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

ALERT

The Centers for Medicare & Medicaid Services (CMS) identify stages III and IV pressure injuries as preventable when evidence-based interventions are implemented. Health care organization reimbursement will be denied for a hospital-acquired condition.^{undefined#ref5">5}

Obesity increases the risks of morbidity from hypertension; dyslipidemia; type 2 diabetes; coronary heart disease; stroke; gallbladder disease; osteoarthritis; sleep apnea and respiratory problems; and endometrial, breast, prostate, and colon cancers.¹ A high body weight is also associated with increases in all-cause mortality.

OVERVIEW

Overweight and obesity are terms used to describe a medical condition in which body fat is greater than what is considered healthy for a given height—a condition that may have a negative effect on health.⁴ Overweight and obesity ranges are determined by using an individual’s height and weight to calculate the body mass index (BMI). An adult who has a BMI between 25 and 29.9 kg/m² is considered overweight.⁴ An adult who has a BMI of 30 kg/m² or higher is considered obese.^4,6 Class 3 obesity describes adults who have a BMI of more than 40 kg/m².⁴

Patients with obesity frequently have preexisting comorbidities and are at risk for other complications during an operative or invasive procedure. Patients with obesity are at 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 more than 2 hours, have an even higher risk.^1,6 Patients with extreme obesity are at increased risk for stroke and sudden death, and they may have other health conditions, such as hypertension, atherosclerosis, arthritis, sleep apnea, alveolar hypoventilation, myocardial hypertrophy, coronary artery disease, reflux issues (e.g., gastroesophageal reflux disease [GERD]), and urinary stress continence.^1,8

The perioperative team must be aware of the physiologic effects when placing the patient in the correct position for the operative or invasive procedure. Considerations should be given to the safety of the patient, access to the operative or invasive procedure and IV sites, length of time of the operative or invasive procedure, function of the circulatory and respiratory systems, protection of neuromuscular and skin integrity, and intraoperative monitoring.^6,8

Patient assessment is vital to the preoperative planning and interventions to prevent a perioperative pressure injury and nerve damage.^1,6,8 The unscrubbed perioperative team member should identify patients at risk for positioning injuries and alert the other perioperative team members to create an individualized plan of care for each patient and the specific operative or invasive procedure being performed.¹

A significant potential for injury to the patient exists if correct positioning and monitoring are not carried out by the perioperative team. A patient who is sedated or anesthetized or has had a regional block cannot use the body’s usual mechanisms for avoiding injury from positioning. Injuries related to the positioning of the patient during an operative or invasive procedure may be prevented with effective postoperative monitoring and applicable interventions.¹

SUPPLIES

See Supplies tab at the top of the page.

EDUCATION

• Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
• Explain the perioperative process to the patient.
• Explain the position the patient will need to be in for the operative or invasive procedure.
• Explain to the patient the need to remove all jewelry, because the presence of jewelry during positioning can increase the chance of pressure injuries.
• Explain the need for any additional positioning devices that may be used during the operative or invasive procedure.
• Address any concerns regarding arm, leg, head, and body positioning.
• Encourage questions and answer them as they arise.

ASSESSMENT AND PREPARATION

Assessment

1. Perform hand hygiene before patient contact. Don appropriate personal protective equipment (PPE) based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.
2. Introduce yourself to the patient.
3. Verify the correct patient using two identifiers.
4. Explain the procedure and ensure that the patient agrees to treatment.
5. Determine the location of the operative or invasive procedure site.
6. Perform a thorough preoperative assessment to identify the patient’s risk factors and any specific precautions related to the operative or invasive procedure position (Box 1).
7. Identify any patient considerations that may require additional precautions (e.g., broken bones, contractures, limited range of motion).¹
8. Determine for the presence of tubes (e.g., urinary catheter), invasive lines, and equipment (e.g., traction). If present, secure the tubes, invasive lines, or equipment during patient transfer and positioning.
9. Ask the patient about the presence of any jewelry and ask for it to be removed (as applicable).
10. Determine the need for additional perioperative team members, support devices, equipment, or padding to promote patient and perioperative team member safety.¹
11. During the briefing process (before patient arrival), identify and resolve issues or concerns about the operating room (OR) or procedure room bed, positioning equipment, support surfaces as applicable, the patient’s potential for acquiring a positioning injury related to the Fowler position, and the intraoperative interventions to be implemented to prevent patient positioning injury.

Preparation

1. Ensure that the OR or procedure room and anticipated positioning equipment and support surfaces are set up, intact, functioning correctly, clean, appropriately sized for the patient, and available in the room before patient arrival (Box 2).^1,6

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

2. 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 OR or procedure room beds that have a weight limit are clearly labeled.¹
   2. Ensure that the OR or procedure room bed mattress provides sufficient support and padding for the patient and will not bottom out.¹

      Rationale: Ensuring correct use of OR or procedure room beds that have height and weight limits per the manufacturer’s IFU ensures safe movement and care of the patient.¹

   3. If available, ensure that the OR or procedure room bed mattress is of high-specification reactive foam.

      Rationale: This type of mattress reduces the risk of pressure injury by changing its load distribution in response to an applied load.¹

3. Comply with Universal Protocol.
   1. Use a standardized list to verify that all required items, including informed consent, are available.
   2. Mark the procedure site when required.

      For procedures that must be performed emergently: Comply with Universal Protocol only if it does not delay the procedure.

PROCEDURE

1. Perform hand hygiene and don a mask, eye protection or face shield, gloves, and lead apron if indicated.
2. Verify the correct patient using two identifiers.
3. Apply compression stockings, sequential compression devices (SCDs), or both per the practitioner’s orders and the manufacturer’s IFU. Ensure that the SCD machine is turned ON before general or regional anesthetic is administered.

   Rationale: General or regional anesthesia dilates lower leg veins when initiated, causing stasis; therefore, if venous thromboembolism (VTE) therapy prevention is initiated before the anesthetic is given, this minimizes the time lower leg veins are in stasis.²

4. Ensure that at least one perioperative team member is always attending to the patient on the OR or procedure room bed.

   Rationale: Clear communication about who is responsible for watching the patient on the OR or procedure room bed helps prevent patient falls in the perioperative setting.¹

5. Coordinate patient positioning with all perioperative team members by verifying that team members are ready for patient positioning to occur and by implementing a countdown to start positioning.¹
6. Ensure that the OR or procedure room bed and transport bed or stretcher are locked before the patient moves from one to the other. Assist the patient to slowly move from the transport bed or stretcher to the OR or procedure room bed.
7. Place the patient in the supine position with legs parallel and ankles uncrossed.
8. Place the safety belt on the patient’s thighs, approximately 5 cm (2 inches) above the knees, with enough space to slide two fingers comfortably under the belt.¹

   Do not place the safety belt across the patient’s chest or abdomen.

9. Position the patient for induction of anesthesia per the anesthesia provider’s instructions. If the patient is not able to tolerate the supine position for anesthesia, elevate the patient’s head 25 to 30 degrees.^1,8

   Rationale: Elevating the patient’s head, neck, and shoulders facilitates optimal airway alignment (Figure 1).⁸

   1. Elevate the back of the OR or procedure room bed.
   2. Use a wedge-shaped positioning device that supports the head and shoulders of the patient.
10. Assist with the induction of anesthesia as directed by the anesthesia provider.
11. Ensure that the patient’s eyes are protected when under general anesthesia.
    1. Tape the eyelids closed or use transparent dressings.
    2. Lubricate the eyelids for patients as indicated.
12. Once anesthesia induction is complete, obtain approval from the anesthesia provider to position the patient.
13. Position the patient’s arms safely and as appropriate for the operative or invasive procedure (Table 1) (Figure 2) 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.

    Prevent the patient’s arms and legs from unintentionally falling or hanging below the level of the OR or procedure room bed.¹

14. Perform these steps:
    1. Align the patient’s head and upper body with the patient’s hips and prevent extremes of neck flexion, extension, or rotation.
    2. Place a pillow or soft pad under the patient’s knees so they are slightly flexed (30 degrees)¹ to prevent compression on the popliteal fossa and hyperextension.⁶

       Ensure that the patient’s knees are over the lower break on the OR or procedure room bed.

    3. Raise the head of the OR or procedure room bed to the proper height.

       Protect breathing tubes, IV lines, and monitoring devices from being dislodged during positioning.

    4. Assist with placing the patient’s head into a specialty headrest per the practitioner’s orders, as applicable. Check the position and stability of the patient’s head in the headrest, as applicable.
    5. Lower the leg portion of the OR or procedure room bed.⁶

       Ensure that the patient’s fingers are protected from the hinges on both sides of the OR or procedure room bed.⁶

    6. Pad the patient’s buttocks.
    7. Pad the patient’s heels and the peroneal, saphenous, and sciatic nerves.¹
15. If the patient is pregnant, place a wedge under the right flank or under the right lumbar region above the iliac crest and below the lower costal region for a 12- to 15-degree lateral tilt,³ place a wedge under the right pelvis for a 12- to 15-degree lateral tilt,³ or tilt the OR or procedure room bed 15 degrees to 45 degrees to the left if the operative or invasive procedure allows.³

    Rationale: The gravid uterus compresses the vena cava in the supine position (supine hypotensive syndrome). A wedge placed under the right flank or under the right pelvis, or tilting the OR or procedure room bed 15 degrees to 45 degrees to the left, relieves this compression.³

    Place positioning items underneath the patient. Do not place them beneath the mattress or overlay.

    Rationale: Placing positioning items underneath the mattress negates the pressure-reducing effect of the mattress or overlay.

16. Position patients with spinal cord lesions in a manner that prevents direct pressure on the lesions, as applicable.¹
17. Check the patient’s position once it is made final by the practitioner, before draping, and intraoperatively after any repositioning of the patient, OR or procedure room bed, or equipment that attaches to the OR or procedure room bed.

    Rationale: Changing position may expose or damage otherwise protected body tissue. The safety belt may shift and apply increased pressure when repositioning the patient or adding extra padding.¹

18. 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
19. Assess the patient’s relevant pulses after securing the safety straps and positioning devices. Implement corrective actions as applicable.
20. Comply with Universal Protocol: Perform a time-out to verify the correct patient, correct site, and correct procedure. Also verify the patient’s position, positioning equipment, and any equipment-related concerns during the pre-incision time-out, using a standardized checklist.
21. At the end of the operative or invasive procedure, coordinate with the anesthesia provider and the perioperative team to return the patient to a supine position.
    1. Lower the head of the bed and flatten out the legs.
    2. Ensure that the patient is in a neutral supine position.
    3. Assist with removing the patient’s head from a specialty headrest (if used) per the practitioner’s instructions.
22. Discard supplies, remove gloves, and perform hand hygiene.
23. Document the procedure in the patient’s record.

MONITORING AND CARE

1. Monitor body alignment, arms, legs, genitals as appropriate, safety belt, and padding after the initial positioning and after any movement of the patient, OR or procedure room bed, or any equipment that attaches to the OR or procedure room bed. Implement corrective interventions and repositioning actions as applicable.

   Rationale: A position change may shift safety equipment, expose or damage body tissues, and apply increased pressure to the patient’s body.¹

2. Monitor for adequate padding and support material between the patient’s body and any hard or metal surface of the OR or procedure room bed.
3. Reassess safety belts, monitoring devices, invasive lines, and catheters periodically during the operative or invasive procedure to ensure that they are working correctly, are in the correct place, are not too tight, and are secured.
4. Closely monitor the patient for physiologic signs of increased blood loss.
5. Perform a postoperative debriefing.
6. Perform a postoperative skin assessment at the completion of the operative or invasive procedure.¹

   Be aware that pressure injuries that originate during the operative or invasive procedure have a distinguishing purple appearance that may look like a burn and fail to blanch when compressed.⁷

7. Schedule and align appropriate preventive maintenance and repair of positioning devices by qualified health care team members, per the manufacturer’s IFU.

EXPECTED OUTCOMES

• The patient experiences no tingling, numbness, or pain related to the operative or invasive procedure or positioning.
• The patient resumes preprocedure patterns of mobility.
• Normal skin and tissue integrity is maintained.
• Normal peripheral neurovascular function is maintained.
• Normal cardiovascular, neurologic, and respiratory function is maintained.

UNEXPECTED OUTCOMES

• Numbness, tingling, or pain unrelated to the operative or invasive procedure
• Inability of patient to resume preprocedure patterns of mobility
• Impaired peripheral neurovascular function
• Skin and tissue breakdown

DOCUMENTATION

• Preoperative interview, assessment, and physical examination
• Preoperative and postoperative skin assessment
• Education
• Intraoperative positioning, including type and location of positioning aids
• Names and titles of perioperative team members involved in positioning the patient
• Musculoskeletal and neurovascular changes if any
• Time of intraoperative repositioning (as applicable)
• Any intraoperative change in patient position on OR or procedure room bed
• Position, distal pulses, skin color, and temperature of arms and legs
• Unexpected outcomes and related interventions

PEDIATRIC CONSIDERATIONS

• The pediatric patient’s size and weight should be considered when selecting positioning aids.
• The perioperative team members should establish a rapport with the pediatric patient and family.

OLDER ADULT CONSIDERATIONS

• Older adult patients who have arthritis, decreased mobility, loss of subcutaneous fat, poor skin turgor, and tissue fragility may require additional attention when positioning.
• The thin skin layer and increased incidence of arteriosclerosis make older adult patients more prone to skin breakdown due to pressure.
• If the patient seems confused, short and clear instructions should be used.

REFERENCES

1. Association of periOperative Registered Nurses (AORN). (2023). Positioning the patient. In Guidelines for perioperative practice (pp. 701-750). Denver: Author.
2. Association of periOperative Registered Nurses (AORN). (2023). Venous thromboembolism. In Guidelines for perioperative practice (pp. 1215-1241). Denver: Author.
3. Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN). (2019). Perioperative care of the pregnant woman: Evidenced-based clinical practice guideline (2nd ed., pp. 1-128). Washington, DC: Author.
4. Centers for Disease Control and Prevention (CDC). (2022). Defining adult overweight & obesity. Retrieved January 22, 2024, from https://www.cdc.gov/obesity/basics/adult-defining.html
5. Centers for Medicare & Medicaid Services (CMS). (2023). Hospital-acquired conditions. Retrieved January 22, 2024, from https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Hospital-Acquired_Conditions.html
6. Devlin, C.A., Nanaviti, 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.
7. European Pressure Ulcer Advisory Panel (EPUAP), National Pressure Injury Advisory Panel (NPIAP), Pan Pacific Pressure Injury Alliance (PPPIA). (2019). Prevention and treatment of pressure ulcers/injuries: Quick reference guide 2019. Retrieved January 22, 2024, from https://static1.squarespace.com/static/6479484083027f25a6246fcb/t/647dc6c178b260694b5c9365/1685964483662/Quick_Reference_Guide-10Mar2019.pdf
8. 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

Association of periOperative Registered Nurses (AORN). (2022). Guideline quick view: Positioning the patient. AORN Journal, 116(1), 87-92. doi:10.1002/aorn.13743

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

Speth, J. (2023). Guidelines in practice: Prevention of perioperative pressure injury. AORN Journal, 118(1), 37-44. doi:10.1002/aorn.13948

Clinical Review: Susan M. Scully, MSN, RN, CNOR

Published: March 2024