm guards, placed on padded arm boards positioned parallel to the OR bed, or placed on padded arm rests with adjustment joints.

  • When tucking and securing the patient's arms with a draw sheet:

    • - place the arms in a neutral position with the palms facing the body

    • - do not hyperextend the elbows

    • - pull the draw sheet up between the patient's body and arm, place it over the arm, and tuck it between the patient and the OR bed mattress

    • - ensure the draw sheet extends from above the patient's elbow to the fingertips

    • - ensure the draw sheet is tight enough to secure the arm but not so tight that it creates a pressure source

  • When extending and securing the patient's arms on arm boards or arm rests:

    • - Place the arm boards or arm rests at a level lower than the chest

    • - abduct the arms less than 90 degrees with the elbows flexed

    • - position the arms with the palms facing down

    • - maintain the arms and wrists in neutral alignment

    • - do not position the arms above the head

  • Position the patient on two chest supports that extend from the clavicle to the iliac crest.

  • Position the breasts, abdomen, and genitals in a manner that frees them from torsion or pressure.

  • Pad the patient's knees.

  • Elevate the patient's toes off the bed with padding under the patient's shins.

  • Assess the patient's pedal pulses after positioning in the knee-chest position.

  • Position the patient in 5- to 10-degree reverse Trendelenburg.

  • Keep the patient in the prone position for the shortest time possible.

  • Have a gurney readily accessible to reposition the patient from prone to supine if CPR becomes necessary.

The prone position provides access to the dorsal aspects of the patient's body. Potential complications associated with this position include increased abdominal pressure, increased bleeding, compartment syndrome, nerve injuries, cardiovascular compromise, ocular injuries, and venous air embolism.

Positioning Documentation

Document the following:
  • preoperative assessment

  • identification and titles of people participating in positioning the patient

  • patient's position, including the position of the arms and legs and any repositioning activities

  • type and location of positioning equipment or devices

  • type and location of safety restraints

  • type and location of any additional padding

  • specific actions taken to prevent patient injury

  • the chain of custody for any jewelry or other items that are removed from the patient

  • the type and location of implants, jewelry, or other items that cannot be removed

  • actions taken to prevent injury from items that cannot be removed

  • postoperative assessment

Documentation provides a description of the perioperative care administered, the status of patient outcomes upon transfer, information to support continuity of care, and data for identifying trends and demonstrating compliance with regulatory requirements and accreditation standards. Comprehensive documentation is necessary for demonstrating the standard of care was met.