Patient Positioning: Patients with Obesity (Perioperative) - CE/NCPD

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OVERVIEW

Patients with obesity have an increased risk for nerve damage during an operative or invasive procedure, and those with preexisting neurologic symptoms, diabetes mellitus, peripheral vascular disease, alcohol dependency, or tobacco use, as well as those whose operative or invasive procedure lasts longer than 2 hours, have an even higher risk (Table 1) (Box 1).^{undefined#ref1">1,2} Patients with obesity also have an increased risk for cardiovascular (e.g., stroke, sudden death, hypertension, atherosclerosis, myocardial hypertrophy) and respiratory (e.g., sleep apnea, alveolar hypoventilation, coronary artery disease) changes because of excess adipose tissue, increased oxygen consumption and carbon dioxide production, reduced myocardial compliance, increased breathing effort and decreased efficiency of air exchange, and decreased resting functional residual lung capacity.

Patients with obesity may have other health conditions, such as arthritis, reflux issues (e.g., gastroesophageal reflux disease [GERD], hiatal hernia), and urinary stress continence.^1,3 Patients with obesity also may have increased intra-abdominal and central venous pressures in the prone position because of their larger abdominal girth. Increased intra-abdominal pressure increases the risk for abdominal compartment syndrome.^1,2

Positioning the patient is a perioperative team effort, and the perioperative team must understand how positioning the patient for an operative or invasive procedure affects the patient’s body. Safe patient care during positioning includes:^1,2

• Providing optimal exposure for the perioperative team
• Maintaining body alignment
• Allowing for the placement of positioning equipment
• Incorporating necessary changes to accommodate the patient’s physical needs
• Providing sufficient access to the anesthesia provider to give the necessary depth of sedation

SUPPLIES

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EDUCATION

• Give developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, preferred learning style, and overall neurologic and psychosocial state.

ASSESSMENT AND PREPARATION

Assessment

1. Determine if the patient has health literacy needs or requires tools or assistance to effectively communicate. Be sure these needs can be met without compromising safety.
2. Determine the location of the procedure site per the licensed practitioner (LP)’s preference card and procedure schedule.
3. Review the patient’s previous experience and knowledge of intraoperative positioning and understanding of the care to be provided.
4. Do a preprocedure patient assessment to identify a patient at risk for a positioning injury (Box 1). Communicate the patient’s risk with the other members of the perioperative team, as applicable.
5. Plan how the operating room (OR) or procedure room bed, positioning equipment, devices, and support surfaces will be used and identify any considerations that might affect the patient (Box 2).
6. Ask the patient about the presence of any jewelry, body piercings, and hair accessories (e.g., hair extensions or braids).¹ Remove these items as applicable.

   Rationale: Jewelry, body piercings, hair accessories, and other items may pose a risk for patient injuries.

7. Determine the need for neurophysiologic monitoring (e.g., somatosensory evoked potential [SEEP], transcranial electric motor-evoked potential [TceMEP]) to be used intraoperatively to identify potential positioning injuries and prevent peripheral nerve injury.
8. Determine the need for additional perioperative team members, support devices, equipment, or padding to promote patient and perioperative team member safety.¹

Preparation

1. Make sure the OR or procedure room, bed, devices, support surfaces, and positioning equipment are ready before the patient arrives. Check to make sure that everything is set up, working correctly, clean, the right size for the patient, and available in the room.^1,2

   Rationale: Ensuring that the OR or procedure room, bed, and positioning equipment are intact, correctly functioning, clean, and available in the room contributes to patient and perioperative team member safety.¹

2. During the preoperative briefing, resolve any conflicts in the availability of positioning equipment and determine interventions to be used to prevent patient positioning injuries related to the procedure (as applicable).¹
3. During the preoperative briefing, include any safety needs of the patient, such as the need for additional perioperative team members, equipment, and time to position the patient.¹ Use safe practices when positioning the patient.
4. Verify that the OR or procedure room bed and positioning devices can support the patient’s height and weight per the manufacturer’s instructions for use (IFU).¹
   1. Ensure that the OR or procedure room bed has a weight limit that is clearly labeled.
   2. Ensure that the OR or procedure room bed mattress provides sufficient support and padding for the patient.
   3. Use an OR or procedure room bed designed to support a patient with morbid obesity.

      Rationale: Patients with obesity have an increased risk for falls, especially when the steep Trendelenburg positioned is used.¹

PROCEDURE

1. Clean hands and don appropriate personal protective equipment (PPE) based on the risk of exposure to bodily fluids or infection precautions.
2. Verify that the transport bed or stretcher and the OR or procedure room bed are locked before the patient moves from one to the other.
3. Coordinate with all perioperative team members to position the patient by confirming everyone is ready and using a countdown to begin the positioning process.¹
4. Safely secure the patient to prevent the patient from falling off the transport bed or stretcher or the OR or procedure room bed.¹
5. Help the patient slowly move from the transport bed or stretcher to the OR or procedure room bed. Safely secure the patient to the OR or procedure room bed after transfer.
6. Have the patient lie in the supine position with legs parallel and ankles uncrossed.
   1. Elevate the patient’s head as appropriate by elevating the back of the OR or procedure room bed or using a wedge positioning device that supports the patient’s head and shoulders.¹
   2. Put a wedge positioning device under the patient’s right lumbar region or tilt the OR or procedure room bed to the left at least 15 degrees,¹ as appropriate.

      Rationale: Some patients with obesity may not be able to tolerate the supine position because of difficulty breathing.¹

7. After anesthesia induction, safely position the patient for the procedure, as appropriate.

   Monitor the patient’s arterial blood gases when positioning a patient with a body mass index (BMI) of greater than 40 kg/m² in the Trendelenburg position.¹

   Rationale: A change from the supine to the Trendelenburg position in a patient with extreme obesity may result in significant reduction in the mean arterial pressure.¹

8. Position the patient’s arms safely and as appropriate for the procedure by tucking them at the sides, securing them with arm cradles, securing them across the patient’s body, using an arm positioner device, or placing them on arm boards (Table 2) (Figure 1).
9. Ensure access to the operative or invasive procedure site, monitoring devices (e.g., blood pressure cuff, pulse oximetry sensor), and invasive lines and tubing as applicable. Ensure that the devices function effectively without causing nerve, tissue, or circulatory compromise.¹
10. Reassess the placement and security of safety belts and positioning devices and check the patient's relevant pulses after positioning or repositioning.¹ Make changes as applicable.
11. After positioning and repositioning, confirm that positioning equipment, devices, and the scrubbed team members are not resting against the patient.

    Rationale: Positioning equipment, devices, or scrubbed team members that rest against the patient increase the risk for patient tissue or nerve damage.¹

12. At the end of the procedure, coordinate with the anesthesia provider and the perioperative team to return the patient to a supine position.
13. At the end of the procedure, do a postoperative patient assessment to identify any potential positioning injuries.^1,2
14. After transport to the phase I recovery area, tell the postoperative nurse about any potential patient injuries related to positioning from the procedure using a standardized communication tool.^1,2

    Rationale: Pressure injuries related to positioning during the procedure may not show up immediately after the procedure. Monitoring the areas may help with early recognition and treatment.^1,2

MONITORING AND CARE

1. With other perioperative team members, decide on regular times to check the patient’s position, safety belts, and positioning equipment during an operative or invasive procedure to make sure the patient stays in the correct position and has not moved.¹
2. Watch the position of the patient’s hands, fingers, feet, toes, and genital area when changing position of the OR or procedure room bed.¹
3. Keep an eye on the patient’s position throughout the procedure. Make changes if needed and as applicable. Some repositioning options may be limited or not possible for certain patients.¹

   Rationale: Regularly checking the patient’s position helps spot potential issues and lowers the risk of injury.

EXPECTED OUTCOMES

• Patient resumes preprocedure patterns of mobility.
• Patient experiences a safe transfer to and from the OR or procedure room bed.
• Patient does not experience tingling, numbness, or pain related to the operative or invasive procedure or positioning.
• Patient’s skin and tissue integrity is maintained (i.e., consistent with the preoperative assessment).
• Patient’s peripheral neurovascular function is maintained.
• Patient’s cardiovascular, neurologic, and respiratory functions are maintained.

UNEXPECTED OUTCOMES

• Patient is unable to resume preprocedure patterns of mobility.
• Patient experiences a fall or other injury during the transfer to and from the OR or procedure room bed.
• Patient experiences numbness, tingling, or pain related to the operative or invasive procedure or positioning.
• Patient has skin and tissue breakdown.
• Patient has impaired peripheral neurovascular, cardiovascular, neurologic, or respiratory function.

DOCUMENTATION

• Intraoperative position of the patient, including disposition of the patient’s arms and legs
• Type and location of positioning equipment, devices, support surfaces, additional padding, and safety belts (as applicable)
• Name and title of perioperative team members involved in positioning the patient
• Time of intraoperative repositioning (as applicable)
• Preoperative and postoperative assessments
• Unexpected outcomes and related interventions
• Actions taken to prevent patient injury related to positioning during the procedure, especially if the patient is at high risk

PEDIATRIC CONSIDERATIONS

• The pediatric patient’s size and weight should be considered when selecting positioning aids.

OLDER ADULT CONSIDERATIONS

• Thinner layers of skin make older adult patients more prone to skin breakdown due to pressure injury.²

REFERENCES

1. Association of periOperative Registered Nurses (AORN). (2024). Positioning the patient. In Guidelines for perioperative practice (pp. 701-750). Denver: Author.
2. Devlin, C.A., Nanavati, H. (2023). Chapter 6: Positioning the patient for surgery. In J.C. Rothrock (Ed.), Alexander’s care of the patient in surgery (17th ed., pp. 139-173). St. Louis: Elsevier.
3. Phillips, N., Hornacky, A. (2021). Chapter 26: Positioning, prepping, and draping the patient. In Berry and Kohn’s operating room technique (14th ed., pp. 487-522). St. Louis: Elsevier.

ADDITIONAL READINGS

Carron, M. and others. (2020). Perioperative care of the obese patient. British Journal of Surgery, 107(2), e39-e55. doi:10.1002/bjs.11447

Clinical Review: Kerrie L. Chambers, MSN, RN, CNOR, CNS-CP(E)

Published: November 2024