Receiving and Positioning Surgical Patient (1 hrs).pptx

RECEIVING AND POSITIONING
SURGICAL PATIENT (1 hrs)
By Ame Mehadi(BSc, MSc-EMCCN)

November 6, 2021 © Haramaya University, CHMS,
Department of Emergency and Critical Care Nursing
Operation Room Technique
By:- Ame Mehadi (BSc, MSc-EMCCN) 2
Outline
Objectives
Introduction
Receiving the Surgical Patient
Activities during receiving surgical patients
Positioning the Surgical Patient
Preliminary considerations for positioning
Responsibilities of team members during Patient Positioning
Timing and positioning
Preparation for positioning a surgical patient
Safety measures and equipment used for safety

Learning Objectives
After the completion of this chapter, the learner will be able to:
►Mention some of the responsibilities of the OR team during receiving the surgical
patient.
►Identify the safety hazards associated with moving a patient from one surface to
another
►Describe the effects of positioning on the patient’s body systems.
►Describe the safety measures to consider while positioning, moving and
transporting surgical patients.

Introduction
 The patient is the reason for the existence of the health care team.
 The patient is always the focus of attention, not just when she or he is under the OR
spotlight.
 The goal of the surgical position is to provide optimal visualization of, and access to, the
surgical site that causes the least physiological compromise of the patient, while also
protecting the skin and joints.
 The goals of positioning the surgical patient are
►ensuring patient comfort and dignity;
►maintaining homeostasis;
►protecting anatomical structures and avoiding complications and injuries;
►promoting access to the surgery site;
►promoting access for the administration of IV fluids and anesthetic agents; and
►promoting access of OR surgical equipment.
 The three components of safe positioning of the surgical patient on an OR table include
knowledge, planning and teamwork.

Receiving the Surgical Patient
Each patient should be adequately assessed and prepared so that the impact
and potential risks of the surgical intervention are minimized.
This involves both physical and emotional preparations.
When we receive the patient:
►Greet the patient by name and introduce yourself and explain the purpose of
coming to the OR
►Review the patient’s chart for completeness
►Obtain information by asking about the patient’s understanding of the surgical
procedure
►Check whether all pre op preparations have been done
►Answer the patient’s questions about the surgical procedure

►Answer the patient’s questions about the surgical procedure
►Encourage the patient and his/her family to discuss their feelings or anxieties
regarding the surgical procedure and anticipated results.
►Identify any special needs of the patient that will alter the plan for intra op care.
►Offer the patient psychological reassurance and maintain an attitude of hope.
►Avoid using phrases such as, “Everything will be all right” or “You are okay.”
►Reinforce the concept that the team will provide good care.
►By fulfilling spiritual and psychosocial needs, the caregiver helps to provide the
preoperative patient with as much peace of mind as possible.

►Understandably, the patient’s tension level rises as the time for the surgical
procedure approaches.
►The better prepared emotionally, the smoother postoperatively.
►Generally, the impact inherent in any type of surgical intervention can be
reconciled when the patient has hope and confidence in the caregivers.
►Nurses are the central figures in patient care and can do much to relieve
fear and provide security.
►Pre op preparations can influence the outcome of the surgical procedure.

Positioning the Patient
Each operative position represents an agreement between the surgeon and
the anesthesia provider to the patient.
The surgeon requires an accessible, stable operative area.
The anesthesia provider must have space in which to administer the
anesthetic and free flowing intravenous.
The result must come well within the rules for maximum safety and comfort
to the patient.

Preliminary Considerations
Proper positioning for a surgical procedure
►is a facet of patient care.
►is as important to patient outcome as adequate pre op preparation and safe anesthesia.
►requires
 Knowledge: both the theoretical and practical principles of arranging the posture of
unconscious or awake patient for operation.
• a knowledge of anatomy and
• the application of physiologic principles, as well as
• familiarity with the necessary equipment.
 Planning: encompasses an understanding of the intended operation, as well as the
specific problems that face the surgeon and the anesthesia provider.
 Teamwork: involves the careful coordination of the activities of all personnel.
 Housekeeping: includes having the appropriate positioning devices on hand and
ensuring that each part fits and functions as intended.

the type of procedure to be performed
the type of operative site
the length of the procedure
the technique of anesthetic administration
physical condition of the patient
Safety is a primary consideration

Factors that influence positioning
►age, height, weight,
►cardiopulmonary status, and
►preexisting disease (e.g., arthritis)
Preoperatively, the patient should be assessed for:
►Alterations in skin integrity
►Joint mobility, and
►The presence of joint or vascular prostheses.
The expected outcome is that the patient will not be harmed by positioning
for surgical procedure.

Responsibility for Patient Positioning
Patient positioning is a shared responsibility among all team members.
The choice of surgical position is made by the surgeon in consultation with the
anesthesia provider.
Adjustments are made as necessary for the administration of anesthetic and
for maintenance of the patient’s physiology.
The anesthesia provider has the final word on positioning when the patient’s
physiologic status and monitoring is in question.

Timing of Patient Positioning and
Anesthetic Administration
The following states the time at which the patient is positioned and/or
anesthetized.
►After transfer from the stretcher to the operating bed, the patient is usually
placed face up on his/her back (supine).
►The patient may either be anesthetized in this position and then positioned for
the surgical procedure or first positioned and then anesthetized.
►If the patient is having a procedure performed while in a face down (prone)
position and under general anesthesia, he/she is anesthetized and intubated on
the transport stretcher.
►A minimum of four people are required to place the patient safely in the prone
position on the operating bed.

Timing of Patient Positioning and
Anesthetic Administration
Several factors influence the time at which the patient is positioned.
Some of these include:
►The site of the surgical procedure
►The age and size of the patient
►The technique of anesthetic administration and
►If the patient is conscious, has pain on moving
Remember that the patient is not positioned or moved until the anesthesia
provider indicates it is safe to do so.

Preparation for Positioning
Before the patient is brought to the OR, the circulating nurse should do the
following:
►Review the proposed position by referring to the surgeon’s preference in the patient’s
chart
►Ask for assistance if unsure how to position the patient
►Consult the surgeon as soon as she/he arrives if not sure which position is to be used
►Check the working part of the operating table before bringing the patient into the room
►Assemble all attachments and protective pads anticipated for the surgical procedure
►Test positioning devices for patient safety.
►Check for cleanliness.
►Review the plan of care for unique needs of the patient.

Steps of Safe pt Positioning
Assessing the patient’s needs.
Developing a plan of care.
Assembling the necessary positioning devices.
The actual positioning of the patient.
Re-evaluating body alignment and tissue integrity intra-operatively.
Evaluating patient outcomes with respect to positioning-related
complications.

Safety Measures
Injuries to the back, arms, or shoulders as a result of lifting patients or moving
equipment are common to the staff working in the OR.
Several principles of body mechanics (using the body as a machine) should be
observed to minimize physical injury.
Some of these principles include, but are not limited to, the following:
►Keep the body as close as possible to the person or equipment to be lifted or
moved while maintaining a straight back.
►Lift with the large muscle groups of the legs and abdominal muscles, not the back.
►Lift with a slow, even motion, keeping pressure off the lumbar (lower back) area.
►Bend forward with hip flexion and hand support.

Safety Measures
Safety measures, including the following, are observed while transferring,
moving, and positioning patients:
►The patient is properly identified before being transferred to the operating bed
and the surgical site is affirmed
►The patient is assessed for mobility status
►The operating bed and transport vehicle are securely locked in position, with the
mattress stabilized during transfer to and from the operating bed
►Two persons should assist an awake patient with the transfer by positioning
themselves on each side of the patient
►Adequate assistance in lifting unconscious, obese, or weak patients is necessary to
prevent injury

Safety Measures
The anesthesia provider guards the head of the anesthetized patient at all
times and support it during movement.
The anesthetized patient is not moved without permission of the anesthesia
provider.
He/she is moved slowly and gently to allow the control of airway and
circulatory system during movement.
No body part should extend beyond the edges of the operating bed or contact
metal parts or unpadded surfaces.
Body exposure should be minimal to prevent hypothermia and to preserve
dignity.

Safety Measures
 Movement and positioning should not obstruct or dislodge catheters, IV infusion tubing,
and drainage materials.
 When the patient is on the back (supine), the ankles and legs must not be crossed.
 Crossing the ankles and legs creates occlusive pressure on blood vessels and nerves and
pressure necrosis may occur.
 When the patient is on the abdomen (prone), the thorax is relieved of pressure by using
chest rolls to facilitate chest expansion with respiration
 When patient is on the side (lateral), a pillow is placed lengthwise between his/her legs to
prevent pressure on bony prominences, blood vessels, and nerves
 During articulation of the operating bed, the patient is protected from crush injury at the
flex points of the operating bed

Safety Measures
Improper positioning of the arms, hands, legs, or feet may cause serious injury or paralysis.
 The vascular supply should not be obstructed by awkward position or undue pressure on a
part
 Nerves must be protected from undue pressure.
 no interference with the patient’s respiration as a result of pressure of the arms on the
chest or constriction of the neck or chest caused by a gown.
 Precautions for patient safety must be observed, particularly with thin, elderly, or obese
patients.
 The patient needs gentle restraint before induction, in case of excitement.

Criteria For Qualifications of Positioning
 optimum exposure of the operative site
 Free access of breathing
 Free access of circulation.
 no, pressure on any nerve
►e.g.
 Bracheal plexus.
 Ulnar
 Radial
 Facial
 Accessibility for anesthetic administration
 No, undue post OP discomforts
►e.g.
 Strain on muscle.
 Prolonged neck extension stiffness
 Preservation of pt’s dignity.

Anatomic and physiologic considerations
A patient’s tolerance of the stresses of the surgical procedure depends greatly
on normal functioning of the vital systems of the body.
The patient’s physical condition is considered, and proper body alignment is
important.
Criteria are met for physiologic positioning to prevent injury from pressure,
obstruction, or stretching.

Anatomic and physiologic considerations
Accessibility of the Surgical Site
►The surgical procedure and patient condition 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.
Accessibility for Anesthetic Administration
►The anesthesia provider should be able to
 attach monitoring electrodes,
 administer the anesthetic process and observe its effects, and
 maintain IV access.
►airway is prime concern and must be patent and accessible at all times.

Individual Positioning Considerations
extremely obese patients may need arm boards.
Patients with joint problems may need special individualized care because of
limited ROM in their joints.
cardiac/obese patients may experience orthopnea or dyspnea when lying flat.

Equipment for Positioning
operating table different type and attachment, joints/breaks for diversification
Special equipment for stabilizing the pt on desired position to prevent trauma
or abrasions.
The type of positioning equipment is determined by the type of positioning.

 The following are list of special equipment
for positioning a surgical patient:
►Operating Bed
►Ring pads
►Shoulder bridge/thyroid elevator
►Shoulder braces or supports
►Wrist or arm strips
►Arm boards
►Wrist or arm strap(hanger)
►Elbow pads or protectors
►Safety belt/thigh strap
►Anesthesia screen
►Body Rests and Braces
►Kidney Rests
►Body (Hip) Restraint Strap
►Pressure-minimizing mattress
►Safety restraints
►Pillows
►Wedge
►Tape-Plaster
►Footboards
►Stirrups

Surgical Positioning
Depends on
►the type of surgical procedure to be performed
►physical condition of the patient.
the type of operative site
the length of the surgical procedure.
Underlying condition of the patient
Obesity
Arthritis
Cardiac pt
e.g. The obese pt’s hands should be put on arm boards.
Other specific factors that also important to assess prior to surgery are
Age, Weight/Size and Skin condition

 Many positions are used for surgical
procedures including:
►supine (dorsal) position
►Prone position
►Lateral position
►Trendelenburg’s position
►Reverse Trendelenburg’s position
►Lithotomy position
►knee-chest position
►Simi’s position
►Kidney position
►Thyroid position
►Fowler’s position
►Sitting upright position
►Thoracotomy position
 Basically surgical positioning are three:
►Supine or dorsal recumbent
►Lateral
►Prone
 Modified positions are:
►Trendelenburg’s
►Reverse Trendelenburg’s
►Lithotomy
►Fowler’s
►Sitting upright
►knee-chest
►Simi’s position
 The most common surgical positions are:
►Supine, Prone, Lateral and Lithotomy.

By:- Ame Mehadi (BSc, MSc-EMCCN)
(A) Supine,
(B) Trendelenburg’s,
(C) Lithotomy,
(D) modified Sim’s/Kidney position.

A. Supine/Dorsal Recumbent position
 The usual position for surgery is flat on the back;
 the patient lies face up on the padded table with arms
tucked in at the sides (using the lift sheet), or extended
on (padded) arm boards
 one arm is at the side of the table, with the hand placed
palm down;
 The other is carefully positioned on arm board for IV
infusion.
 Employed for
►procedures on the face ,the neck, the abdomen, the
upper extremities and the lower extremities.
►eye, ear, nose, face, chest, abdomen, legs, breast, arms
or hands.
►orthopedic, urologic, ophthalmologic,
otorhinolaryngologic, plastic and thoracic operations.

A. Supine/Dorsal Recumbent position
Complications that can arise during supine
positioning include
►neuropathies (Ulnar-most common, Brachial
plexus-abduction of the arms should be limited
to less than 90 degrees) and
►pressure areas(the occiput, sacrum and heels),
where a reduction in perfusion leads to tissue
ischemia and subsequent tissue breakdown.

B. Trendelenburg's position
The patient is on the back on a table
upper section is inclined 45 degrees
the head is lower than the rest of the body;
the patient's legs and knees are flexed.
There is support to keep the patient from
slipping.
The patient is held in position by padded
shoulder braces
Usually used for surgery on the lower
abdomen and the pelvis to obtain good
exposure by displacing the intestines into
the upper abdomen.

B. Trendelenburg's position
 Employed for
►Surgical removal of one or both Fallopian tubes
►Bladder operation
►Salpingectomy/Sulpingostomy
►Sulpingo-oophorectomy
►abdominal hysterectomy and
►other procedures in the pelvic area
►Trendelenburg’s position
 Risks
►increases ICP and IOP.
►increases the risk for atelectasis.
►Increases the risks for cardiovascular changes
 Should be avoided in patients with
►head injury or intracranial pathology
►cardiovascular pathologies(CHF, MI)

C. Reverse Trendelenburg's position
leg tilt down
the patient on a plane inclined with the head higher than the rest of the body.
Needs appropriate safety devices such as a footboard.
with soft roll under shoulders for thyroid, neck, or shoulder procedures
Employed for
►eye, ear, nose & dental operations
►neck procedures such as
 Throat operations
 Thyroidectomy,
 Para thyroidectomy
►laparoscopic procedures such as
 Cholecystectomy operations.

C. Reverse Trendelenburg's position
The primary complications are
►Hypotension and increased risk of venous air
embolism.
Patients with cardiovascular disorders such as
VHD can become hypotensive if the movement
from level supine to reverse Trendelenburg is
too rapid.
Cerebral perfusion decreases in the presence of
hypotension.
To avoid these complications, the OR table
should be slowly moved into the reverse
Trendelenburg position to allow the
physiological processes of the body to adjust as
well as slowly leveled at the end of the surgical
procedure.

D. Fowler's position
 the head of the patient's bed is raised 30 to 90 degrees
above the level, with the knees sometimes also
elevated.
 Employed for
►cranial procedures
 Craniotomy
 Cranioplasty
►posterior craniotomy,
►selected shoulder, and ear, nose, and throat,
(ENT) procedures.
Sitting position- upright: - oto-rhinology.

D. Fowler's position
 Risks
►The primary risks are
 venous air embolism,
 venous pooling
 Cerebral ischemia (due to Hypotension &
inadequate cerebral perfusion)
►The adjustments to the OR table should be made
slowly to decrease the chance of these risk factors from
occurring.
►The table breaks should be underneath the
lumbosacral area and knee joints.

E. Lithotomy Position
 The patient lies on the back with the legs well
separated, thighs acutely flexed on the abdomen, and
legs on thighs;
 stirrups may be used to support the feet and legs.
 The position is maintained by placing the feet in
stirrups.
 Nearly all perineal, rectal, and vaginal surgical
procedures require this position.
 Employed for
►Low rectal resections,
►Some vaginal surgeries.
►External genitalia
►Hemorrhoidectomy
►Circumcision/vaginal hystrectomy
►Scopic examination

E. Lithotomy Position
Risks
►pulmonary oedema
►Peripheral neuropathies including the sciatic,
common peroneal and saphenous nerves.
 it is important to pad the area and avoid any
pressure on the nerve.
►development of venous thrombosis.

F. Sims’ (Semi-Prone) position
The patient lies on the left side with the left
thigh slightly flexed and the right thigh acutely
flexed on the abdomen; the left arm is behind
the body with the body inclined forward, and
the right arm is positioned according to the
patient's comfort.
Called also lateral position
Employed for
►procedures requiring access to the vagina,
anorectal, and perineum.

G. Lateral Kidney position
The patient is placed in the lateral position and
the iliac crest positioned over the “kidney”
elevator.
The head is placed on a padded donut,
protecting the face and ear on the unaffected
side from undue pressure.
Employed for
►Nephrectomy operation.
►procedures on the
 upper urinary tract (e.g., kidney), and
 structures in the retroperitoneal space.

Lateral position
Complications
►The radial nerve and the common peroneal
nerve are particularly susceptible to
positioning injury in the lateral position

H. Prone Position
Patient lies on abdomen.
Chest rolls under axillae and sides of chest to iliac
crests raise body weight from chest to facilitate
respiration; pillow under feet protects toes.
 The patient lying face down with arms bent comfortably at
the elbow and padded with the arm boards positioned
forward.
 Employed for
►cerebral operation
►High cervical
►On back e.g. lymphoma, laminectomy
►Anorectal procedures.

H. Prone Position
 The eyes are at particular risk for compression injuries.
►Direct pressure on the eyes should be avoided by not
using a horseshoe-shaped headrest.
►The eyes should not be padded but gently taped shut.
►A softly padded headrest should be used that does
not apply pressure to the eyes and nose and provides
for airway access.
 Special head rings minimize pressure areas on the face,
but it is important to ensure there is no pressure on the
eyes or nose.
 Pressure areas may develop on the breasts, genitalia
and over bony prominences.
 Retinal ischemia can result from direct pressure on the
eye
 Ischemic optic neuropathy is another form of eye injury

I. knee-chest position
The patient rests on the knees and chest with
head is turned to one side, arms extended on the
bed, and elbows flexed and resting so that they
partially bear the patient's weight; the abdomen
remains unsupported, though a small pillow may
be placed under the chest.
Employed for
►Sigmodoscopy
►Rectal examination

For Kidney Surgery
►The patient is placed on the non-operative side in Sim’s position with an air pillow 12.5 to
15 cm thick under the loin, or on a table with a kidney or back lift
For Chest and Abdominothoracic Surgery
►The position varies with the surgery to be performed.
►The surgeon and the anesthesia provider place the patient on the operating table/bed in
the desired position.
Surgery on the Neck
►Neck surgery, for example, surgery involving the thyroid, is performed with the patient
on the back, the neck extended somewhat by a pillow beneath the shoulders, and the
head and chest elevated to reduce venous pressure.
Surgery on the Skull and the Brain
►Such procedures demand special positions and apparatus, usually adjusted by the
surgeon.

Modifications for Individual Patient Needs
►As with everything else, the patient’s individual needs are met during positioning.
►Anomalies and physical defects are considered.
►Whether the patient is unconscious or conscious, the avoidance of unnecessary
exposure is an essential consideration for all patients.
►The patient’s position should be observed objectively before skin preparation and
draping to see that it adheres to physiologic principles.
►Protective devices, positioning aids, and padded areas should be reassessed
before draping, because they could have shifted during the skin preparation
procedure or during insertion of an indwelling urinary catheter.
►Careful observation of patient protection and positioning facilitates the expected
outcome.

Documentation in the patient’s record should include:
►Names and titles of persons participating in positioning.
►A written pre op ass’t, including a skin ass’t on arrival and
discharge.
►Any pre op limitations in the patient’s range of motion,
►The condition of the skin before and after the surgical
procedure, and
►The position during the surgical procedure, including the use
of special equipment.
►Position patient is placed in and new position if repositioning
occurs.
►The type and location of positioning equipment.
►Post-operative ass’t for injury.

Hazards during positioning patient
Both for pt and personnel are.
potential electrical shock.
Burns fire
Explosions/flammable substances e.g. oxygen.
mechanical injury
►e.g.
 fall from the table
 Sliding fall and injury
 Sharp injures

Review Questions
1. List the preliminary considerations during positioning.
2. State the factors that influence the time at which the patient is positioned?
3. List at least five devices used in positioning the surgical patient on the
operating bed.
4. Mention at least three most commonly used operative positions.

Receiving and Positioning Surgical Patient (1 hrs).pptx

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