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 pt’s 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 pt’s head, spine, and legs. Ensure that the pt’s 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 pt’s 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 pt’s 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 pt’s 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 pt’s arms more that 90 degrees. • Secure eh arms to the arm boards with safety straps. • If the arms are to be placed at the pt’s 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 pt’s 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 pt’s 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 pt’s 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 pt’s 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 surgeon’s work are. • Check that the pt’s 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 pt’s arms across the abdomen. • Have the asst stand by the pt to protect the arms. • Stand between the pt’s legs and move the pt to the edge of the OR bed break by placing the hands and arms under the pt’s 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 pt’s arms.

20. High Lithotomy Position • Repositioning the pt after surgery • Check to ensure that the pt’s 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 pt’s legs and remove the stirrup strap. • With one hand under the pt’s 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 pt’s 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 pt’s 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 pt’s 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 pt’s 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.