Anatomy, Patient Positioning
- Maggie Armstrong
- Ross Moore
- Mitchell FarrellBrian Froelke
- Frank SmeeksScott DulebohnErin HughesPritesh ShethMark PellegriniJames HughesRichard CiresiPhillip Hynes
- 10/27/2018 12:31:46 PM
Introduction
Appropriate patient position can facilitate proper physiologic function during pathophysiologic processes and can also facilitate access to certain anatomical locations during surgical procedures. Multiple factors should be considered when choosing the patient's position. These factors include patient age, weight, and size as well as past medical history including respiratory or circulatory disorders.
Structure and Function
Most common patient positions with common indications and concerns include the following.
Supine Position
This is the most common position for surgery with a patient lying on his or her back with head, neck, and spine in neutral positioning and arms either adducted alongside the patient or abducted to less than 90 degrees.
- Arm abduction maintained less than 90 degrees prevents undue pressure of the humerus on the axilla, thereby preventing brachial plexus injury.
- Arm adduction with hands and forearms maintained in neutral position with palms facing the body or supinated decreases external pressure on the ulnar nerve and prevents injury. A “draw sheet” that passes under the body and over the arm before tucking under the torso can hold the arm in proper position against the body.
Supine Position Variations
Lawnchair position: A variation of supine in which the hips and knees are slightly flexed and above the level of the heart relieves pressure on the back, hips, and knees and facilitates venous drainage from the lower extremities and reduces tension on the abdominal musculature
Frog-leg position: A variation of supine in which the hips and knees are flexed, and the hips are externally rotated facilitates access to the perineum, groin, rectum and inner thigh, but the knees must be supported to avoid stress and dislocation of the hips
Trendelenburg position: A variation of supine in which the head of the bed is tilted down such that the pubic symphysis is the highest point of the trunk facilitates venous return and improves exposure during abdominal and laparoscopic surgeries
- Hemodynamic changes, including increased venous return and cardiac output, are temporary with the majority of hemodynamic variables returning to baseline within ten minutes
- Respiratory changes, including upward displacement of the abdominal contents into the diaphragm, decrease functional residual capacity and respiratory compliance, therefore, requiring higher airway pressures to maintain ventilation
- Gravitational changes from prolonged head down positioning can result in increased intracranial pressure, increased intraocular pressure, and swelling of the face, larynx, and tongue which can increase the risk for post-operative airway obstruction
- Sliding and shifting of a patient in Trendelenburg positioning is often prevented with shoulder braces, however, caution must be used to prevent undue pressure which could result in compression or stretch injury to the brachial plexus
Reverse Trendelenburg position: A variation of supine in which the head of the bed is tilted upward such that the head is the highest point of the trunk facilitates upper abdominal surgery
- Hemodynamic changes include decreased venous return and can result in hypotension
- Gravitational changes in concert with hemodynamic changes can result in decreased cerebral perfusion and invasive arterial monitoring should be considered
- Sliding and shifting of a patient in Reverse Trendelenburg positioning can result in increased pressure over the posterior calcaneus
Lithotomy Position
Commonly used during gynecologic, rectal, and urologic surgeries with a patient lying supine with legs abducted 30 to 45 degrees from midline with knees flexed and legs held supported with the foot of the bed lowered or removed to facilitate the procedure
- Legs are raised and lowered in concert with one another to prevent spinal torsion and muscular injury; prolonged procedure time increases the risk for lower extremity compartment syndrome secondary to inadequate perfusion, recommendations include periodically lowering the extremities throughout prolonged procedures
- Lower extremity padding prevents nerve compression against leg supports; common peroneal nerve injury is most common as the peroneal nerve wraps around the head of the fibula which rests against leg supports
- Hemodynamic changes include increased venous return and transient increases in preload and cardiac output
- Respiratory changes result from cephalad displacement of abdominal contents resulting in decreased lung compliance, functional residual capacity, and tidal volume
Lateral Decubitus Position
Commonly used during surgery requiring access to the thorax, retroperitoneum, or hip with a patient lying on the nonoperative side and careful positioning of the extremities
- The lower extremities are carefully padded between the knees and below the dependent knee to avoid excessive external pressure over bony prominences and the dependent lower extremity is somewhat flexed to avoid stretch or compression of the lower extremity nerves
- Upper extremities are placed in front of the patient with neither arm abducted more than 90 degrees to prevent brachial plexus injury; an axillary roll should be placed below the axilla to prevent compression of the brachial plexus and axillary vascular structures
- The dependent upper extremity is flexed at the shoulder and slightly flexed at the elbow and secured on a padded arm board with padding under bony prominences; invasive arterial monitoring should be placed in the dependent arm to better detect compression of the axillary vascular structures
- The nondependent upper extremity is flexed at the shoulder and slightly flexed at the elbow and often secured with a suspended armrest with care not to abduct the arm more than 90 degrees and to pad the bony prominences
- The head and neck are maintained in a neutral position to prevent lateral rotation and stretch injury to the brachial plexus; care must be given to avoid folding or rolling of the dependent ear or undue external pressure on the dependent eye
- Respiratory changes from the lateral weight of the mediastinum and cephalad displacement of abdominal contents results in decreased pulmonary compliance and lateral decubitus positioning favors ventilation of the nondependent lung
Prone Position
Commonly used during surgery requiring access to the posterior fossa of the skull, posterior spine, buttocks or perirectal area, or lower extremities with patient lying on his or her front with head, neck, and spine maintained in neutral position; patient is turned from supine to prone while maintaining neutral position of the head, neck, and spine
- Risk of dislodgement of monitors and tubes can be minimized by disconnecting as many monitors, lines, and catheters as possible prior to turning the patient; temporary disconnection of the ventilator from endotracheal tube prevents dislodgement
- Many commercially available headrests and pillows are designed to support the forehead and malar regions with openings for the eyes, nose, and chin preventing external pressure on these structures; special caution must be taken to avoid undue pressure on the eyes as perioperative vision loss is an avoidable complication of the prone position
- Respiratory changes result in alveolar recruitment and increased oxygenation without affecting cardiac output and, therefore, is a useful maneuver in severely hypoxemic patients in early acute respiratory distress syndrome (ARDS)
Fowler's Position
Most common position for patient resting comfortably inpatient or in the emergency department with knees either straight or slightly bent and the head of the bed between 45 and 60 degrees
- Respiratory changes result in increased oxygenation by maximizing chest expansion, minimizing abdominal muscular tension, and minimizing the effects of gravity on the chest wall, therefore, a useful maneuver for patients in mild to moderate respiratory distress
- High Fowler's position with the head of the bed between 60 and 90 degrees is useful during placement of orogastric and nasogastric tubes as it decreases the risk of aspiration
Blood Supply and Lymphatics
Lower extremity compartment syndrome is a rare but serious complication of the lithotomy position resulting from inadequate perfusion of the lower extremity. The resulting tissue ischemia, edema, and muscle breakdown increase facial compartmental pressure. Recommendations include periodically lowering the legs of patients in lithotomy position during prolonged procedures to promote perfusion.
Nerves
Nerves are most commonly injured during surgical procedures secondary to external compression or stretch. The most commonly injured nerve is the ulnar nerve from malpositioning of the upper extremity in the supine position. Ensure that the arm is supinated or in the neutral position to avoid ulnar nerve compression and abducted no more than 90 degrees from the body to prevent stretch injury to the brachial plexus.
Lower extremity nerve injuries are less common, though precautions can still be taken. Common peroneal nerve compression can result from direct compression over the fibular head in the lithotomy position; ensure proper padding between bony prominences and supports. Sciatic nerve stretch can result from flexion at the hip in lithotomy position; take care when positioning the patient to move the lower extremities in concert with one another and to prevent hyperflexion at the hip.
Muscles
Muscle strain is a less common side effect of patient positioning but can result due to patient’s inability to react to the movement of the extremities. Take care especially with the lower extremities to move simultaneously to avoid muscle and joint injury.
Surgical Considerations
A significant consideration for patient positioning, especially during prolonged surgical procedures is compression and damage to underlying nervous and vascular structures. Common surgical positions and frequently associated complications can be found above. Providers should ensure that all bony prominences, as well as foreign bodies held against the patient, are appropriately padded to avoid undue pressure on the skin and soft tissues.
Clinical Significance
Proper positioning of the patient can facilitate access to anatomical locations during surgical procedures and promote appropriate physiologic function during pathologic states, for example, Trendelenburg position to increase venous return in a hypovolemic patient. Care to position the patient properly both facilitates procedural aims and aids in preventing subsequent complications.
Interested in Participating?
We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE courses, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.
Improve Content - Become an Author or Editor
This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.
Anatomy, Patient Positioning - Questions
Take a quiz of the questions on this article.
Take Quiz
In a patient placed in the position shown in the image, what nerve is most likely to be injured?
(Move Mouse on Image to Enlarge)
(Move Mouse on Image to Enlarge)
Image courtesy S Bhimji MD
Attributed To: Image courtesy S Bhimji MD
Click Your Answer Below
When a patient is placed in the prone position, what body part has the least amount of pressure on it?
(Move Mouse on Image to Enlarge)
(Move Mouse on Image to Enlarge)
Contributed by Wikimedia Commons (CC0 1.0) PD
Attributed To: Contributed by Wikimedia Commons (CC0 1.0) PD
Click Your Answer Below
Moving a patient from the supine to Trendelenburg position is least likely to increase which of the following?
Click Your Answer Below
Which of the following is false regarding the positioning of pillows for a patient in the left lateral decubitus position to maintain proper body alignment during an examination or procedure?
(Move Mouse on Image to Enlarge)
(Move Mouse on Image to Enlarge)
Contributed Illustration by Beckie Palmer
Attributed To: Contributed Illustration by Beckie Palmer
Click Your Answer Below
The lithotomy position most commonly affects what nerve?
Click Your Answer Below
What is the result of placing a patient in the Trendelenburg position?
Click Your Answer Below
Patients are placed in the Sims position for which procedure?
Click Your Answer Below
Which patients will benefit the most from a high-Fowler position?
Click Your Answer Below
What type of surgery requires a patient to be placed in lithotomy position?
Click Your Answer Below
What is rotating the anterior surface of the forearm so it's facing upward?
Click Your Answer Below
A 5 month old is placed supine and provided overhead toys to encourage movement against gravity. Which of the following will this most promote?
Click Your Answer Below
Which of the following is not a reason to ensure proper body alignment?
Click Your Answer Below
Select the activity that would be best for a child with problems with supination.
Click Your Answer Below
What moves during supination?
Click Your Answer Below
Which of the following best describes the Trendelenburg position?
(Move Mouse on Image to Enlarge)
(Move Mouse on Image to Enlarge)
Contributed by Tammy J. Toney-Butler, AS, RN, CEN, TCRN, CPEN
Attributed To: Contributed by Tammy J. Toney-Butler, AS, RN, CEN, TCRN, CPEN
Click Your Answer Below
In a supine patient, what can be done to prevent external rotation of the legs and maintain proper body alignment?
(Move Mouse on Image to Enlarge)
(Move Mouse on Image to Enlarge)
Contributed by Wikimedia Commons (CC0 1.0) PD
Attributed To: Contributed by Wikimedia Commons (CC0 1.0) PD
Click Your Answer Below
A quadriplegic patient has partially slid down in the bed. What should be done to relocate the patient?
Click Your Answer Below
Why is the semi-Fowler position the preferred position for a patient with a chest tube?
(Move Mouse on Image to Enlarge)
(Move Mouse on Image to Enlarge)
Contributed by Tammy J. Toney-Butler, AS, RN, CEN, TCRN, CPEN/Own work
Attributed To: Contributed by Tammy J. Toney-Butler, AS, RN, CEN, TCRN, CPEN/Own work
Click Your Answer Below
A patient just spent two hours in the OR in the lithotomy position. What should be evaluated post-op?
Click Your Answer Below
Which of the following is an effect of the Trendelenburg position?
Click Your Answer Below
What is the difference between the Sims and the left lateral position?
Click Your Answer Below
What is the correct patient position for a pelvic exam?
(Move Mouse on Image to Enlarge)
(Move Mouse on Image to Enlarge)
Image courtesy S Bhimji MD
Attributed To: Image courtesy S Bhimji MD
Click Your Answer Below
What is the modified Trendelenburg position?
Click Your Answer Below
A patient in the operating room is positioned in the lateral decubitus position on their right side. A pillow is beneath their head and an axillary roll is placed below the axilla. The right arm is extended next to the hip. The left arm is flexed at the shoulder, slightly flexed at the elbow, and secured to a suspended armrest. The right leg is extended and parallel to the left leg with the right knee slightly flexed and a pillow between the knees. What should be done to correct the patient's position?
Click Your Answer Below
A patient with asthma is wheezing. Why would the patient be placed in a high Fowler's position as soon as possible?
(Move Mouse on Image to Enlarge)
(Move Mouse on Image to Enlarge)
Contributed by Tammy J. Toney-Butler, AS, RN, CEN, TCRN, CPEN/Own work
Attributed To: Contributed by Tammy J. Toney-Butler, AS, RN, CEN, TCRN, CPEN/Own work
Click Your Answer Below
A 65-year-old female is admitted for an exacerbation of chronic bronchitis. What position would be most appropriate?
Click Your Answer Below
A client presents with an acute cerebrovascular accident. What position is the safest for this patient?
Click Your Answer Below
A patient returns to the floor after an appendectomy and has continued pain after receiving pain medication. What is the most appropriate intervention at this time?
Click Your Answer Below
A 65-year-old male is admitted after a left lower extremity angiogram for intermittent claudication. Which of the following positions would be best?
Click Your Answer Below
Which shoulder projection best shows the LESSER tubercle in profile?
Click Your Answer Below
Which of the following can occur in a patient with reverse Trendelenburg position?
(Move Mouse on Image to Enlarge)
(Move Mouse on Image to Enlarge)
Contributed Illustration by Beckie Palmer
Attributed To: Contributed Illustration by Beckie Palmer
Click Your Answer Below
Why is a patient is placed in the reverse Trendelenburg position during neck surgery?
(Move Mouse on Image to Enlarge)
(Move Mouse on Image to Enlarge)
Contributed Illustration by Beckie Palmer
Attributed To: Contributed Illustration by Beckie Palmer
Click Your Answer Below
Which of the following is a complication of lithotomy position?
Click Your Answer Below
How should a patient be positioned for a left thoracotomy?
(Move Mouse on Image to Enlarge)
(Move Mouse on Image to Enlarge)
Contributed Illustration by Beckie Palmer
Attributed To: Contributed Illustration by Beckie Palmer
Click Your Answer Below
Evaluation of a patient's station is accomplished by which of the following?
Click Your Answer Below
A surgical resident comes to the floor and asks you to help set a client in the position shown below. This position often is used for which of the following? Select all that apply.
(Move Mouse on Image to Enlarge)
(Move Mouse on Image to Enlarge)
Contributed by Steve Bhmji, MS, MD, PhD
Attributed To: Contributed by Steve Bhmji, MS, MD, PhD
Click Your Answer Below
While in nursing school, a student nurse is taught about the client position shown in the image below. What are the uses of this position? Select all that apply.
(Move Mouse on Image to Enlarge)
(Move Mouse on Image to Enlarge)
Image courtesy S Bhimji MD
Attributed To: Image courtesy S Bhimji MD
Click Your Answer Below
A nurse is asked to place a client in the position shown below. This position often is used for medical or surgical procedures. Which of the following is a correct statement regarding this position? Select all that apply.
(Move Mouse on Image to Enlarge)
(Move Mouse on Image to Enlarge)
Image courtesy S Bhimji MD
Attributed To: Image courtesy S Bhimji MD
Click Your Answer Below
While rounding in the intensive care unit, you note that the provider has placed a patient in the position shown in the image below. Which of the following is true about this position? Select all that apply.
(Move Mouse on Image to Enlarge)
(Move Mouse on Image to Enlarge)
Contributed by Steve Bhmji, MS, MD, PhD
Attributed To: Contributed by Steve Bhmji, MS, MD, PhD
Click Your Answer Below
During surgery, the surgeon positions the client as shown in the image. What is true about this position? Select all that apply.
(Move Mouse on Image to Enlarge)
(Move Mouse on Image to Enlarge)
Image courtesy S Bhimji MD
Attributed To: Image courtesy S Bhimji MD
Click Your Answer Below
A female underwent a complex hysterectomy while in the position shown in the image below. What are the potential complications of this position? Select all that apply.
(Move Mouse on Image to Enlarge)
(Move Mouse on Image to Enlarge)
Image courtesy S Bhimji MD
Attributed To: Image courtesy S Bhimji MD
Click Your Answer Below
Proper positioning of patients is essential in the assessment of bodily systems, carrying out procedures, and overall comfort and safety of the patient. Which body positioning technique coincides with the reason the position is the choice for assessment, procedure, or safety? Select all that apply.
Click Your Answer Below
Anatomy, Patient Positioning - References
References
| Patient position and semi-rigid ureteroscopy outcomes., Korkes F,Lopes-Neto AC,Mattos MH,Pompeo AC,Wroclawski ER,, International braz j urol : official journal of the Brazilian Society of Urology, 2009 Sep-Oct [PubMed] |
| Compartment syndrome of bilateral lower extremities following laparoscopic surgery of rectal cancer in lithotomy position: report of a case., Ikeya E,Taguchi J,Ohta K,Miyazaki Y,Hashimoto O,Yagi K,Yamaguchi M,Inamura S,Makuuchi H,, Surgery today, 2006 [PubMed] |
| Severe leg compartment syndrome associated with dorsal lithotomy position during radical hysterectomy., Yanazume S,Yanazume Y,Iwamoto I,Tsuji T,Yoshinaga M,Douchi T,, The journal of obstetrics and gynaecology research, 2006 Dec [PubMed] |
| Positional alterations of the Kambin's triangle and foraminal areas in the lumbosacral region., Botanlıoğlu H,Aydıngöz Ö,Kantarcı F,Kaynak G,Güven MF,Ertan S,, Acta orthopaedica et traumatologica turcica, 2015 [PubMed] |
| The effect of maternal supine position on umbilical and cerebral blood flow indices., Khatib N,Weiner Z,Beloosesky R,Vitner D,Thaler I,, European journal of obstetrics, gynecology, and reproductive biology, 2014 Apr [PubMed] |
| Thoracoscopic oesophageal mobilization during thoracolaparoscopy three-stage oesophagectomy: a comparison of lateral decubitus versus semiprone positions., Lin J,Kang M,Chen C,Lin R,, Interactive cardiovascular and thoracic surgery, 2013 Nov [PubMed] |
| Lateral position could provide more excellent hemodynamic parameters during video-assisted thoracoscopic esophagectomy for cancer., Zou YB,Yan H,Liu XH,Zhao YJ,Jiang YG,Wang RW,Guo W,, Surgical endoscopy, 2013 Oct [PubMed] |
| Is there an advantage to delivering breast boost in the lateral decubitus position?, Kannan N,Kabolizadeh P,Kim H,Houser C,Beriwal S,, Radiation oncology (London, England), 2012 Sep 24 [PubMed] |
| Anatomical relationships of human pelvises and their application to registration techniques., Haimerl M,Schubert M,Wegner M,Kling S,, Computer aided surgery : official journal of the International Society for Computer Aided Surgery, 2012 [PubMed] |
| Trendelenburg position does not increase cross-sectional area of the internal jugular vein predictably., Nassar B,Deol GR,Ashby A,Collett N,Schmidt GA,, Chest, 2013 Jul [PubMed] |
| Effects of leg and body position on transcutaneous oxygen measurements in healthy subjects and subjects with peripheral artery disease after lower-extremity arterial revascularization: a pilot study., Rich K,, Journal of vascular nursing : official publication of the Society for Peripheral Vascular Nursing, 2002 Dec [PubMed] |
| Comparison of direct blood pressure measurement at the radial and dorsalis pedis arteries during surgery in the horizontal and reverse Trendelenburg positions., Parry T,Hirsch N,Fauvel N,, Anaesthesia, 1995 Jun [PubMed] |
| Anatomy and biomechanics of the forearm interosseous membrane., Farr LD,Werner FW,McGrattan ML,Zwerling SR,Harley BJ,, The Journal of hand surgery, 2015 Jun [PubMed] |
| Variations in the anatomic relations of the posterior interosseous nerve associated with proximal forearm trauma., Calfee RP,Wilson JM,Wong AH,, The Journal of bone and joint surgery. American volume, 2011 Jan 5 [PubMed] |
| Measurement of wrist flexion and extension torques in different forearm positions., Yoshii Y,Yuine H,Kazuki O,Tung WL,Ishii T,, Biomedical engineering online, 2015 Dec 12 [PubMed] |
| Terrible triad of the elbow: is it still a troublesome injury?, Giannicola G,Calella P,Piccioli A,Scacchi M,Gumina S,, Injury, 2015 Dec [PubMed] |
| Pure elbow dislocation in the paediatric age group., Sofu H,Gursu S,Camurcu Y,Yildirim T,Sahin V,, International orthopaedics, 2015 Dec 19 [PubMed] |
| Vascular anatomy relevant to distal biceps tendon repair., Zeltser DW,Strauch RJ,, Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons ... [et al.], 2016 Feb [PubMed] |
| Short-term effects of prone position in critically ill patients with acute respiratory distress syndrome., Blanch L,Mancebo J,Perez M,Martinez M,Mas A,Betbese AJ,Joseph D,Ballús J,Lucangelo U,Bak E,, Intensive care medicine, 1997 Oct [PubMed] |
No comments:
Post a Comment