Pay attention to patient positioning!
By: Carla Millsaps, RN, BSN
Originally published: January 2, 2006
A patient undergoing abdominal surgery in a Louisiana hospital was placed on the operating table with his arms extended 45 degrees on armboards. The surgeon stood at the patient's right side throughout the hour-and-20-minute procedure. Postoperatively, the patient reported numbness and tingling in his right hand, which persisted well after his discharge from the hospital.
Eventually the patient was diagnosed with an ulnar nerve injury, with numbness and pain that didn't respond to physical therapy. The injury occurred in the OR, the patient alleged in a lawsuit; tests ruled out other causes.
After hearing expert testimony at the trial, the jury found for the plaintiff. The most likely scenario: The patient's arms weren't properly positioned, so the surgeon had to lean on the patient's right arm to perform the operation. The jury assigned fault to the anesthesiologist, the surgeon, and the nurse, as well, for failing to meet the standard of care.1,2
The positioning payoff, short- and long-term
This case, which was decided a decade ago, illustrates the importance of a nurse's role in helping to prepare patients for surgery. Whether you work in a traditional OR, an ambulatory surgery unit, or any other setting where procedures are performed, you'll need to help plan for and maintain proper patient positioning—which can prevent immediate problems as well as long-term pain and disability.3
Proper positioning ensures that the surgical team has ready access to the patient and a clear view of the surgical site. It reduces bleeding, mostly by avoiding venous congestion; minimizes cardiac and respiratory problems; and decreases the risk of pressure-related damage to the skin, nerves, joints, and muscles.4 Proper positioning techniques, used with supportive equipment and devices, contribute to patient safety, according to the Association of Perioperative Registered Nurses.5
Good positioning starts with an assessment
There are many factors to consider in planning how best to safeguard your patients. In addition to finding out what type of procedure is scheduled, how long it will last, and what type of anesthesia will be administered, you will need to determine whether any equipment that could affect positioning will be used—and to identify patients at high risk. Take note of the patient's age, height, and weight. Obese individuals face a greater likelihood of nerve and pressure point injuries, for example, and older people tend to have less flexibility and poorer peripheral circulation than their younger counterparts, making them more susceptible to injury.6
Bear in mind, though, that advanced age alone isn't necessarily an independent risk factor: A healthy 82-year-old may be less vulnerable than an overweight 35-year-old with diabetes.3
Be sure to assess nutritional status and examine the skin of all patients. Lesions, bruises, and dry skin can all contribute to impaired blood flow during surgery.6 Note any preexisting conditions, particularly those affecting the vascular, respiratory, circulatory, neurologic, or immune system. And look for signs of impaired mobility or any physical limitations, such as a bad back, prosthesis, or an implant.
Use your findings to help create a positioning plan well before the procedure, in accordance with your facility's policy and procedure manual, and if applicable, the surgical OR checklist. Share the information with the other clinicians to determine the best way to position the patient before, during, and after the procedure and to shift him from one position to another, as needed.3
There are four basic surgical positions: supine, prone, lateral, and lithotomy. (See the "How to avoid positioning injuries" at the end of the article for illustrations, risks, and safety considerations associated with each.)
Variations include Trendelenburg (patient is supine with head lower than feet), reverse Trendelenburg (patient is supine with head higher than feet), modified Fowler's (variation of reverse Trendelenburg; patient is sitting), and Kraske (variation of prone position; patient lies on his stomach in a jackknife, achieved by flexing the table at center break).7
The choice of position will depend on the type of procedure. But any of them can affect the major body systems, and, coupled with the effects of anesthesia, become a potential danger for patients in the following ways:
Some positions—including supine—can restrict movement of the rib cage or diaphragm and impede airflow, particularly with obese patients. Obese patients must be seated upright for the duration of most procedures because of increased abdominal pressure on the chest when they are supine.3,6
Lithotomy positions and the severe head-down positions used during some laparoscopic procedures may compromise blood flow to the lower extremities or venous blood return to the heart.3 Pressure or obstruction of a vessel can cause the greatest amount of damage to the cardiovascular system.7 This can be avoided by reducing the procedure time, if possible, or by moving limbs and massaging them at regular intervals during the procedure.
Friction and pressure on soft tissues, especially over bony prominences, may result in changes ranging from mild irritation to severe pressure-induced ischemia.3
Pressure or obstruction caused by faulty positioning is a common cause of nerve injury, as the case of the patient with ulnar nerve damage makes clear. Motor or sensory nerve damage can happen within minutes, and can have a long-term effect.7
Some positioning problems are particularly likely in specific patient groups: Men 40 – 70 years old who undergo abdominal or pelvic procedures have a higher risk of developing ulnar neuropathy, for example.3 Women over 60 have a greater risk of developing obturator and lateral femoral cutaneous neuropathies after procedures in which they remain in the lithotomy position, such as cystoscopies and other gynecologic outpatient procedures.3 Being aware of patients' particular risks will help you determine when—and where—to provide extra protection.