Transcript Surgical Patient Positioning

Surgical Patient Positioning
ST210
Concorde Career College, Portland
Positioning
Objectives:


List the basic surgical positions and analyze the use of
each
Identify basic positioning aids and describe the use of
each
Positioning
Objectives:

List the steps for placing the patient in the basic surgical
positions and list the potential hazards and safety
precautions that relate to each position
Surgical Technology Lecture Series
2000©
Power-Point®
Production Notes
Primary Author - Kevin Frey CST, MA
Coauthor and Executive Editor - Bob Caruthers CST, PhD
Series Editor - Teri Junge, MEd, CSFA, CST, FAST
Table of Contents
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General Information
Patient Safety
Equipment
Patient Positions
General Information
Position Determination

General factors
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Surgical procedure
Surgeon’s preference
Technique of anesthetic administration
Patient factors
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Age
Size (height and weight)
Cardiopulmonary status
Preexisting conditions
Responsibilities
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Choice of position is made by surgeon and anesthetist

The surgeon will ensure the patient is properly
positioned
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Safe positioning of the surgical patient is the responsibility
of the entire surgical team
Timing of Positioning
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Patient is not positioned or moved until the
anesthetist indicates it is okay to do so
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Factors that influence time of positioning
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Site of surgical procedure
Age and size of patient
Type of anesthetic administered
Pain associated with moving conscious patient
Patient Safety
Patient Safety
Safety
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Properly identify patient
Operating table and gurney locked
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Mattress secured to operating table
Minimum of 2 people assist an awake patient
during transfer
Person on “gurney side” helps patient move to
operating table
Person on “operating table side” prevents patient
from falling off the narrow table
Safety (continued)
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Minimum 4 persons to move unconsciousness, obese,
or weak patients
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Move on the count of three
Anesthetist controls timing
Anesthetist controls head and neck at all times
Lift - do not slide or pull the patient
Surgeon is responsible for stabilizing un-splinted fractures
during move
Safety (continued)
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Anesthetized patient is moved slowly to allow circulatory
system to adjust
Body parts not to extend beyond table edges, rest on
metal parts, or unpadded surfaces
Body exposure kept to minimum
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Prevent hypothermia
Maintain patient’s dignity (especially awake patient)
Safety (continued)
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Protect arms
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Prevent accidental IV removal
Avoid hyperextension of arm board
Be sure patient in the supine position has not crossed
legs
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Uncrossed to avoid neurovascular compromise
Safety (continued)
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Chest rolls are used in the
prone position to facilitate
respiration
Protect patient’s fingers
and skin at flex points of
table
Mayo stand must not rest
on patient
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If table raised during
procedure; Mayo stand
must also be raised
Respiratory System Requirements
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Unhindered diaphragmatic
movement
Patent airway
Prevent hypoxia
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Some hypoxia may be
unavoidable
Facilitate inhalation
anesthesia
No constriction about neck
or chest
Place arms at sides, on arm
boards, not crossed on the
chest
Circulatory System Requirements
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Adequate circulation
required
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Maintain BP
Provide oxygenated blood
to tissue
Facilitate venous return,
Prevent thrombus
formation
Pressure on peripheral
blood vessels avoided
Body support and safety
straps not too tight
Peripheral Nervous System Requirements
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Avoid prolonged pressure
or stretching on
peripheral nerves
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Injury can range from
sensory and motor loss to
paralysis
Positioning devices that
come in contact with
patient must be well
padded
Peripheral Nerves (continued)
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Frequent sites of injury
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Divisions of the brachial
plexus
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Ulnar nerve
Radial nerve
Peroneal nerve
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Due to extreme positions of
head and arm
Extremity nerves damaged by
compression against bone,
stirrups, or operating table
Facial nerve
Musculoskeletal System Requirements
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Anesthetized patients lack muscle tone or control
Strain on muscles results in injury
Body alignment must be maintained
Soft Tissue Requirements
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Body weight distributed unevenly
on operating table
Weight on bony prominences can
lead to skin ulceration
Tissue folded under skin of obese
patient will not receive proper
perfusion
Debilitated patients and diabetics
are at high risk for decubitus
ulcers
Wrinkled sheets and edges of
positioning devices under the
patient can cause pressure on skin
Patient Access
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Anesthetist must be able
to
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Attach monitoring devices
Administer anesthesia
Observe patient
Maintain access to airway
and IV sites
Equipment
Operating Table
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Electric or manual
hydraulic
Metal top
3 hinged sections: head,
body, leg
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Allow patient to be
manipulated; flexed
Joints of table referred to
as breaks
Flexing the table is referred
to as breaking
Operating Table (continued)
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Metal crossbar between
two upper sections to
elevate kidney area
X-ray penetrable top
extends length of table for
insertion of X-ray cassette
Rubber; foam mattress
adhered with Velcro®
Foot extension board for
tall patient; also used with
lithotomy position
Operating Table (continued)
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Table is manipulated into
desired position either by
electronic controls or
lever-operated hydraulic
system
Control set on back, side,
foot, or flex
Brake is set to maintain
table position
Table Accessories
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Safety belt (knee strap)
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Placed over thighs 2” above knees
Circulator should be able to pass fingers between strap and
patient
Some straps attached at sides of table; others fastened in
middle
Blanket placed on patient between skin and belt
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Belt placed over, not under blanket
Table Accessories (continued)
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Anesthesia screen
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Metal bar attaches to head
of table to hold drapes off
patient’s face
Substitute for IV poles
Lift sheet (draw sheet)
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Folded sheet placed
horizontally across top of
sheet on operating table
Can be used in moving
patient
Table Accessories (continued)
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Lift sheet (continued)
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Arms can be enclosed in sheet with hands placed palm down
or turned inwards toward body
Finger tips must extend beyond edges of sheet
Tuck sheet under patient’s sides
Do not tuck under sides of mattress
Table Accessories (continued)
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Arm boards
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Support arms
Provide access to IV
Support arm or hand
where surgical site is
located
Hand placed palm up on
board to prevent ulnar
nerve pressure and
abnormal shoulder rotation
Exceptions
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Prone position
Upper arm of lateral position
Table Accessories (continued)
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Arm boards (continued)
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Arm board can be adjusted to different angles
Never abduct arm more than 90 degrees from shoulder
Double arm board
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Arms positioned one above the other
Also called overhead arm support
Table Accessories (continued)
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Wrist straps
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Narrow straps placed
around wrists to secure
hand and arm to arm board
Hand table (upper
extremity table)
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Slipped under mattress on
one side of table
Other end of table
supported by legs
Can use 2 arm boards
placed side-by-side; not as
effective or safe
Table Accessories (continued)
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Shoulder braces
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Padded concave supports
to prevent patient from
slipping off table when using
Trendelenburg position
Acromion processes must
rest on braces, not muscles
or soft tissue near the neck
Table Accessories (continued)
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Kidney rests
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Padded concave pieces that
slide under mattress on
kidney elevator
Placed snugly against body
to provide stability in
kidney position
Table Accessories (continued)
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Body (hip) restraint strap
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A wide belt or tape (preferred) is used
Placed over patient’s hips to help secure patient in lateral
position
Table Accessories (continued)
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Hemorrhoid strap
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Benzoin spray
3” wide adhesive tape
Strips placed approximately
4” lateral to surgical site
Use 2 strips per side
Spread buttocks when
patient is in Kraske position
Table Accessories (continued)
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Stirrups (candy canes)
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Metal poles placed in
holder on each side of
operating table to support
legs and feet in lithotomy
position
Feet supported by canvas
or fabric loops, suspending
the legs
Table Accessories (continued)
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Metal footboard
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Foot extension board
placed perpendicular to
table to keep patient from
slipping off operating table
in reverse Trendelenburg
Used to prevent foot drop
during extended
procedures
Table Accessories (continued)
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Donut
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Ring-shaped foam pad for head
Also used to protect pressure points
Bolsters
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Used to elevate specific part of body
Chest roll
Axillary roll
Table Accessories (continued)
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Suction bean bag
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Placed on top of operating
table
Patient lays on the bean bag
Suction attached to one
end of bag
As air is withdrawn the pad
hardens and is molded to
the patient’s body by the
surgical team
Table Accessories (continued)
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Suction bean bag (continued)
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Suction disconnected to release
To allow air to reenter, valve is squeezed
Excellent positioning device for stabilizing patient in lateral
position
Table Accessories (continued)
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Wilson Frame
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For thoracic spinal surgery
Used to open the
intervertebral spaces
Table Accessories
(continued)
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Trauma attachments
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Used for extraction during
procedures such as ORIF,
nail or rod insertion, and
percutaneous pinning
Table Accessories (Continued)
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OSI Jackson Table
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Modular table system used
primarily for spinal
procedures
Choice of flat table top or
open frame
Carbon construction
facilitates fluoroscopy use
Patient Positions
Supine (Dorsal) Position
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Patient lies on back
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If arms at side, supported
by draw sheet, palms down
If arms on arm boards,
palms up
Legs straight and in line
with head and spine
Hips parallel to spine
Supine (continued)
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Safety belt across thighs 2” above knees
Pillows placed under head, under knees, under lumbar
curvature
Protect heels from pressure
Feet must not be in prolonged plantar flexion (foot drop)
Supine (continued)
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Procedures
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Anterior surface of body
Extremities
Modifications
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Procedures on face or neck: Place rolled towel lengthwise
along upper boarder of scapula to slightly hyperextend neck
and/or lower head section of operating table
Supine (continued)
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Modifications (continued)
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Modified dorsal recumbent (frog leg)
Knees slightly flexed with a pillow under each
 Thighs externally rotated
 Soles of feet rest on table top
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Trendelenburg Position
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Supine with head tilted
downward
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Safety belt 2” above knees
Shoulder brace may be
used
Lung volume decreased
Heart mechanically
compressed by pressure
of organs against
diaphragm
Trendelenburg (continued)
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Level entire table slowly at end of procedure
Procedures
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Lower abdomen or pelvis to allow abdominal viscera to fall
away from surgical site
Reverse Trendelenburg Position
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Supine with head tilted
upward
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Padded foot board may be
necessary
Small pillows placed under
knees and lumbar curvature
Donut for the head
Safety belt 2” below the
knees
Footboard may be used to
retain patient on table
Reverse Trendelenburg (continued)
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Procedures
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Upper abdomen
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Allows abdominal viscera to fall away from surgical site
Examples: gallbladder, biliary tract, splenectomy
Thyroidectomy
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Facilitates breathing and decreases blood supply to surgical site
Fowler’s (Sitting) Position
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Start with patient in the
supine position
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Buttocks at flex in table
Knees over lower break
Foot section lowered slightly
to flex knees
Body section raised
becoming the “back” of the
chair
Arms rest on armboards
parallel to operating table
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Alternative: Secure arms to
large pillow placed on lap
Fowler’s (continued)
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Safety belt placed 2” above the knees
Table tilted slightly head downward
Table resembles modified armchair
Procedures
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Shoulder
Nasopharyngeal
Facial
Breast reconstruction
Lithotomy Position
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Wrap ankle and foot of
patient with towel,
leggings, or cotton boots
for padding against canvas
loops
Transfer head section to
foot end of table to serve
as foot extension
Place stirrup on side of
table that will not be used
for patient transfer
Lithotomy (continued)
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Start with the patient in the supine position
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Arms placed on armboards
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Hands not to extend along table where fingers could be crushed
in breaks while leg section is lowered or raised
Buttocks resting along break between body and leg
section
Place other stirrup
Stirrups must be of equal position and at an appropriate
height according to length of patient’s legs
Lithotomy (continued)
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When anesthetist gives permission, both legs are raised
simultaneously by two persons
Support the foot, ankle, and calf
Flex the knees and legs; place inside the stirrup posts
Place feet in canvas loops
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First loop of canvas around ankle
Second loop around sole of foot
Lithotomy (continued)
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Lower section of mattress is removed
Leg section of table is lowered
Lower leg or ankles must not touch any metal part of the
stirrup
Buttocks must be even and not extend beyond table edge
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Extension beyond edge causes strain on lumbosacral muscles
and ligaments due to body weight placed on sacrum
Lithotomy (continued)
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Conclusion of surgical procedure
 Raise leg section
 Replace mattress
 When anesthetist gives permission, both legs are extended,
brought together, and lowered slowly and simultaneously by
two persons
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Prevents hypotension as blood reenters legs and leaves the torso
Essential to avoid lower back strain
Reapply safety belt
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Safety belt not applied when patient is in lithotomy
Lithotomy (continued)
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Lung compliance is decreased by pressure of thighs on
abdomen
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Diaphragmatic movement restricted
Procedures
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Perineal
Vaginal
Urological
Rectal
Prone Position
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Patient lays on abdomen (face
down)
Chest rolls pre-placed on
operating table
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Extend from clavicles to iliac
crest to facilitate respiration
Patient is anesthetized and
intubated in the supine position
on the gurney
When anesthetist gives
permission, patient is slowly
rolled onto abdomen on
operating table by team of at
least 4 people
Prone (continued)
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Breasts moved laterally
External genitalia toward foot of table
Arms
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Placed along side of body with palms up or towards side of body
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Placed on armboards, angled with elbows flexed
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Can cause pressure on breasts
Palm downward
When moving arm, lower toward floor rotating in an upward in
natural movement
Prone (continued)
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Head turned to one side; use a donut
Pillow under anterior of ankles
Safety belt above the knees
Procedures
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Spine
Posterior aspect of lower extremity
Kraske (Jackknife) Position
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Modification of the prone
position
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Hips over center break
between body and leg
sections of operating table
Chest rolls employed
Arms on arm boards;
elbows flexed; palms down
Head to the side on donut
Pillow under ankles
Safety belt below the knees
Kraske (continued)
Leg section lowered; entire table tilted head downward so
hips are elevated above body
 Return patient to level position slowly
 Remove safety belt when moving table parts
 Venous pooling occurs cephalad and caudad
 Kraske position not tolerated well by patients
Procedures
 Rectal
 Pilonidal sinus
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Knee-Chest Position
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Modification of the prone
position
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Foot extension
Table flexed at center break
Leg section at right angle to
operating table
Patient kneels on lower
section
Knees are flexed at right
angle to body
Head turned to side; placed
on donut
Knee-Chest (continued)
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Arms placed on pillow near head with elbows flexed
Safety belt above the knees or tape used
Pillows placed on foot board and taped into place
Procedures
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Spine
Lateral Position
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Anesthesia administered
with the patient in the
supine position, then
repositioned onto the nonoperative side
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Turned by no fewer than 4
people
As patient is turned, patient’s
back drawn to edge of
operating table
Arms placed on overhead
armboard; lower arm palm up;
upper arm slightly flexed with
palm down
Lateral (continued)
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Lower leg flexed at knee
Upper leg straight
Large pillow placed lengthwise between legs to prevent
pressure on peroneal nerve
Safety belt or wide tape placed over hip to provide stability
BP taken from lower arm
Small roll under axilla to relieve pressure
Lateral (continued)
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Shoulders in alignment
Head in cervical alignment
Supported by pillow between shoulder and neck to prevent
stretching the neck, brachial plexus, aid in maintaining patent
airway
Procedures
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Thorax
Kidney
Retroperitoneal space
Kidney Position

Modification of lateral
position with flank region
over kidney elevator
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Short kidney rest attached
to elevator at patient’s back
Longer rest placed on front
below level of iliac crest to
prevent pressure on
abdominal organs
Table slightly flexed
Kidney elevator raised to
increase space between
lower ribs and iliac crest
Kidney Position (continued)
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Safety strap or wide tape placed after table flexed and
elevator raised
Entire table tilted head downward until surgical area is
horizontal
For all lateral positions, keep shoulder, hip, knee, and ankle
in alignment
Before closure, table is flattened to allow better
approximation of tissues
Procedures
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Kidney