Positioning a patient properly on the OR table is critical for patient safety and comfort and surgeon and staff efficiency. Proper positioning ensures that the surgeon, staff, and anesthesia providers have ready access to the patient and a clear view of the surgical site. It also reduces bleeding, minimizes cardiac and respiratory problems and decreases the risk of pressure-related damage to the skin, nerves, joints, and muscles. Says Adam Dorin, MD, MBA, chief of the department of anesthesiology at Maryland General Hospital, "The number one thing to keep in mind with positioning is to be vigilant in ensuring that you don't place the patient in positions that will compromise the nerves and joints. Check the ulna bone and the lumbar area-they're especially vulnerable. Check the tubes and lines, too, not just at the beginning of a procedure, but throughout the case. Particularly during long procedures, some OR teams get into trouble because they stop checking for positioning and leave the patient in compromised positions for extended periods of time."

It may not be possible to keep patients in optimal positions because of the nature of the procedure, according to Nancy Dawes, an RN from Chicago, Ill. "Patients often need to be shifted around during surgery," she says. "The key is to make certain that the patient is not put in high-pressure positions any longer than necessary and, if possible, to return them as closely and quickly as possible to ?guideline'-type positions. Sometimes there are devices that will help you do this, sometimes one or more people in the OR team have to physically move the patient."

In this article, we'll focus on each body part, explain what injuries and complications the body part is vulnerable to, and provide general tips for positioning the patient comfortably, safely, and accessibly.

Skin. According to Ms. Dawes, you should examine the skin of all patients, even healthy ones. Lesions, bruises, and dry skin can all contribute to complications in blood flow during surgery.

Head and neck. Pillows and head rests are crucial. If the patient is in the supine or Trendeleberg position, use "donuts" to protect bony prominences on the back of the head.

Advises Dr. Dorin, "Even for short procedures, look at the patients' eyes, ears, and nose. Ensure that these areas aren't being pinched. Also, especially with female patients, check their hair to make sure they aren't wearing hair clips or twists. Sometimes, patients will come into the OR with the clips still in the back of their hair. That can cause totally avoidable injuries."

Ms. Dawes suggests padding the neck liberally to reduce stress in this area. "Think about how often people wake up from their beds at home with a stiff neck," she says. "Add in being under anesthesia on an OR table, plus the physical demands of surgery itself. That's why the head and neck are always trouble spots."

Arms and shoulders. There is some disagreement over the amount of abduction that is advisable for the patient. The general guideline is to keep the arms at a 90 degree angle to the rest of the body. However, Dr. Dorin notes, "Be careful. I've seen studies that say you should never have abduction greater than 60 degrees or you can cause brachial plexus injuries. There are times when you may have to move the patient's arms to 90 degrees, but as a practical rule, the less severe the angle, the better off you are."

Experts also advise padding the arms and securing them to the OR bed, so that the arms and shoulders don't hang over the edge of the bed or roll under the ribcage.

Hips. The key goal to remember with hip placement, whether the patient is in a vertical, prone, Trendelenburg or reverse Trendelenburg position, is to maintain proper alignment. Dr. Dorin notes that during orthopedic procedures in particular, the hips are prone to lumbar plexus damage if they are put under excessive strain. Keeping the hips aligned takes a lot of pressure off both the lower back and the hip joints themselves.

Ms. Dawes recommends taking the following steps to help maintain hip alignment:

• Lift the patient's legs together, rather than one at a time.
• Use hip supports so that the hips will not flex.
• Make sure the patient's legs are straight and don't get twisted.

She says, "If you don't have positioning devices to help you with these steps, you may have to do them manually. This is sometimes easier said than done, so it may take several members of the OR staff working as a team."

Buttocks. In many procedures, the buttocks can remain in contact with the surface of the OR table. In longer procedures, this can cause pressure sores and other complications. Avoid this by placing padding underneath the buttocks; the padding can also aid with hip and leg placement.

Knees and lower extremities. Keep the patient's knees flexed if possible, with support from underneath and minimal rotation to the sides. Surgical socks and soft bolsters are good for maintaining circulation to the lower extremities.

Says Dr. Dorin, "Even for short procedures, I always ask for pillows to be placed under the knees to make sure they flex. If it's a lateral position procedure, put the pillow between the knees."

Prepare for special cases
Sometimes there are patients or situations that don't go "by-the-book." Here are some ways to prepare for special cases.

Tall patients: Says Ms. Dawes, "I remember one time when we had a very tall gentleman. He must have been about 6-foot-10; maybe even 7 feet tall. His legs and arms were so long that we knew there could be a problem with numbness in the extremities. It ended up taking quite a bit of work to move his knees and arms into the proper position. We had to scrounge up all the extra padding we could think of to get his knees flexed sufficiently. Everything went fine, although none of us had ever dealt with the special issues of a patient like that before. It was a learning experience to take general knowledge and apply it to his case."

Geriatric patients: Elderly patients require special care, even for short procedures that would be routine for younger patients. They are particularly prone to skin- and nerve-related problems.

Notes Dr. Dorin, "Osteoporosis and degenerative nerve conditions are a major pre-existing concern with a large number of elderly patients. Many are frail and thin, so they are liable to sustain soft-tissue damage. There are issues of reduced breathing capacity, as well."

The key to positioning elderly patients is to proceed with extra caution. "It can take less pressure to injure an elderly patient, so be gentle and don't rush," says Ms. Dawes. "You also have to examine their skin even more carefully and be concerned about anything that looks like bruising, because that can be a warning sign that pressure ulcers and other complications can follow."

Remember that even the hardiest of elderly patients will have some diminished range of motion and weakening of muscles and joints. Therefore, experts advise taking the same precautions even if the patient is in good health.

Obese patients: Obese patients must be seated upright for the duration of the procedure, due to increased abdominal pressure on the chest when they are supine. Obese patients are also especially susceptible to nerve and pressure point injuries, so you may need extra padding. Experts also advise that when you are positioning obese patients, you should consider them full stomach patients, even if they abide by the standard NPO requirement.

Although many of the aspects of patient positioning are fundamental, it's advisable to establish guidelines and procedures in your facility and help your staff develop their skills. You may want to look into having your nurses attend a training seminar to review strategies to prevent pressure injuries and review the salient points of positioning.

Liz Sparks an RN in Oklahoma City, Ok., concludes, "It's not all about technique. It's about knowledge. If you know what causes complications and how to prevent them, you will be more likely to keep patient positioning in mind as something you should routinely monitor." n