As a circulating nurse, I'm very conscientious about how I position my patients. After they go to sleep, I am their protector and their voice. It is my job to make sure not only that the surgeon has unobstructed access to the surgical site, but also that the patient remains positioned correctly and comfortably throughout the surgery. Patients are in jeopardy if we give more thought to access than to safety when we position them. Plus, we know that many medical negligence cases are pursued as a result of patient positioning injuries, such as nerve damage, palsy, skin breakdown and pressure ulcers. We can easily avoid these injuries if we take appropriate precautions, such as those you'll see in the photos illustrating proper technique over the following pages. OSM

OVERLOOKED DANGERS There are so many different things to hook up and get going before the drapes go on that it's easy to rush through and overlook positioning dangers. Note the forced-air warming tube resting between the patient's legs. Had the tube been resting on the patient's foot for a couple hours, it could have prevented blood from perfusing to the toe and caused post-op numbness and tingling and possibly nerve damage. Similarly, you wouldn't want an upper-body warming tube to rest against a patient's arm (in that situation, we'd suspend the tube from a clamp on the IV pole). Also note the egg crate under the patient's heels to prevent skin breakdown. Because he's sitting up, blood is flowing down toward his feet.

LITHOTOMY POSITION For this urological procedure, the patient is going into the lithotomy position. When suspending the patient's legs in the stirrups, raise the legs slowly and pay extra attention to the hip joints. The knees should be of equal height and angle to prevent back strain. Don't flex the hips more than 90 degrees; you could dislocate them or put extra tension on the hip joints and nerves. The patient's lumbar area should not hang over the table. You want the patient's leg to only touch the cushioned part of the stirrups.

LATERAL POSITION The bean bag positioner molds to the patient's shape to keep her safely and securely on her side for a lateral shoulder repair. Ensure there's a draw sheet between the patient and the bean bag so her skin isn't right up against the plastic bean bag. Plus, you can use the draw sheet to help turn the patient over on her side. Once a patient is on his or her side, ensure that the scrotum or breasts are in a neutral position so they aren't squished. The blue foam axillary role puts the shoulder the patient is lying on in a more neutral position. The pillow is folded to keep the head and neck aligned.

HANDOFF This patient's hand is well padded and supported, so her skin is not pushing up against a plastic and metal bar. Also note that the hand is in a neutral position, resting comfortably down at her side on the foam donut. A safety strap keeps her arm from falling off the bed.

BEACH-CHAIR The sitting or beach-chair (semi-Fowler's) position keeps all structures anatomically oriented to allow manipulation of the arm during surgery. Plus, the patient is positioned for an open anterior approach. The foam padding over the forehead and chin supports the patient's head. Make sure the strap's not too tight on the foam headrest once the patient is sitting up; a too-tight strap could hyperextend the neck. You also want to make sure the endotracheal tube doesn't get snagged on the bed or IV pole as you sit the patient up. Though we can't see it, the patient's opposite arm is protected with egg crate and wrapped in a sheet. Finally, when the Mayo stand in the background is moved over the patient's abdomen to hold the camera, shaver and other tools, be sure it doesn't squish the patient.

PRONE AND JACK-KNIFED This patient is nicely positioned for a rectal procedure. The yellow chest roll supports her chest while she's slightly bent over. Make sure her breasts are neutral so they're not being pinched or squished. The blue and white prone pillow supporting her face keeps her head, neck and back in alignment. Notice how the pulse oximeter cord is draped up over her head so it's not touching the patient's skin. The patient's right arm is at her side, palm facing in towards her so her elbow is comfortably flexed.

HAPPY FEET Non-skid socks prevent the patient from slipping and falling while she ambulates. Her feet, ankles and knees are slightly bent and padded. A pillow gives her legs added support. Note the angle of the purple foam — it's folded in half to support her feet and her ankles and avoid strain, pronation and contact with bony prominences.

POSITIONING AIDS Positioning aids like this purple arm foam help you adapt and think on your feet. We couldn't lay this patient's arm flat by her side, so we use an aid. The foam is folded under her arm so that her palms are facing out and her arm's not overflexed (more than 90 degrees). Her wrist is also supported.

ALIGNED AND NEUTRAL This patient is perfectly aligned in the prone position. The yellow chest roll and the strap over her back keep her center of gravity on the table so we can safely move the bed up and down or in a jackknife position. Her arms rest on armboards and her elbows are padded. Her hands are facing the padding and her arm's not bent at the shoulder.

KNEE ARTHROSCOPY Note the white wash cloth under the patient's knee so that the knee's not touching the metal leg holder. The adjustable leg holder's green U-shaped support is padded. The knee is at the break of the bed. When the surgeon drops the foot of the bed, you want the calf suspended, but not touching the metal. We should have a stockinette underneath the tourniquet to protect the skin.

WHAT NOT TO DO
Can You Spot These Positioning Errors?

• The bottom arm is not supported by the arm board and the wrist is cocked so that the palm is facing the wrong way.
• The bed strap should be around her thighs, not her knees.
• Head's not neutral or supported (plus, she's wearing glasses).
• The top arm is positioned well: padded, neutral, palm facing the right way.

• The fingers are not protected by foam or eggcrate padding.
• The hand is positioned in such a way that it'll likely be pinched or sprained.

 

ELBOW ARTHROSCOPY We move this patient into the lateral position for his elbow arthroscopy. A pillow protects his knees, and eggcrate cushions his ankles and feet. You don't want both legs bent like this, so we'll straighten the top leg for better support and leave the bottom leg bent. The bean bag, still flat and squishy, has not yet been vacuumed. Note the drawsheet underneath the patient.

FLIPPING Here the OR team expertly flips an unconscious patient from the stretcher (supine) to the OR bed (prone). You should have at least 4 people for a flip: anesthesia to protect the head and airway, 1 person to flip the patient, 1 person to catch the patient and 1 person to support the legs during transfer.

TRENDELENBURG There are plenty of pads, restraints and bolsters out there designed to secure patients in Trendelenburg. You want to avoid friction and shear when patients are in a steep head-down tilt. Securely strap the patient to the bed to prevent slipping and sliding.