POSITIONING IN

OPERATING THEATRE
BY MURSIDI H.A
PATIENT SAFETY
To provide knowledge on common surgical
position of patient in during surgery
To identify and develop awareness of
potential complication in patient positioning
To practice measure to avoid injuries and
others complication to patient during
surgery
To promote safety and safeguarding patient
well-being during intra-operative period
AIM AND OBJECTIVES
UNDERSTANDING BODILY
SYSTEM
INTEGUMENTARY SYSTEM
Forces include pressure, shear, friction and
maceration
VASCULAR SYSTEM
Dilation of peripheral vessels lead to drop in BP
Venous compression predispose to thrombosis
NERVOUS SYSTEM
CNS depression due to anaesthetic drugs
Pressure on nerves may lead to temporary or
permanent damage
NERVOUS
SYSTEMS
RESPIRATORY SYSTEM
Alteration in diaphragmatic movements and
lung expansion
Inadequate tissue oxygenation and perfusion
MUSCULOSKELETAL SYSTEM
Loss control of normal ROM
May resulted in joint damage, muscle stretch,
strain and dislocation
Potential of pressure formation
UNDERSTANDING BODILY
SYSTEM
Occiput
Peri - orbital arch
Zygomatic Arch
Mastoid region
Acromion process
Scapulae
Thoracic vertebrae
I liac crest
Greater trochanter
Medial or lateral femoral epicondyles
Tibial condyles
Malleolus
Olecranon
Sacrum and coccyx
Patella
Calcaneus

BONY PROMINENCES
ASSOCIATED RISK PATIENT
FACTOR
ADVANCED AGE
NUTRITIONAL STATUS
RESPIRATORY DISORDER
CIRCULATORY DISEASE
OBESE PATIENT
CHRONIC IMMOBILITY
PRESCRIBED MEDICATIONS
UNDERLYING MEDICAL PROBLEMS
NATURE OF SURGERY
GOAL OF PATIENT POSITIONING
PROMOTE PROPER PHYSIOLOGICAL
ALIGNMENT
MINIMAL INTEFERENCE WITH
CIRCULATION
PROTECTION OF SKELETAL AND
NEUROMASCULAR STRUCTURES
OPTIMUM EXPOSURE TO OPERATIVE AND
ANAESTHETIST SITE
PROVIDE PATIENTS COMFORT AND
SAFETY
MAINTENANCE OF PATIENTS DIGNITY
STABILITY AND SECURITY IN POSITION
OPERATIVE NURSING
ROLES
Be knowledgeable on table mechanism
Prepare table attachments and accessories
Familiar with various patient position for
optimum surgery access
Placement of patient to comfortable position
Correct position placement when a table break
is needed intra-operatively
Prevent interference with respiration whilst
moving
Ensure patient is fully anaesthetized before
positioning
Never reposition without anaesthetist
supervision
Table fitting must be placed without
obstruction to incision site
All fitting and attachments must be secure
completely
Ergonomic care whilst positioning
Applying diathermy plate
OPERATIVE NURSING
ROLES
INTRAOPERATIVE NURSING
CONSIDERATIONS
Maintenance of unimpaired respiratory action
Maintenance of physiological alignment from
pressure
Maintenance of adequate circulation avoiding
impaired venous return
Maintenance of body temperature by limiting
exposure
Avoiding metal contact
Sufficient staffs and equipments for positioning
Pressure over the patient
POSITION DEVICES
Patient-positioning devices can be
divided into two categories
One which are primarily geared toward
pressure-relief
Ones which are designed to provide
better access to the surgical site
TABLE ACCESSORIES
AND ATTACHMENTS





TABLE FEATURES AND
ATTACHMENTS
HYDRAULIC
WHEELED BASE
STAND
DETACHABLE
FOOT REST
MANUAL
LEVER
ARM BOARD
SLIDING
BARS
BREAKABLE
HEAD REST
ELEVATED
ARM REST
LATERAL SUPPORT STIRRUPS
METAL SOCKET
OTHERS PILLOWS, HEAD RING, SANDBAGS, ROLL SUPPORT, SOFT PADS, MATTRESS
POSITION DURING INDUCTION OF
ANAESTHESIA
SUPINE POSITION
HEAD EXTENDED
NECK FLEXED
AIM to visualized Oral,
Pharyngeal and Tracheal
spaces
POSSIBLE COMPLICATIONS Trauma to lips
and teeth, Jaw dislocations, laryngeal or vocal cords
injury, epistaxis and trauma to pharyngeal wall
SURGICAL POSITIONING
The patient lies flat
on his back
The arms may be
placed beside the
body, on an armboard
or supported across
the chest by lifting
up the gown which acts as sling
Most common Operative position, such as in
Laparotomy, certain Gynecological and Orthopedic
cases
SUPINE OR DORSAL POSITION
SUPINE/DORSAL POSITION
NURSING PRECAUTIONS POTENTIAL COMPLICATIONS
Head not Hyperextended Backache resulted from
unsupported lumbosacral
curvature
To ensure that arms are
not abducted < 90
Paralysis of arm and hand due
to over abduction
Armboard is padded
Hand in prone position
Radial or Ulnar nerve palsy due
to arm or elbow hanging or
tight strapping
Arms do not overlap or
hang over table edge
Patient protected from
metal contact
Continuous pressure on the
calves may caused venous stasis
resulting thrombosis which can
lead to Pulmonary Embolisms
Bony prominences are
protected (occiput, scapulae,
thoracic vertebrae, olecranaon,
sacrum and coccyx, calcaneus)
Potential pressure points
PRONE POSITION
The patient lying with abdomen on table surface
Arms are placed above the head
Pillows are placed under the shoulders, hips and feet
Access for all surgeries involving posterior back
(cervical spine, back, rectal area and dorsal extremities)
PRONE POSITION
NURSING PRECAUTIONS POTENTIAL COMPLICATIONS
Pillow or towel under
shoulders and hip
facilitate chest expansion,
reduce abdominal
pressure and venous
oozing at operation site
Lower neck and upper back
pain resulting from
hyperextension of head
Radial and ulnar nerve palsy
due to arm restrainer
Hypotension resulted from
pressure on inferior vena cava
and pooling of blood in lower
limbs
Head not hyperextended,
placed on side and kept
supported
Pressure point are well
protected with pad (cheek,
ear, acromion process,
breast, genitalia, patella,
dorsum of feet, toes)
Shoulder dislocation during arm
positioning
Brachial plexus injury due to
over extension of arm < 90
Potential Nerve Injuries
Brachial Plexus
Potential pressure points
Patient lying in supine
position with knees
over lower break of
the table
Head tilted down to 15 or according to the surgeon
preferences
Arms may placed on the chest or armboard
Common position for laparoscopic surgeries in pelvic or
lower abdominal region
Using of shoulder or knee braces may benefit patient
from sliding

TRENDELENBURG POSITION
TRENDELENBURG POSITION
NURSING PRECAUTIONS POTENTIAL COMPLICATIONS
Head not hyperextended and arm
not abducted beyond 90
A 30 Trendelenburg
position may caused
changes in blood pressure,
cerebral edema, congestion
of face and neck
Hands on padded armboards are
supinated
Arms not overlap the table edge or
hang over
A too steep position may
result in cyanosis due to
alteration on diaphragmatic
extension and lung
expansion
Patient is protected from metal
contact
Bony prominences are well
protected (occiput, scapulae,
thoracic vertebrae, olecranon,
sacrum and coccyx and calcaneus)
Shearing of skin may
occurred during
positioning

Returning leg first to reverse
venous stasis
REVERSE TRENDELEBURG
POSITION
Patient in supine
position with arms
by sides or on armboard
Table tilted to 5-10
raising the head
A sand bag may used
below the neck and the shoulder blade for extension of
neck (RUSS TECHNIQUE)
The head stabilized by head ring
Position often used for head and neck surgery to reduce
venous congestion
To prevent stomach regurgitation during induction of
anaesthesia
REVERSE
TRENDELENBURG POSITION
NURSING PRECAUTIONS POTENTIAL COMPLICATIONS
Head not hyperextended and arm not
abducted beyond 90
Backache may result from
unsupported lumbosacral
curvature Hands on padded armboards are
supinated
Paralysis may occurred due
to over abduction of arm
Arms not overlap the table edge or
hang over
Ulnar and radial palsy due to
elbow or arm hanging over
the table or tight restraint
Patient is protected from metal contact
Bony prominences are well protected
(occiput, scapulae, thoracic vertebrae,
olecranon, sacrum and coccyx and
calcaneus)
Pulmonary embolisms as a
result of venous stasis
Cardiovascular overloaded
due to quick return
Anti embolic stocking may be used to
prevent blood pooling
Skin shearing due to sliding
down
Foot bracket may used to prevent
sliding
Potential pressure points
















LITHOTOMY POSITION
Patient lies in supine
position with buttocks
at the lower break of
the table
Lithotomy stirrups placed
in position level with
patient ischial spine
Arms placed over the chest or on an armboard
Legs are lifted together upwards and outwards and feet
placed in knee crutch or candy cane
Common position for Urology, Gynecology, perineal or
rectal operations
LITHOTOMY POSITION
NURSING PRECAUTIONS POTENTIAL COMPLICATIONS
Two person required to raised
the legs simultaneously by
grasping the sole and other
hand supporting the calf
Severe backache caused by too
high stirrups
Calf holder may resulted
peroneal or femoral obturator
nerve damage
Stirrups bars must be checked
and secure before use and its
height must be similar and not
suspend the patient weight
Osteoarthritis or stiff hips due
to rough handling
Too quick of lowering the legs
may cause hypotension
The buttock must be even with
the edge of bed to prevent
lumbosacral strain
Femoral nerve damage due to
acutely flexed thighs
Anti embolic stocking may
used to promote venous return
Bony prominences protected
Hip dislocation or fracture as a
result faulty stirrups
Potential Nerve Injuries
TYPES OF STIRRUPS AND ITS
HAZARDS
KNEE CRUTCH
Pressure on peroneal nerve
resulting footdrop and
neuropathies
CANDY CANE
Pressure on distalsural and
plantar nerves which can
cause neuropathies of the
foot
Hyperabduction may
exaggerated flexion and
stretch sciatic nerve
BOOTH TYPE
May produce support more
evenly and reduce localized
pressure
KNEE CRUTCH
BOOTH TYPE
CANDY CANE
Patient lying with one
side facing operative
side uppermost
The legs flexed to 90
and a pillow is placed
in between
Upper arm rested on
elevated arm rest and the other remains flexed on the
table or armboard
A roll bags may used below the hip/kidney to increased
exposure of iliac region
Position is maintained by use of sandbags or braces
attached to the side of bed
Head supported on a pillow

LATERAL OR KIDNEY POSITION
LATERAL/KIDNEY POSITION
NURSING PRECAUTIONS POTENTIAL COMPLICATIONS
If table break is used, it must
be correctly level with iliac
crest to prevent alteration in
respiration and severe post-
operative backache
If the kidney rest raised too
much, the lungs will not expand
adequately which will result in
cyanosis and hypotension
Injuries to brachial plexus,
median, radial and ulnar nerves
can occur if upper arm is not
supported
Ensure ear is not trapped
when supporting the head
Arms are supported with
adequate padding to prevent
pressure necrosis
If the head is not supported
adequately, brachial plexus can
get stretched
Perineal nerve damage may
resulted from compression on
the down knee against hard
surface
Bony prominences are fully
protected (ribs, iliac crest, greater
trochanter, medial and lateral femoral
epicondyles, Tibial condyles, Malleous)
Potential pressure points
NEUROSURGICAL POSITION
The patient may lying
in a supine position,
prone or lateral
The head is positioned
either on soft ring or a
spiked head rest
The head of the table may be tilted a little to
facilitate venous drainage and to reduce CSF
pressure in the brain

NEUROSURGICAL POSITION
NURSING PRECAUTIONS POTENTIAL COMPLICATIONS
Ensure patient is fully
anaesthetized before
Similar complications
as for prone and supine
positions
positioning or insertion or head
spike
Development of skin
pressure over the ear,
cheek or face if using
head ring for several
hours (supine)
Eye are well covered and fully
protected by pads
Position of spike must not harm
patients ears and eyes
Face is protected from pressure
when in prone position
Sciatic nerve damage
may result due to long
pressure on the dorsum
of the foots
Arms are in good anatomical
alignments
Bony prominences is protected
whilst in all position
Patient positioned in
supine with the pelvis
stabilized against well
padded vertical perineal
post
Traction of operative leg is achieved either by boot-
shaped cuff or devices with restraining straps
Un affected leg may be rested on well padded,
elevated leg holder
Common position for ORIF of hip or closed femoral
nailing
FRACTURE TABLE POSITION
FRACTURE TABLE POSITION























ORTHOPAEDIC FRACTURE TABLE
NURSING PRECAUTIONS POTENTIAL COMPLICATIONS
Patient usually brought into
theatre with hospital bed and
traction applied
Pressure due to perineal
post may injured genital
structure
Ensure patient is anaesthetized
before transfer onto OT table
Fecal incontinence and
loss of perineal sensation
may occurred as a result of
pressure injury to perineal
and pudendal nerve
Operating table are and
attachments are ready according
to surgeon preferences or
standard manual
Tight strap may resulted
peroneal or femoral
obturator nerve damage
resulting in foot drop

Cautions and extra care regarding
shear force injuries,
musculoskeletal and nervous
system during transfer
Bony prominences protected
Patient lying into
prone position
Both legs are abducted
and flexed together
at right angles
Knees flexed and hip
elevated
Head, shoulders and chest rest directly on the table
Arms are placed above the head
Primary position for sigmoidoscopies and laminectomy
procedure
KNEE-CHEST POSITION
KNEE-CHEST POSITION
NURSING PRECAUTIONS POTENTIAL COMPLICATIONS
Legs moved together to
prevent back strain
Lower neck and upper back
pain due to hyperextended head
Arms gently lift up to
prevent dislocation
Ulnar or radial nerve palsies as
a result tight arm restrainer
Head is not hyperextended
and placed to the side on a
pillow
Hypotension due to pressure on
inferior vena cava and pooling
of blood at lower extremities
Bony prominences are
well protected (cheek, ear,
forehead, nose, eyes,
acromion process, breast
[women], genitalia, patella,
dorsum of feet, toes)
Shoulder dislocation or brachial
plexus injury when placing the
arms
Patient may fall from table if
bracket are not secure and fail
to support patients weight
Potential pressure points
The patient positioned in
supine with the upper body
part is flexed to 45 or 90
and the knees slightly
flexed and legs lowered
Arms may be placed over
the laps or armboard
A footrest is used to prevent
footdrop and head spike to stabilized head
Useful position for craniotomies, shoulder or
breast reconstruction and ENTS
SEMI-FOWLERS AND FOWLERS
POSITION
SEMI-FOWLERS AND
FOWLERS POSITION
NURSING PRECAUTIONS POTENTIAL COMPLICATIONS
The cervical, thoracic and
lumbar section of spine must
be aligned once position
established
Orthostatic hypotension due
to blood pooling at lower
extremities
Risk of venous thrombosis
and embolisms as a result of
impended venous return
Extra padding are requires
over bony prominences
(coccyx, ischial tuberosities,
calcaneus, elbows, knees and
scapulae)
High risk of development of
skin pressure over affected
bony prominences
The use of anti-embolism
stocking may necessary to
assist venous return
Alteration on chest
movement due to restriction
from rested arms or tight
straps
Reposition after surgery must
be done gently and slowly
Potential pressure points
JACKNIFE POSITION
A modification of prone
position
Patient hips are supported
on a pillow and the table
are flexed at 90 angle,
raising the hips and lowering head and body
A straps used over the thigh to prevent shearing and
sliding
The head, face, shoulders, chest and feet are supported by
soft pads or rolls to prevent bony pressure
Common position for hemorrhoidectomy or pilonidal
sinus procedures
JACKKNIFE POSITION
(KRASKES)
NURSING PRECAUTIONS POTENTIAL COMPLICATIONS
Pillow or towel under shoulders
and hip facilitate chest
expansion and reduced
abdominal pressure
Lower neck and upper back pain
resulting from hyperextension
of head
Injury to genitalia due to
pressure Anti-embolisms stocking aid
venous return
Radial and ulnar nerve palsy
due to arm restrainer Head not hyperextended, placed
on side and kept supported
Hypotension resulted from
pooling of blood in lower limbs
Pressure point are well
protected with pad (cheek, ear,
acromion process, breast,
genitalia, patella, dorsum of
feet, toes)
Shoulder dislocation during arm
positioning
Brachial plexus injury due to
over extension of arm < 90


Patient turn using log-roll
technique end of procedure
POSITIONING OF ELDERLY PATIENT
FRAGILE SKIN SURFACES
ARTHRITIC JOINTS
LIMITED RANGE OF MOTION
PARALYSIS
LIFTING RATHER THAN SLIDING OR
DRAGGING
AVOID OF ADHESIVE TAPE FOR
STRAPPING
ADEQUATE PADDING FOR BONY
PROMINENCES
ALLOW PATIENT TO POSITIONING BEFORE
ANAESTHETIZED
POSITIONING OF PAEDIATRIC
PATIENT
Think of appropriate size
Right size for bed and attachments
May necessary to use safety strap
Never overextended limbs or keep in one
position for longer periods
Due to small size, children are prone to and
has greater risk of physiologically
compromised
Appropriate positioning and observation
are essential
Liz Sparks an RN in Oklahoma
City, concludes, I t s not all
about technique. I t s about
knowledge. I f 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.
THANK YOU