POSITIONING, PREPPING AND DRAPING THE PATIENT

Preliminary Considerations
Positioning for a surgical procedure is important to the patients outcome. Proper positioning facilitates preoperative skin preparation and appropriate draping with sterile drapes.

 Positioning requires a detailed knowledge of

anatomy and physiologic principles, as familiarity with the necessary equipment.

Safety is a prime consideration.

Factors: Age Weight Cardiopulmonary status Pre-existing disease

Pre-op patients should be assessed:

For alteration in skin integrity Joint mobility Vascular prosthesis

Main Objective for Positioning

Optimize surgical site exposure for the surgeon
Minimize risk for adverse physiologic effects

Facilitate physiologic monitoring by the anesthesia

Promote safety and security for the patient

Responsibility for Patient Positioning

Surgeon selects surgical position in

consultation with the anesthesia provider

Circulator or first assistant responsible for

placing the patient in a surgical position

 In essence, patient positioning is a shared responsibility among all team members. The anesthesia provider has the final word on positioning when the patients physiologic status and monitoring are in questioning.

Factors that influence the time at which the patient is positioned

Site of the surgical procedure Age and size of the patient Technique of anesthesia administration If the patient is conscious Pain on moving

*The patient is not moved, positioned, or prepped until the anesthesia provider indicates it is safe to do so.

Preparation for Positioning

1. Review the proposed position by referring to the position book and the surgeons preference card in comparison with the

scheduled procedure. 2. Ask the surgeon for guidance and assistance if unsure how to position the patient. 3. Check the working parts of the operating bed before bringing the patient into the room.

4. Assemble and check all table attachments and protective pads anticipated for surgical procedure 5. Review the plan of care for unique needs of the patient.

Body Areas that need Padding during Positioning

Supine Position:

Occiput Heels Elbows Sacrum

Prone or Other Face Down Position

Anterior Knees of kneeling patient Face (particularly the forehead) and

Ears Dorsum of foot to protect toes Genitalia and breast

Lateral Position

Face and Ears Medial Knees Axilla Ankles and feet Arms

Safety Measures
1. The patient is properly identified before being transferred to the operating bed, and the surgical site is affirmed according to

facility policy. 2. The patient is assessed for mobility status. 3. The operating bed and transport vehicle are securely locked in position, with the mattress stabilized during transfer to and from the operating bed.

4. Two persons should assist an awake patient with the transfer by positioning themselves on each side of the patient transfer path. 5. Adequate assistance in lifting unconscious, anesthetized, obese, or weak patients is necessary to prevent injury. 6. The anesthesia provider guards the head of the anesthetized patient at all times and supports it during movement. 7. The physician assumes responsibility for protecting unsplinted fracture during movement.

8. The anesthetized patient is not moved without permission of the anesthesia provider. 9. The anesthetized patient is moved slowly and gently to allow circulatory system to adjust and to control the body during movement. 10. No body part should extend beyond the edges of the operating bed or contact metal parts or unpadded surfaces. 11. Body exposure should be minimal to prevent hypothermia and preserve dignity.

12. Movement & positioning should not obstruct or dislodge catheters, IV infusion tubing, oxygen cannulas and monitors. 13. The armboard is protected to avoid hyperextending the arm or dislodging the IV cannula. 14. When patient is supine, the ankles and legs must not be crossed. 15. When patient is prone, the thorax is relieved of pressure by using chest rolls to facilitate chest expansion with respiration.

16. When patient is positioned lateral, a pillow is placed lengthwise between the legs to prevent pressure over bony prominences, blood vessels and nerves. This also relieves pressure on the superior hip. 17. During articulation of the operating bed, the patient is protected from crash injury at the flex points of the operating bed. 18. When the bed is elevated, the patients feet & protuberant parts are protected from compression of over-bed tables, mayo stands & frames. 19. Surfaces should not create pressure on body parts

Anatomic and Physiologic Considerations

1. Respiratory Considerations

*Unhindered diaphragmatic movement and a patent airway are essential for maintaining respiratory function, preventing hypoxia, and facilitating induction by inhalation.
*Chest excursion is a concern, because

inspiration expands chest anteriorly.

Considerations
Some hypoxia is always present in horizontal position.
There should be no constriction around the

neck or chest. Patients arms must be on the sides not crossed on the chest

2. Circulatory Considerations
*Adequate arterial circulation is necessary for maintaining blood pressure, perfusing tissues with oxygen, facilitating venous return, and preventing thrombus prevention.
Occlusion and pressure on the peripheral blood

vessels are avoided. Body restraints must not be fasten too tightly. Some drugs can cause constriction or dilatation of blood vessels.

3. Peripheral Nerve Consideration *Prolonged pressure on or stretching of the peripheral nerves can result in injuries that range from sensory and motor loss to paralysis and wasting.
Most common sites of injuries: Brachial plexus Ulnar Radial Peroneal Facial nerve

4. Musculoskeletal Considerations When turning a patient, always keep the spine in alignment by grasping the shoulder girdle and hip in a rolling fashion Do not turn or elevate a patient by grasping on the hip and twisting the spine

5. Soft Tissue Consideration

*Body weight is distributed unevenly when the

patient lies on the operating bed. Weight that is concentrated over bony prominence can cause skin ulcers and deep tissue injury. These areas should be protected from constant pressure against hard surfaces. *Wrinkled sheet and the edges of a positioning or other device under the patient can cause pressure on the skin. Consideration: Gel pads are preferred

6. Accessibility of the Surgical Site

The surgical procedure & patient consideration determine the position in which the patient is placed.

*To minimize trauma and operating time, the surgeon must have adequate exposure of the surgical site.

7. Accessibility for Anesthetic Administration

*The anesthesia provider should be able to

attach monitoring electrodes, administer the anesthetic and observe its effects, and maintain IV access. *The patients airway is of prime concern and must be patent and accessible at all times.
8. Individual Positioning Consideration

Complications caused by positioning

Hemodynamic instability by orthostatic

position Poor ventilation by thoracic compression Peripheral nerve injury Tissue damage Ischemia of hair-bearing scalps

Pressure necrosis Digit amputation in table bends Blindness from optic nerve ischemia Corneal abrasions Venous emboli Vertebral Injury Panic attacks and feeling of claustrophobia in awake patient

Equipments for Positioning

Operating Bed mostly consist of rectangular tops measuring 79 89 inches long by 20 -24 inches wide Hinged Sections: Head Body Leg

Special Equipments and Bed Attachments

Safety belts (thigh strap) to restrain leg movements during surgical procedure

 Anesthesia Screen a metal bar attaches

to the head of the operating bed and holds the drapes from the patients face

 Lift Sheet (Draw Sheet) a double-layer sheet placed horizontally across the top of a clean sheet on the operating bed
Armboard used to support the arm if IV fluid is

being infused, if the arm or hand is the site of the surgical procedure, if the arm at the side would interfere with access to the surgical area

Double armboard supports both arm with one directly above the other n lateral position

 Wrist or Arm strap narrow strap placed

around the wrist to secure the arms to the armboard

 Upper Extremity Table for surgical procedure on an arm or hand; used in lieu of armboard Shoulder Bridge (thyroid Elevator) head section is temporarily removed and a metal bar is slipped under a mattress between the head

and the body section

Shoulder Braces or Support placed in metal clamps on the side of the operating bed and slipped in from the edge of the bed

Lateral Positioner (kidney rest) concave metal pieces with grooved notches at the base and placed under the mattress on the body elevator flexion of the operating bed.

Body (hip) Restraint Strap helps to hold the patient securely in a lateral position

 Positioning for anal procedures with adhesive

tape - Patient is placed on prone position

Adjustable arched spinal frame consists of two padded arches mounted on a frame that is attached to the operating bed

Wilson spine frame

Andrews spine frame

Four-poster spine frame

 Stirrups supports the legs in the lithotomy

position

Additional Types of Stirrups

Urologic Stirrups
Stirrups used for abdominal or perineal

and obstetric procedures

Allen-style stirrups

Headrests used with supine, prone, sitting or lateral position

 Accessories
Donut (ring-shaped rubber) used during

procedures on the head or face to keep the surgical area in a horizontal plane Bolsters used to elevate specific parts of the body

 Pressure Minimizing Matress minimize pressure on bony prominence, peripheral blood vessels, and nerves during a

prolonged procedure
Surgical Vacuum Positioning System

soft pads filled with tiny beads are placed under body parts to be supported. Vacuum is created inside the pad causing the beads to press together

Surgical positions
1. Supine (Dorsal) Position - Patient lies flat on the back with arms secured at the side with the lift sheet and the palms extend along the side of the body.

Modifications: Procedure on the face or neck Shoulder or anterolateral procedures Dorsal recumbent position Modified dorsal recumbent Arm extension

2. Trendelenburgs Position
- Patient lies on his/her back in the supine position with knees

over the lower break of operating bed. The foot of operating bed is lowered to the desired angle. - Used for procedures in the lower abdomen or pelvis when it is desirable to tilt the abdominal viscera away from pelvic area for better exposure.

3. Reverse Trendelenburgs Position - The patient lies in supine position and mattress is adjusted adjusted so the surgical area is over the elevator bridge on the operating bed This position is used for thyroidectomy to facilitate breathing and to decrease blood supply to the surgical site. - It is also used for laparoscopic gallbladder, biliary tract, or stomach procedures.
-

4. Fowlers Position - The patient lies on his or her back with the buttocks at the flex in the operating bed and the knees over the lower break, the foot of the bed lower slightly while the body section is raised 45 degrees. - May be used for shoulder, nasopharyngeal, facial and breast reconstruction procedure.

Sitting Position patient is in fowlers position except that the torso is in upright position. - used on occasion for some otorhinologic ad neurosurgical procedure. Beach Chair or Modified Sitting Position - The patient is supine with the back and legs slightly elevated. The entire spine is slightly contoured.

5. Lithotomy Position - Used for perineal, vaginal, endourologic, and rectal procedures - The patients buttocks rest along the break between the body and leg sections of the operating bed

Commonly Used Lithotomy Position

Low Lithotomy Standard Lithotomy Hemi (Split) Lithotomy High Lithotomy Exagerated Lithotomy Tilted Low Lithotomy

6. Prone Position Patient is placed on abdomen. Chest rolls are placed under axillae and sides of chest to level of the iliac crest to facilitate respiration.