Positioning the Periop Patient

1
Positioning the Periop Patient
Source Phippen, M.L. Wells, M.P. (1995).
Perioperative nursing handbook. (p. 165-167).
2

• The perioperative nurse demonstrates competency
  to position by placing the pt in the
• Supine
• Trendelenburg position
• Reverse Trendelenburg position
• Low lithotomy position
• High lithotomy position
• Lateral decubitus position
• Prone position
• Jackknife position
• Sitting position

3
Communication

• Communication with the pt and members of the
  operative team is essential.
• Inform pt of the position procedure during the pt
  teaching session.

4
Prepare the OR Bed

• Ensure safety of OR bed functioning properly,
  clean, free from hazards, padded.
• Check that pads are of equal height.
• Lock the bed in place.
• College all required positioning
  devices/attachments. Check that these are
  functional, clean, free from hazards.
• Attach a padded table extension if the pts body
  will extend beyond the end of the OR bed.
• Transfer the pt to the OR bed.

Center the Pt on the OR Bed

• Align the pts head, spine, and legs. Ensure
  that the pts legs are not crossed.
• Apply the safety strap at least 2 inches above
  the knees without excessive pressure.
• Insert a hand between the strap and the thighs to
  check for excessive pressure.

5
Place the pts Arms on the Arm Boards

• Attach the arm boards to the OR bed at less than
  a 90-degree angle to the body.
• Secure each arm with a safety strap.
• If the palms are placed at the sides, turn them
  toward the pts sides with the fingers extended.
• Pad the arms and tuck them with the draw sheet.
• Check the elbows to ensure that they are not
  flexed or resting on the metal edge of the OR
  bed.
• Ensure that the fingers are clear of the OR bed
  breaks and other possible hazards.
• Pad bony prominences.

6
Moving the Anesthetized Pt

• Check with the anesthetist before positioning or
  repositioning the anesthetized pt.
• Do not move the pt unless adequate assistance is
  available.
• Move the pt slowly, as a coordinated team.
• Reassess the pt for body alignment and tissue
  integrity before draping.
• Examine the safety strap to ensure that it is
  secure and not constrictive.

7
Supine Position
8
Supine Position
9
Supine Position

• Supplies and Equipment
• Primary
• Arm boards
• Arm restraints
• Pillow or headrest
• Padding for bony prominences (foam, sheepskin,
  blankets, pillows)
• Safety strap.
• Supplementary
• Padded footboard
• Pelvic wedge
• OR bed extension
• Toboggans

10
Supine Position

• Procedure
• After the transfer, align the pts head, neck,
  spine, and legs.
• Ensure that the legs are not crossed and are
  slightly apart.
• Secure the safety belt above the knees.
• Check that the pt is not resting on any unpadded
  surfaces.
• Check that the extremities are secured away from
  the OR bed joints (breaks) and attachments.
• When using arm boards, do not abduct the pts
  arms more that 90 degrees.
• Secure eh arms to the arm boards with safety
  straps.
• If the arms are to be placed at the pts sides,
  turn the palms toward the body or the bed and
  secure the full length of the arms with a draw
  sheet or a padded toboggan).
• Apply protective padding to all area that are
  susceptible to injury.
• Place a small pad under the pts head, lower the
  lumbar area, and heels and avoid hyper extending
  the knees.
• For pregnant or obese pts, place a small pelvic
  sedge under the right side of the pt to relieve
  pressure on the vena cava.
• If needed attach a padded footboard to the bed.

11
Trendelenburg Position
12
Trendelenburg Position

• Supplies and Equipment see supine position.

• Procedure
• Position the pt as described for supine position.
• If the knee section of the OR bed is to be
  lowered to minimize pressure on the calves and
  knee joints, position the top edge of the pts
  knees below the hinge at a distance approx. equal
  to the thickness of the OR bed pad and x-ray
  tunnel.
• Tilt the bed, feet up and head down to the
  desired angle.

13
Reverse Trendelenburg Position
14
Reverse Trendelenburg Position

• Supplies and Equipment
• See supine position.
• Procedure
• Position the pt as described for the supine
  position.
• Attach a padded footboard to keep the pt from
  sliding toward the foot of the OR bed.
• Tilt the bed, feet down and head up, to the
  desired angle.

15
High Lithotomy Position
16
High Lithotomy Position

• Personnel Requirements
• Two persons are required.
• Supplies and Equipment
• See supine position.
• Protective leg covering (foam boots, towels).
• Stirrups
• Stirrup holders
• Rail sockets.

17
High Lithotomy Position

• Procedure
• Adjust the OR bed and transfer the pt.
• Before transfering the pt, adjust the OR bed.
• Release the head section of the mattress pad and
  pull the headpiece and mattress pad out.
• Attach the head piece and mattress to the foot of
  the OR bed.
• Refit the bedsheet to the OR bed.
• Transfer and prepare the pt for administraetion
  of anesthesia in the supine position as described
  for interventions for all surgical positions.
• Apply protective padding to the pts feet and
  lower legs.
• Use other protective padding as described for
  interventions for all surgical positions.

18
High Lithotomy Position

• Attach the stirrups
• Attach the stirrup holder to the OR bed above the
  knee break hinge.
• Insert the stirrup into the holders and tighten.
• Adjust the stirrups to the appro ht., ensure that
  they are level and secure.
• Place the pt in the High Lithotomy Position
• After the pt is anesthetized, remove the safety
  strap from the legs.
• Grasp the sole of one ft in one hand, supporting
  the leg at the knee with the other hand.
• Instruct the assistant to perform the same
  maneuver for the other leg.
• Together with the assistant, slowly flex the legs
  toward the abdomen, then slightly externally
  rotate the hips and secure the feet to the
  stirrups.
• Cover the pts genitalia and perineum with a
  towel or sheet.

19
High Lithotomy Position

• Complete the modification of the OR RM
• Remove the headrest and the leg section of the OR
  bed.
• Place the headrest and the leg section on a clean
  surface outside of the surgeons work are.
• Check that the pts fingers are not in the hinges
  of the bed.
• Lower the leg section of the OR bed.
• Repositioning the Pt before Surgery
• Remove the arm board and straps and fold the pts
  arms across the abdomen.
• Have the asst stand by the pt to protect the
  arms.
• Stand between the pts legs and move the pt to
  the edge of the OR bed break by placing the hands
  and arms under the pts buttocks and gently
  lifting using proper body mechanics, or with
  another team member lift the pt with the draw
  sheet.
• Move the arm boards and resecure the pts arms.

20
High Lithotomy Position

• Repositioning the pt after surgery
• Check to ensure that the pts hands and fingers
  are extending beyond the OR bed break.
• Elevate the leg section to the horizontal
  position.
• Replace the mattress pad on the leg section.
• Put the head section and mattress pad back on the
  foot of the bed.
• Have the asst stand on the opposite side of the
  OR bed and perform the same maneuvers for the
  other leg.
• When given clearance by the anesthetist, grasp
  the pts legs and remove the stirrup strap.
• With one hand under the pts heel and the other
  under the knee, slowly extend the legs and lower
  them together.
• Reapply the safety strap securely across the
  thighs.
• Cover the pt with a warm sheet or blanket.
• Remove the positioning equipment from the OR bed.

21
Low Lithotomy Position
22
Low Lithotomy Position

• Staffing Requirements
• The perioperative nurse and an asst. are the
  minimal staff needed.
• Supplies and Equipment
• See supplies and equipment for High Lithotomy
  Position.
• Procedure
• Adjust the Operating Rm bed and transfer the pt.
• Adjust the OR bed as described for high Lithotomy
  position.
• Transfer and prepare the pt for administration of
  anesthesia in the supine position as described
  under interventions for all surgical positions.
• Apply protective Devices
• Apply protective padding to the pts feet and
  lower legs.
• Apply additional protective padding as described
  under interventions for all surgical positions.

23
Low Lithotomy Position

• Attach the Leg holders.
• Attach the rail socket to the OR bed above the
  knee break hinge. Insert the leg holders into
  the rail socket and tighten. Adjust the leg
  holders to the appro height ensure that they are
  level and secure.
• Place the pt in the low Lithotomy position
• After the pt is anesthetized, remove the safety
  strap from the legs.
• Grasp the sole of one foot in one hand,
  supporting the leg at the knee with the other
  hand.
• Instruct the asst to perform the same maneuver
  with the other leg. Together with the asst,
  slowly flex the legs toward the abdomen, then
  slightly externally rotate the hips and secure
  the legs to the leg holders.
• Ensure that the thighs are at an obtuse angle to
  the trunk.
• Cover the pts genitalia and perineum with a
  towel or sheet.
• Complete modification of the OR bed as described
  for the high Lithotomy position.
• Reposition the pt if necessary as described for
  the high Lithotomy position.

24
Low Lithotomy Position

• Repositioning after surgery
• Check to ensure that the pts hands and fingers
  are not extending beyond the OR bed break.
• Elevate the leg section to the horizontal
  position.
• Replace the mattress pad on the leg section and
  put the head section and mattress pad back on the
  foot of the bed.
• Have the asst stand on the opposite side of the
  OR bed and perform the same maneuvers for the
  other leg.
• When given clearance by the anesthetist, place
  one hand under the pts heel and the othe under
  the knee, slowly lift the legs off the leg
  holder, extend the elgs, and lower them together.
• Reapply the safety strap.
• Cover the pt with a warm sheet or blanket.
• Remove the positioning equipment from the OR bed.