HOLY TRINITY COLLEGE

Puerto Princesa City

In Partial Fulfilment of the Requirements in

Related Learning Experience
at theOperating Room
(11th day to 15th day of May 2009)

Submitted by:

Eduardo L. Alcantara
BSN Second Year N1

Submitted to:

Ma’am Rhodora May C. Libiran,

R.N.
Clinical Instructor

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Why is positioning important?
o Patient cannot make clinician aware of compromising positions
o Enables IV lines and catheters to remain patent
o Enables monitors to function properly
o Facilitates the surgeon’s technical approach
o Patient safety (aka Don’t Let The Patient Fall Off The Table)

THE POSITIONS:

Supine (a.k.a. Dorsal Recumbent)

o A position in which the client is lying flat on the back.
o Arms on arm boards

o Check orientation of
arm (arms < 90
degrees)

o Place additional padding under elbow if able

o Arms tucked

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 o Check fingers
o Check IV lines and SaO2 probe

Uses: This is the usual position for administering general anesthesia and
for doing most surgery of the abdomen such as laparotomy,
herniorrhaphy, and appendectomy. With slight modifications, it is also
used for other types of surgery, such as surgery on the arms or legs.
Procedure:
1. Start with the bed flat and the patient lying on the back. The patient's
head should be about two to three inches from the head of the bed.
2. Place a pillow under the patient's head. It should extend about two inches
below the patient's shoulders, with the head in the middle of the pillow.
3. Place a trochanter roll along the affected hip or along the both hips if the
patient has little control over the legs. A trochanter roll is devised by rolling a
bath blanket into a shape about 12-14 inches in length. The roll should be
just long enough to reach from above the hip to above the knee. The
trochanter roll prevents external rotation of the hip.
4. Place pillows under the legs to reach from above the back of the knee to
the ankle so that the ankles and heels do not rub on the sheets.
5. If care plan so indicates, position the footboard or place a folded pillow to
support the patient's feet. The ankles should be at 90° angles.
6. Extend the patient's arms and place small pillows to reach from the elbow
to below the wrist. The hand should be in alignment with the wrist.

Variation: SEMI-SUPINE POSITION

Start with the patient in supine position. Roll the patient's trunk and shoulder
away from you so that there is a 45° angle between the patient's back and
the bed.

1. Place a pillow behind the patient's back for support.

2. Bring the patient's left shoulder forward. Flex the elbow of the left arm and
place the lower left arm, palm up, on a pillow.
3. Flex the elbow of the right arm and bring the forearm across the chest
with palm down.

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4. Extend both legs. Place right leg a little behind left leg. Support right leg
with two pillows folded in half that extend from groin to ankle.

Prone

 A position in which the client is lying on the abdomen with the head
turned to one side.
 Face down
 HEAD PLACEMENT

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  Head straight forward
 ET tube placement and patency
 Check bilateral eyes/ears for pressure points
 Head turned
 Check dependent eye/ear ETT placement
 Be aware of potential vascular occlusion
 Arm placement
 Tucked – similar concerns to supine
 Abducted
 Check neck rotation and arm extension to avoid possible
brachial plexus injury
 Make sure elbows are padded
 Chest Rolls
 Often up to surgeon as to what type of rolls are used
 Ileac support
 Make sure some sort of padding is placed under iliac crests

Procedure:
Start with the bed flat and the patient lying on the abdomen with head
turned to either side, spine straight and legs extended.
1. Place a small pillow under the head so that it extends to the patient's
shoulders and five to six inches beyond the face.
2. Place a small pillow under the abdomen. This relieves pressure on the
back and reduces pressure against a female patient's breasts. An alternate
method is to roll a towel and place it under the shoulders.

3. Place a pillow under the arms to reach from the elbow to below the wrists.
The shoulders and elbows may be flexed or extended, whichever is more
comfortable for the patient.

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4. Place a pillow under the lower legs to prevent pressure on the toes. The
patient may be moved down in the bed before starting the procedure, so that
the feet extend over the end of the mattress. This allows the foot to assume
a normal standing position.

Uses: The prone position is used for surgical procedures- major or minor-
that are performed on the back, shoulders, neck, or back of the head.
Placement of the patient in the prone position for minor surgery, using local
anesthesia, differs in some respects with placement for general anesthesia.

Variation: SEMI-PRONE POSITION

This position relieves pressure on the hips. Breathing is easier in this position
than in the full prone position. Directions given here are for the patient lying
on the left side. These can be easily adapted for the right side.

1. Extend the patient's left arm and tuck it slightly beneath the patient's
body.
2. Place a pillow in front of and at right angles to the patient's chest.
3. Flex the patient's right knee and hip. Support with pillows that are parallel
to the leg.
4. Grasp the patient's left arm from the back of the patient. Turn the patient
onto his chest facing away from you. Gently pull his left arm toward you and
push on his hip.
5. Extend the right arm upward and toward the head of the bed. Place it on
the head pillow with the fingers and palm against the bed.
6. Flex the upper arm on a pillow.
7. Lift up the sheepskin and place a foam block under the sheepskin above
the iliac crest (hip bone).
8. Place another foam block under the sheepskin just below the iliac crest.
You should be able to slide your hand between the hip and the bed.

Lateral

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  Patient on side (lateral decubitus position).
 i.e. left lateral decubitus position means right side up
 Most important to maintain body alignment
 Keep neck in neutral position
 Always place axillary roll
 Place padding between knees
 Try and place padding below lateral aspect of dependent leg
(prevent peroneal nerve damage)
 Position arms to parallel to one another
 Place padding between arms or place non-dependent are on
padded surface
 Check pulses

Variations:
A. LATERAL KIDNEY POSITION
Uses: The lateral kidney position is used for surgery on the kidney or the
proximal third of the ureter.

B. LATERAL CHEST POSITION

Uses: The lateral chest position is used for thoracoplasty, pneumonectomy, &
lobectomy.

C. RIGHT LATERAL POSITION

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Procedure:
1. Start with the bed flat and the patient turned to the left side, with spine
straight. Remember before turning to move the patient to the right side of
the bed.
2. Place a pillow under the head so it extends five to six inches beyond the
patient's face and down to the shoulders.
3. Position patient's right arm so shoulder and elbow are flexed and palm of
hand is facing up.
4. Place patient's left arm so it is extended or only slightly flexed and rest it
on patient's hip or bring it forward and place it on a pillow. The patient's
shoulder, elbow, and wrist should be at approximately the same height.
5. Place a pillow between the patient's legs so that it extends from above the
knee to below the ankle. The patient's hip, knee, and ankle should be at
approximately the same height.
6. A pillow may be placed behind the patient to help maintain the position.

Lithotomy

The
position is
used for
procedures
ranging
from simple
pelvic
exams to
surgeries and procedures involving, but not
limited to reproductive organs, urology, and
gastrointestinal systems.

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  Various types of stirrups
 Candy cane
 Allen stirrups
 Knee cradles
 Various degrees of lithotomy
 Low
 High
 Move legs at same time when positioning patient in and out of
lithotomy

Uses: The Lithotomy position is used for surgery in the perineal area, such
as drainage of rectal abscesses and perineal prostatectomy, and for
gynecological surgery such as vaginal hysterectomy.

Stirrups

Sitting Position

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  Position used in neurosurgery procedure to facilitate access to
posterior fossa.
 Potential complications from sitting position
 Venous air emboli
 Need to take measures to detect and extract VAE
 Hypotension
 Brainstem manipulations resulting in hemodynamic changes
 Risk of airway obstruction

Uses:Included in surgery for which the patient sits upright are various
operations on the nose and throat, as well as some plastic surgical
procedures. The sitting position is described using the operating table as a
chair.

Procedure:
Patients should be positioned in a comfortable, well-constructed chair, so
that the head and the spine are erect. The back and buttocks should be up
against the chair back. The feet should be flat on the floor.

1. Pillows or postural supports may be needed to maintain the position.

2. A small pillow may be folded and placed at the small of the back to add
comfort and support.
3. Do not permit the back of the patient's knees to rest against the chair.

Jack-Knife (a.k.a. Kraske position)

It is an anatomic position in which the
patient is placed on the stomach with the
hips flexed and the knees bent at a 90-
degree angle and the arms outstretched in
front of the patient. Examination and
instrumentation of the rectum are
facilitated by this position.

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POSITIONING STEPS:

1. The patient is induced on the transport cart, which is positioned next

to the OR table.
2. With multiple assistants, the patient is flipped prone onto the OR table
while the CRNA commands at the head and secures the airway.
3. Parallel thoracic or chest rolls (made from tightly rolled sheets and
blankets or manufactured gel rolls) are placed under the thorax, lateral
to the breasts, following the long line of the body to free the abdomen
from compression. Care is given not to compress the breasts with the
rolls or cause undue pressure under the axilla.
4. The head is positioned prone, with face placed in a foam prone-cutout
pillow (with ETT, OGT and EGS exiting out the side), in a skull-pin
head clamp, or in a rocker-based face/forehead rest. It can
alternatively be placed laterally, using a gel donut, pillow or blankets,
while avoiding forced rotation of the pronated head. Eyes, ears, and
nose should be checked to assure that these areas are free from
pressure. Most important: *The C-spine should be in neutral
alignment (check for neutral position of the neck in all 3 planes). The
tube should be free without kinking or undue traction, and the
anesthesia provider should be able to visually see or reach in and
check all connections.
5. The arms are padded and positioned to prevent nerve stretch or
compression. This can be accomplished in a variety of ways
depending on the exact nature of the surgery and access required
(check with the surgeon). The arms are secured to prevent accidental
dislocation or trauma from movement or falling off of table during the
procedure.
6. Legs are maintained in the long axis of the body. Knees should be
padded with egg crate or gel. Pillows should be placed under the
calves and feet to take pressure off the lumbar spine and prevent
pressure sores on toes.
7. The patient is secured to the table with tape or a belt across the thighs
immediately under the buttocks.
8. Break the table from the middle hinge at the hips, bringing both the
thorax and thighs lower than the hips. Caution should be taken to not
allow the lower portion of the bed to hit the floor. The degree of flexion
depends on surgeon preference, patient tolerability, and table surface
hinges.

Uses: The jackknife (Kraske) position is used for surgery on the

coccyx, buttocks, or rectum, particularly when the patient has had
spinal anesthesia and there is no objection to his being placed either
face downward or head low.

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Trendelenburg Position
The body is laid flat on the back with the head lower than the
pelvis, in contrast to the reverse Trendelenburg position, where
the body is tilted in the opposite direction. This is a standard position
used in abdominal and gynecological surgery. It allows better access
to the pelvic organs as gravity pulls the intestines towards the head. It
was named after the German surgeon Friedrich Trendelenburg.

Uses: The Trendelenburg position is used for operations on the bladder,

prostate gland, colon, female reproductive system, or for any operation in
which it is desirable to tilt the abdominal viscera away from the pelvic area
for better exposure.

Procedure:

1. Place the patient in the supine (dorsal recumbent) position and

adjust the mattress so that his knee joints are directly over the lower break.
The knees must bend where the table breaks to prevent pressure on blood
vessels and nerves in the popliteal region, avoiding complications of
phlebitis or paralysis of the leg. Secure patient's arms and legs.
2. Attach well-padded shoulder braces to the table. Check to see that
the braces are the same distance from the head of the table.
3. Adjust braces so that they are on the outer part (bony joint) of the
shoulders rather than against the neck. Braces should be adjusted one-half
inch from shoulders to prevent excessive pressure when the head of the
table is lowered.
4. Flex the table at the knees, dropping the leg portion usually to an

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angle of 30 to 40 degrees.
5. Tilt the entire table, the head low, to the angle desired by the
surgeon, usually 30 to 40 degrees. The head should be lower than the
knees.

Variation: REVERSE TRENDELENBURG POSITION

Use: The reverse Trendelenburg position may be used for surgery on the
neck, such as thyroidectomy, and for certain abdominal surgery, such as
liver or gallbladder operations.

Procedure:
1. Place the patient flat on his back. Adjust the mattress so that
his shoulders are at the upper break of the table. If surgery is in
the neck area, place a small pillow or a folded sheet transversely
under the neck and shoulders, as shown in figure 1-7.
2. Attach the padded footboard at a 90-degree angle to the table
and adjust it so that the soles of the feet are resting against it.
Place padding under the legs(see figure 1-7) to take pressure off
the heels.
3. Secure the arms and legs.
4. Tilt the table, foot forward, to the desired angle.

Sources:
http://www.pitt.edu/~position/Prone/prone4_1.htm;http://www.moondragon.org/health/disorders/pat
ientpositions.html;http://encyclopedia.thefreedictionary.com/;http://www.wikipedia.org/;http://www.
moondragon.org/health/disorders/patientpositions.html; SUBCOURSE MD0927 (PDF File)

Related Reading

Simple clinical interventions improve

patient safety
May 3rd, 2009
Maternal and newborn outcomes were
greatly improved when doctors
implemented a series of simple clinical
interventions at Yale-New Haven
Hospital's obstetrical unit. Yale School
of Medicine researchers report their
results in the May issue of the American 13
Journal of Obstetrics & Gynecology.
 Starting in 2004, the researchers sought to determine if improving
communication between medical staff and standardizing procedures would
reduce the number of adverse outcomes. First author Christian Pettker, M.D.,
senior author Edmund Funai, M.D., and their colleagues attacked the problem
from many different angles. They designed and implemented clinical patient
safety interventions that included communication training for hospital staff,
standardizing interpretation of fetal monitoring, and creating a novel staff
role—the patient safety nurse.
In tracking and analyzing 14 markers for adverse outcomes, the team
found that the rate of adverse events decreased by about 60 percent over
2.5 years, while the staff's own perception of the overall safety climate
increased by 30 percent, according to a survey given by a third party.
"We used these basic principles to make obstetrical care a great deal
safer and they can also be applied to other areas of care as well," said
Pettker, senior research scientist in the Department of Obstetrics,
Gynecology & Reproductive Sciences at Yale School of Medicine.
Funai, associate professor in the medical school's Department of
Obstetrics, Gynecology & Reproductive Sciences and section chief, maternal-
fetal medicine at Yale-New Haven Hospital said, "Interventions of this sort
involve fundamental culture change, requiring enormous effort and
persistence, but the benefits to our patients are priceless."
"We found that implementing various safety techniques could reduce
unanticipated adverse outcomes in an obstetrical unit," said Pettker. "After
taking these steps to improve safety, both patients and staff report that the
care is more seamless and better organized."
Pettker said the next steps in the research are to implement more
safety measures, particularly in the operating room, and standardizing
practices with checklists to improve efficiency in the unit.

Source:

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American Journal of Obstetrics & Gynecology 492 (May 2009),
http://www.ajog.org/article/S0002-9378(09)00092-1/fulltext

MY TAKE
o Summary:

In 2004, the authors/researchers namely Christian Pettker, M.D., Senior Author

Edmund Funai, M.D., and colleagues started their study on proving out the effectiveness of
good communication between the medical staff and the procedures they used in order to
reduce the quantity of unfavorable outcomes. Through this they started on designing and
implementing their clinical patient safety interventions which included communication
education for hospital staff, standardizing interpretation of fetal monitoring, and creating a
novel staff role which they coined the patient safety nurse.
While they’re following and analyzing the 14 indicators for adverse outcomes, the
team found out that the rate of adverse happenings decreased by 60% over 2 ½ years, and 30%
is the staff’s perception on the overall safety environment according to a survey given by a
third party.
According to Pettker they used those basic principles to make obstetrical care a great
deal safer and which can also be applied to other areas of care as well and Funai added that
interventions of this sort involve fundamental culture change, requiring enormous effort and
persistence, but the benefits to our patients are priceless.
Mr. Pettker also stated that they found that implementing various safety techniques
could reduce unanticipated adverse outcomes in an obstetrical unit and after taking these
steps to improve safety, both patients and staff report that the care has improved and well
organized. The next ladders in the said research are to implement more safety measures,
particularly in the operating room, and standardized practices with checklists to improve
efficiency in the unit.

o Reaction or Comment:

After reading this article, I realized how learning and research are important in the
field of science and health. As evidenced by the article, through the studies made by Dr.
Pettker, M.D. and Dr. Funai, M.D. they helped the medical institution/s to furthermore
develop new trends in managing the client’s health.

I realized that being a neophyte in this field of learning, I should learn more and not
be contented on what I have now. It is not only for my good but for the betterment of the
community – to give a quality patient care.

Another is that through this article, I realized how important is updating our nursing
interventions or procedures. We should be knowledgeable on the new nursing interventions
which could give a more effective comfort for our patient.

o Application:

After reading this article one thing appeared into my mind and that is to apply this
learning when doing my nursing interventions.

I should be updated in all new trends about health. An example is having this RR
because through this I’m keeping myself in line with the latest health news, discoveries,

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treatments, and et. al. which would guide me to give a quality patient care (during my studies
and for the near future).

o Why did you choose this article?

This was my chosen article because of its interesting title and content. Plus, it’s
also connected with our area assignment for this week which is the operating room.

o Are you in agreement with this article? Why?

Yes, I am in agreement with this article because it gives me an encouragement to do

will in my works and improve my mistakes as a nursing student. I should learn the right and
true principles in my nursing actions which could help me to practice a good quality of care to
my clients (today and in the near future). Nursing is a matter of certainty and not conjecture.

o Is this related with our country? Why?

Yes, but not that quite. Our government as of today only prioritized the health care
needs by giving only 3% of its budget. Obviously, with that percentage and also through our
observations we can say that the health status of the Filipinos is in a lower percentage and
huge improvement in giving care is really needed by the medical staff and clients or patients.

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