Anatomy, Patient Positioning


Article Author:
Maggie Armstrong


Article Editor:
Ross Moore


Editors In Chief:
Chaddie Doerr


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
2/16/2019 1:10:30 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.[1][2][3][4]

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.[5][6][7][8]

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.[9][10]

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.


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Anatomy, Patient Positioning - Questions

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In a patient placed in the position shown in the image, what nerve is most likely to be injured?

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When a patient is placed in the prone position, what body part has the least amount of pressure on it?

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Moving a patient from the supine to Trendelenburg position is least likely to increase which of the following?



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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?

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The lithotomy position most commonly affects what nerve?



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What is the result of placing a patient in the Trendelenburg position?



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Patients are placed in the Sims position for which procedure?



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Which patients will benefit the most from a high-Fowler position?



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What type of surgery requires a patient to be placed in lithotomy position?



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What is rotating the anterior surface of the forearm so it's facing upward?



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A 5 month old is placed supine and provided overhead toys to encourage movement against gravity. Which of the following will this most promote?



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Which of the following is not a reason to ensure proper body alignment?



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Select the activity that would be best for a child with problems with supination.



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Which of the following best describes the Trendelenburg position?

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In a supine patient, what can be done to prevent external rotation of the legs and maintain proper body alignment?

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Why is the semi-Fowler position the preferred position for a patient with a chest tube?

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A patient just spent two hours in the OR in the lithotomy position. What should be evaluated post-op?



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Which of the following is an effect of the Trendelenburg position?



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What is the difference between the Sims and the left lateral position?



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What is the correct patient position for a pelvic exam?

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What is the modified Trendelenburg position?



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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?



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A patient with asthma is wheezing. Why would the patient be placed in a high Fowler's position as soon as possible?

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A 65-year-old female is admitted for an exacerbation of chronic bronchitis. What position would be most appropriate?



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A client presents with an acute cerebrovascular accident. What position is the safest for this patient?



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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?



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A 65-year-old male is admitted after a left lower extremity angiogram for intermittent claudication. Which of the following positions would be best?



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Which of the following can occur in a patient with reverse Trendelenburg position?

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Why is a patient is placed in the reverse Trendelenburg position during neck surgery?

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Which of the following is a complication of lithotomy position?



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How should a patient be positioned for a left thoracotomy?

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Evaluation of a patient's station is accomplished by which of the following?



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You are observing a pregnant patient with eclampsia. Suddenly the patient develops a seizure. Which of the following positions will you immediately place the patient in?



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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.

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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.

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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.

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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.

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During surgery, the surgeon positions the client as shown in the image. What is true about this position? Select all that apply.

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    Image courtesy S Bhimji MD
Attributed To: Image courtesy S Bhimji MD



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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.

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    Image courtesy S Bhimji MD
Attributed To: Image courtesy S Bhimji MD



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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.



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Anatomy, Patient Positioning - References

References

Karkenny AJ,Mendelis JR,Geller DS,Gomez JA, The Role of Intraoperative Navigation in Orthopaedic Surgery. The Journal of the American Academy of Orthopaedic Surgeons. 2019 Feb 1;     [PubMed]
Dufault CA, Patient Care During Minimally Invasive Lateral Spine Surgery: 1.7 www.aornjournal.org/content/cme. AORN journal. 2018 Aug;     [PubMed]
Towfigh S, Inguinal Hernia: Four Open Approaches. The Surgical clinics of North America. 2018 Jun;     [PubMed]
Lukez A,O'Loughlin L,Bodla M,Baima J,Moni J, Positioning of port films for radiation: variability is present. Medical oncology (Northwood, London, England). 2018 Apr 21;     [PubMed]
Hearon BF,Frantz LM, Ulnar Nerve Anterior Transmuscular Transposition in the Lateral Decubitus Position. The Journal of hand surgery. 2019 Jan 23;     [PubMed]
Kim SJ,Barlog JS,Akhavan A, Robotic-Assisted Urologic Surgery in Infants: Positioning, Trocar Placement, and Physiological Considerations. Frontiers in pediatrics. 2018;     [PubMed]
de Sa D,Sheean AJ,Morales-Restrepo A,Dombrowski M,Kay J,Vyas D, Patient Positioning in Arthroscopic Management of Posterior-Inferior Shoulder Instability: A Systematic Review Comparing Beach Chair and Lateral Decubitus Approaches. Arthroscopy : the journal of arthroscopic     [PubMed]
Mezidi M,Guérin C, Effects of patient positioning on respiratory mechanics in mechanically ventilated ICU patients. Annals of translational medicine. 2018 Oct;     [PubMed]
Katz S,Arish N,Rokach A,Zaltzman Y,Marcus EL, The effect of body position on pulmonary function: a systematic review. BMC pulmonary medicine. 2018 Oct 11;     [PubMed]
Mourmouris P,Berdempes M,Markopoulos T,Lazarou L,Tzelves L,Skolarikos A, Patient positioning during percutaneous nephrolithotomy: what is the current best practice? Research and reports in urology. 2018;     [PubMed]

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