Patient POSITIONING

Positions• Four basic

positions include:–Supine–Prone–Lateral–Lithotomy

• Variations include:–Trendelenburg–Reverse

trendelenburg–Fowler’s– Jackknife–High lithotomy–Low lithotomy

Supine• Most common with the least amount of harm• Placed on back with legs extended and uncrossed at the

ankles• Arms either on arm boards abducted <90* with palms up or

tucked (not touching metal or constricted)• Spinal column should be in alignment with legs parallel to

the bed• Padding is placed under the head, arms, and heels with a

pillow placed under the knees• Safety belt placed 2” above the knees while not impeding

circulation

Prone • Face down, resting on the abdomen and chest• Chest rolls x2 placed lengthwise under the axilla and along

the sides of the chest from the clavicle to iliac crests• One roll is placed at the iliac or pelvic level• Arms lie at the sides or over head on arm boards• Head is face down and turned to one side with accessible

airway• Padding to bilateral feet, arms and knees• Safety strap placed 2” above knees

Lateral • Shoulder & hips turned simultaneously to prevent torsion of

the spine & great vessels• Lower leg is flexed at the hip; upper leg is straight• Head must be in cervical alignment with the spine• Axillary roll placed to the axillary area of the downside arm• Padding placed under lower leg, to ankle and foot of upper

leg, and to lower arm (palm up) and upper arm• Pillow placed lengthwise between

legs and between arms • Stabilize patient with safety

strap and silk tape, if needed

Trendelenburg • The patient is placed in the supine position while

the bed is modified to a head-down tilt of 35 to 45 degrees, the head being lower than the pelvis

• In addition to a safety strap, strips of 3” tape may be used to assist with holding the patient in the position

• Used for procedures in the lower abdomen or pelvis

Reverse Trendelenburg • The bed is tilted so the head is higher than the

feet• Used for head and neck procedures• Facilitates exposure, aids in breathing and

decreases blood supply to the area• A padded footboard is used to prevent the patient

from sliding toward the foot

Fowler’s Position (Sitting/Lawnchair/Beachchair)

• Foot of the bed is lowered, flexing the knees, while the body section is raised to 35 – 45 degree

• Feet rest against a padded footboard• Arms are crossed loosely over

the abdomen and placed on a pillow on the patient’s lap

• A pillow is placed under the knees.• For cranial procedures, the head is

supported in a head rest and/or with sterile tongs

• This position can be used for shoulder or breast reconstruction procedures

Jackknife • Modification of the prone position• The patient is placed in the prone position on the bed and

then inverted in a V position• Chest rolls are placed to raise the chest• Arms are extended on angled arm boards with the elbows

flexed and the palms down• A pillow is placed under the ankles to free the feet and toes

of pressure

• The bed leg section is lowered, and the bed is flexed at a 90 degree angle

• Used in gluteal and anorectal procedures

Lithotomy • With the patient in the supine position, the legs are raised

and abducted to expose the perineal region• The legs and feet are placed in stirrups that support the

lower extremities• Stirrups should be placed at an even height• Adequate padding and support for the legs/feet should

eliminate pressure on joints and nervus plexus• The position must be symmetrical

High Lithotomy • Frequently used for procedures that requires a vaginal or

perineal approach• The patient is in the supine position with legs raised and

abducted by stirrups• Once the feet are positioned in stirrups, the footboard is

removed and the bottom section of the bed is lowered• It may be necessary to bring the

patient’s buttocks further down to the edge of the bed break

Low Lithotomy • All of the positioning techniques used to high

lithotomy apply• Placed in supine position with the legs raised and

abducted in crutch-like or full lower leg support stirrups

• The angle between the patient’s thighs and trunk is not as acute as for the high lithotomy position

• Used in vaginal procedures

Safety Considerations

Key Points• Use safe body mechanics during transfers

and positioning – ensure adequate assistance is used

• Maintain stretcher/bed in a locked position prior to patient transfers and positioning

• Verify weight limit on OR table or bed to be used

• Ensure that the patient is adequately secured to the OR table or bed to be used

• One strap placed across the patient’s thighs and the second across the lower legs

• Extra care must be taken to ensure that loose skin is protected (ie lithotomy position)

SupineRisk #1:• Pressure points:

– occiput;scapulae;thoracic vertebrae;olecranon process;sacrum/coccyx;calcaneaus;knees

Risk #2:• Neural injuries of

extremities, brachial plexus, ulna, radial nerves

Safety Considerations:

• Padding to heels, elbows, knees

• Spine, head alignment with hips

• Legs parallel, uncrossed at ankles

Safety Consideration:

• Arm board at less than 90 degrees

• Head in neutral position• Arm board pads level

with OR bed

ProneRisk #1:

– Head, eyes, nose

Risk #2:– Chest compression,

iliac crest, breast, male genitalia

Risk #3:– Knees

Risk #4:– Feet

Safety Consideration:– Maintain cervical neck

alignment– Protection of forehead,

eyes, chin– Padded headrest to

provide airwaySafety Consideration:

– Chest rolls to allow chest movement and decrease abdominal pressure

– Breasts and genitalia free from torsion

Safety Consideration:– Padded with pillows

Safety Consideration:– Padded footboard

LateralRisk #1:

– Bony prominences and pressure points on dependent side

Risk #2:– Spinal alignment

Safety Consideration:– Axillary roll for

dependent axilla– Lower leg flexed at hip– Upper leg straight with

pillow between legs– Padding between

knees, ankles and feetSafety Consideration:

– Maintain spinal alignment during turning

– Padded support to prevent lateral neck flexion

LithotomyRisk #1:

– Hip/knee joint injury– Lumbar/sacral pressure– Vascular congestion

Risk #2:– Neuropathy of obturator

nerves, femoral nerves, common peroneal nerves/ulnar nerves

Risk #3:– Restricted

diaphragmatic movement

– Pulmonary region

Safety Consideration:– Place stirrups at even

height– Elevate lower legs slowly

and simultaneously from stirrups

Safety Consideration:– Maintain minimal external

hip rotation– Pad lateral or posterior

knees/ankles to prevent pressure and contact with metal surface

Safety Consideration:– Keep arms away from

chest to facilitate respiration

– Arms on arm boards at less than 90 degree angle or over abdomen

Documentation

• Documentation should include:– Preoperative assessments– Type and location of positioning and/or

padding devices– Names and titles of persons positioning

the patient– Intra-operative positioning changes– Postoperative outcome evaluation

• Documentation includes nursing assessments and interventions

• Documenting nursing activities provides an accurate picture of the nursing care provided as well as the outcomes of the care delivered

• Document all of your findings

Don’t Forget:• Good positioning starts with an assessment• Prevent team members from leaning against patients• Cushioning of all pressure points is a priority - the correct

use of padding can protect the patient• Procedures longer than 2 ½ to 3 hours significantly increase

the risk of pressure ulcer formation• During a longer procedure, you should assist with shifting

the patient, adjusting the table, or adding/removing a positioning device

• The nurse must assess extremities at regular intervals for signs of circulatory compromise

• Documentation of the positioning process should be performed accurately and completely

One last note…Positioning problems can result

in significant injuries and successful lawsuits.