Patient Positioning: Patients with Obesity (Perioperative) - CE

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#ref4">4}

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.^1,9 A high body weight is also associated with increases in all-cause mortality.

Immobility for an extended period of time increases the risk of pressure injury development.¹

Use lifting and transfer devices when available.^7,8

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.³ 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 is considered overweight.³ An adult who has a BMI of 30 kg/m² or higher is considered obese.^3,6 Extreme obesity describes adults who have a BMI of more than 40 kg/m² or who weigh more than 45.4 kg (100 lb) over their recommended weight.^1,3,6

Patients with obesity frequently have preexisting comorbidities and are at risk for other complications during a surgery or procedure. Patients with obesity are at an increased risk for nerve damage during surgery, and those with preexisting neurologic symptoms, diabetes mellitus, peripheral vascular disease, alcohol dependency, or tobacco use, as well as those whose surgery lasts more than 3 hours, have an even higher risk.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.^1,9

Patient assessment is vital to the preoperative planning and interventions for the patient with obesity to prevent perioperative pressure injury and nerve damage.⁹ 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 surgery being performed. This includes assessing the patient’s weight and BMI, current skin condition, current musculoskeletal and nerve function, and chronic medical conditions, as well as the patient’s ability to tolerate the operative or invasive procedure position and the presence of any respiratory and circulatory compromise issues.^1,4,6,9

Correctly positioning the patient for an operative or invasive procedure requires the perioperative team to be aware of the physiologic effects of the position that the patient is placed in for the procedure. The team must consider the safety of the patient, access to the procedure and IV sites, length of time of the procedure, function of the circulatory and respiratory systems, protection of neuromuscular and skin integrity, and intraoperative monitoring.

The perioperative team must understand that maintaining the procedure position throughout the length of the case causes the patient to encounter certain physical forces that may affect skin and underlying tissues.⁵ These forces include pressure, shear, and friction.⁶ Additional environmental conditions such as moisture, heat, and cold may compound the effects of these forces and increase the damage to the skin and underlying tissues.⁶

Pressure injury develops when there is localized damage to the skin and underlying soft tissue, usually over bony prominences.⁵ A pressure injury can occur as a result of pressure alone or in combination with a shear.^5,6

The risk for pressure injury development increases for patients who:¹

• Are older than 65 years
• Are malnourished and thin
• Have an American Society of Anesthesiologists classification of III or higher
• Have diabetes mellitus, respiratory disease, or vascular disease
• Have abnormal laboratory test values: serum albumin level less than 3.5 g/L, hematocrit level less than 38%, hemoglobin level less than 14.1 g/dL
• Have a preoperative Braden scale score of less than 20 (Table 1)
• Have a BMI of less than 19 kg/m² or greater than 40 kg/m²
• Are undergoing a procedure lasting longer than 180 minutes

Patients with diabetes, respiratory disease, and peripheral vascular disease are at an increased risk of positioning injuries because of decreased tissue perfusion and oxygenation.¹ Patients are also at risk for nerve damage when they have preexisting neurologic symptoms, diabetes mellitus, peripheral vascular disease, alcohol dependency, or arthritis, or if they are obese, thin, or male (men have a higher incidence of ulnar neuropathy).¹

Patient assessment is vital to the preoperative planning and interventions to prevent a perioperative pressure injury and nerve damage.^1,8 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 surgery being performed.¹

Operative or invasive procedures require patient positioning that allows pressure to be redistributed, especially away from bony prominences. The supine and dorsal decubitus positions are the most common positions used in the operating room (OR) or procedure room.^1,6 Typically, the head is rested on a foam or standard bed pillow, which keeps the neck in a neutral position. The patient’s arms are either tucked at the patient’s side or extended out to less than 90 degrees on arm boards. The arm boards are padded with foam, gel, or prophylactic dressing to protect from pressure and nerve injuries. If the arms are tucked, a drawsheet is typically used to secure the arms against the patient’s sides. The drawsheet is placed under the body of the patient, brought above and around the arm, and then tucked under the body of the patient. The legs are often positioned with the knees slightly flexed, resting on one or two pillows to alleviate pressure on the lower lumbar spine.

Special populations such as patients with obesity may require additional positioning considerations. Side attachments or padded arm sleds, which increase the width of the OR bed, may be required because of the patient’s size. Extra-long and extra-wide safety belts should be available for use on patients whose size exceeds the limits of regular securement devices. When positioning the patient, the perioperative team should also keep in mind that patients with obesity are at greater risk for respiratory and circulatory compromise.^1,6

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 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 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 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.
   1. Determine the patient’s mobility and musculoskeletal and nerve function.
   2. Evaluate the patient’s ability to tolerate the required position for the length of the operative or invasive procedure.
   3. Evaluate the patient for any chronic or preexisting medical conditions, especially comorbidities that affect tissue perfusion.
   4. Determine the patient’s height, weight, BMI (Table 1), and age.
   5. Evaluate the patient’s skin condition and nutritional status.
   6. Determine the patient’s risk for skin breakdown using the Braden scale (Table 2) or other health care organization–approved assessment tools, such as the Norton scale or Scott Triggers tool.¹
   7. Determine whether the patient is at risk for brachial plexus or ulnar nerve injury.
   8. Evaluate the patient for the presence of implanted, corrective, or prosthetic devices.
   9. Determine the patient’s risk for venous thromboembolism (VTE) using an organization-approved VTE risk-scoring tool.²
   10. Assess the patient’s peripheral pulses.
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, invasive lines, and equipment (e.g., traction).
9. Ask the patient if any jewelry is present, and if so, ask the patient to remove it.
10. Determine the need for additional perioperative team members, support devices, equipment, or padding to promote patient and perioperative team member safety.¹

Preparation

1. Ensure that all the positioning equipment is correctly functioning, available, clean, and in the OR suite before use with the patient.¹

   Rationale: Correct functioning of positioning equipment contributes to patient safety by redistributing pressure and reducing the risk of injury to both patients and perioperative team members.¹

   Use positioning equipment per the manufacturer’s instructions for use (IFU).

   1. Verify that an appropriate-size blood pressure cuff and sequential pneumatic compression sleeves are available.
   2. Ensure that an extra-wide, extra-long safety belt is on the OR or procedure bed.
2. Apply graduated compression stockings and intermittent pneumatic compression (IPC) sleeves per the manufacturer’s IFU, per the practitioner’s orders, and before general or regional anesthetic is administered.

   Rationale: The use of mechanical devices and graduated compression stockings reduces the risk of deep vein thrombosis.²

3. Verify that the OR or procedure bed can support the patient’s height and weight per the manufacturer’s IFU.¹
   1. Ensure that OR or procedure beds that have a weight limit are clearly labeled per the organization’s practice.¹
   2. Ensure that the bed mattress is able to provide sufficient support and padding for the patient and will not bottom out.¹

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

4. If available, ensure that the OR or procedure 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

5. 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.

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. Ensure that at least one perioperative team member is attending to the patient on the OR or procedure bed at all times.¹

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

4. 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
5. Prepare for transferring the patient from the bed or stretcher to the OR or procedure bed.
6. Have the patient move from the bed or stretcher to the OR or procedure bed slowly and smoothly, while supporting the entire body.
   1. Use proper body mechanics for transporting, moving, lifting, and positioning the patient.

      Rationale: Maintaining correct body alignment while supporting the patient’s arms and legs and joints decreases the potential for injury during the transfer.¹

   2. If assistance is required, use a friction-reducing sheet, a slider board, or air-assisted transfer devices. Use adequate personnel to move the patient safely.

      Rationale: Adequate assistance protects perioperative team members from self-injury.

      Do not pull or drag the patient.

7. Place the patient in the supine position. Position legs parallel to reduce pressure to the occiput, scapulae, thoracic vertebrae, elbows, sacrum, coccyx, heel, and ischial tuberosities.^1,6

   Do not cross the ankles.

8. 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, place the patient in one of these head-elevated positions: ^1,9

   Rationale: Elevating the patient’s head, neck, and shoulders facilitates optimal airway alignment (Figure 1).⁹

   1. Elevate the head of the OR or procedure bed.
   2. Position the patient into a modified supine or sitting position.
   3. Use a wedge-shaped positioning device that supports the head and shoulders of the patient.
   4. Position the patient in a 15-degree left lateral bed tilt.
9. Fasten an extra-wide, extra-long safety belt on the patient’s upper thighs, above the patient’s knees, with enough space to slide two fingers comfortably under the strap. Use a second safety belt below the patient’s knees if needed for the operative or invasive procedure.

   Rationale: A belt that is too tight or placed directly over the patient’s knees places pressure on peroneal and tibial nerves and restricts venous return.⁶

10. Ensure that the IPC sleeves are turned on (if used) before general or regional anesthetic is administered.²

    Rationale: General or regional anesthesia dilates lower leg veins when initiated, causing stasis; initiating VTE preventive therapy before the anesthetic being given minimizes the time lower leg veins are in stasis.²

11. Assist with the induction of anesthesia as directed by the anesthesia provider.
12. Once anesthesia induction is complete, obtain approval from the anesthesia provider to move the patient, and then proceed with patient positioning for the operative or invasive procedure.
13. Ensure that the patient’s head and neck are in neutral alignment.
14. Ensure that the patient’s eyes are protected when under general anesthesia.
15. Ensure access to the operative or invasive procedure site, monitoring devices, and invasive lines and tubing.
16. Secure the patient’s arms on padded arm boards, maintaining an angle of 90 degrees or less with the forearms and palms facing up (supinated) or in a neutral position.¹

    Rationale: Placing the forearm in the neutral position decreases the risk for ulnar nerve injury by reducing the pressure on the ulnar groove.⁶

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

17. Tuck the patient’s arms at the side only when necessary for the operative or invasive procedure.
    1. Wrap the drawsheet smoothly around the patient’s arm with the forearm in the neutral forearm position. Extend the drawsheet above the level of the elbows.

       Rationale: Placing the forearm in a neutral position decreases the risk of ulnar neuropathy. Extending the drawsheet above the level of the elbows prevents the arm from bending and slipping out of the drawsheet.

    2. Pad bony prominences such as the elbow, and ensure that the patient’s hands and fingers are protected from contact with metal portions of the OR or procedure bed and clear of bed breaks or other hazards.
    3. With the appropriate amount of assistance on the other side of the OR or procedure bed, roll the patient’s body over enough to tuck the drawsheet underneath it.

       Tuck the drawsheet under the patient’s body, not under the mattress (Figure 2).

       Rationale: The drawsheet is tucked under the patient’s body rather than under the mattress to protect the ulnar and median nerves from being compressed against the OR or procedure bed.⁶

    4. Use arm cradles or toboggans if the patient’s arms cannot be contained with the sheet. Ensure that there is sufficient padding between the arm and the arm cradle.

       Rationale: Using arm cradles prevents the arms from sliding down the side of the OR or procedure bed and contacting the bed edge or rigid attachments.

    5. Assess blood flow by palpating the radial pulse or observing the pulse oximetry waveform.

       Rationale: Tucking too tightly causes pressure that interferes with monitoring devices and invasive lines.

    6. Monitor the location of the patient’s hands, fingers, feet, toes, and genitals during positioning activities, including changes in the configuration of the OR or procedure bed.¹
18. If the patient’s arm must be placed across the chest for the operative or invasive procedure, place foam or gel padding under the upper arm, proximal to the elbow. Leave a free space under the elbow.

    Rationale: Correct arm placement eliminates pressure on the ulnar nerve.

19. Place a pillow or pad under the patient’s lumbosacral area and under the patient’s knees (with a 5- to 10-degree flexion) and heels elevated off the mattress.¹
20. Protect all areas of the patient’s body from contact with metal portions and hard surfaces of the OR or procedure bed.
21. Protect all tissue and pressure areas.
    1. Avoid compression of the breasts, genitalia, and tissue folds.
    2. Use alternating pressure reduction surfaces (e.g., gel pads).

       Do not use rolled blankets.

       Rationale: Rolled blankets do not disperse body weight when compressed and become a source of localized pressure.¹

22. Limit the number of foam pads, towels, blankets, and warming blankets underneath the patient.⁵

    Rationale: Materials placed between the patient and the pressure-redistribution surface decreases the effectiveness of weight disbursement. Towels and sheet rolls do not reduce pressure and increase the patient’s risk of friction injuries.⁵

23. Support the patient’s legs, if needed, with stirrups or side attachments connected to the OR or procedure bed. Ensure that a minimum of two people lift each of the patient’s legs in and out of the lithotomy position.^1,6
24. 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,¹ place a wedge under the right pelvis for a 12- to 15-degree lateral tilt,¹ or tilt the OR or procedure bed 15 degrees to 45 degrees to the left if the operative or invasive procedure allows.^1,7

    Rationale: The gravid uterus compresses the vena cava in the supine position (aka supine hypotensive syndrome). A wedge placed under the right flank or under the right pelvis, or tilting the OR or procedure bed 15 degrees to 45 degrees to the left, relieves this compression.^1,7

    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.

25. Check the patient’s physiologic alignment once the position is made final by the practitioner, before draping, and intraoperatively after any repositioning of the patient, OR or procedure bed, or equipment that attaches to the bed.

    Rationale: Ensuring that the patient’s body is in physiologic alignment decreases the potential for injury.¹

26. 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.¹

27. Discard supplies, remove gloves, and perform hand hygiene.
28. Document the procedure in the patient’s record.

MONITORING AND CARE

1. Monitor body alignment, the arms and legs, the safety belt, and padding after the initial positioning, and after any movement of the patient, OR or procedure bed, or any equipment that attaches to the bed.¹

   Rationale: Changing the patient’s position may expose or damage otherwise protected body tissue. The safety belt may shift and apply increased pressure when the patient is repositioned or extra padding is added.

2. Monitor for adequate padding and support material between the patient’s body and any hard or metal surface of the OR or procedure bed.
3. Monitor the patient’s arms and legs periodically during the operative or invasive procedure to ensure circulatory and neurologic function.¹
4. Implement correct actions (e.g., repositioning interventions) if potential positioning injuries are identified during the operative or invasive procedure.
5. Monitor devices, invasive lines, and catheters periodically during the procedure to ensure that they are working correctly.
6. Ensure that appropriate preventive maintenance and repair of positioning devices have been performed 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 peripheral neurovascular function is maintained.
• No injury occurs to the patient related to positioning.
• No injury occurs to perioperative team members.

UNEXPECTED OUTCOMES

• Numbness, tingling, or pain unrelated to the operative or invasive procedure
• Compromised physical mobility postoperatively
• Impaired peripheral neurovascular function
• Injury to the patient related to positioning
• Injury to perioperative team members

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 personnel involved in positioning the patient
• Musculoskeletal and neurovascular changes if any
• Time of intraoperative repositioning (as applicable)
• Any intraoperative change in patient position OR or procedure 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, use short and clear instructions.

HOME CARE CONSIDERATIONS

• The patient should be instructed to contact the practitioner if skin breakdown, numbness, or decreased motor function occurs in a nonoperative area.
• After the patient is discharged, a postoperative phone call and interview should be conducted per the organization’s practice to evaluate the patient for any indication of injury related to positioning.

REFERENCES

1. Association of periOperative Registered Nurses (AORN). (2021). Positioning the patient. In Guidelines for perioperative practice (pp. 643-718). Denver: Author. (Level I)
2. Association of periOperative Registered Nurses (AORN). (2021). Venous thromboembolism. In Guidelines for perioperative practice (pp. 1127-1156). Denver: Author. (Level I)
3. Centers for Disease Control and Prevention (CDC). (2021). Defining adult overweight & obesity. Retrieved August 17, 2021, from https://www.cdc.gov/obesity/adult/defining.html
4. Centers for Medicare & Medicaid Services. (2020). Hospital-acquired conditions. Retrieved August 17, 2021, from https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Hospital-Acquired_Conditions.html (Level VII)
5. 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 August 17, 2021, from https://www.epuap.org/download/11182/ (Level VII)
6. Fawcett, D.L. (2019). Chapter 6: Positioning the patient for surgery. In J.C. Rothrock, D.R. McEwen (Eds.), Alexander’s care of the patient in surgery (16th ed., pp. 142-175). St. Louis: Elsevier.
7. Occupational Safety & Health Administration (OSHA). (n.d.). Healthcare wide hazards: Ergonomics. Retrieved August 17, 2021, from https://www.osha.gov/SLTC/etools/hospital/hazards/ergo/ergo.html (Level VII)
8. Phillips, N., Hornacky, A. (2021). Chapter 7: The patient: The reason for your existence. In Berry and Kohn’s operating room technique (14th ed., pp. 93-117). St. Louis: Elsevier.
9. 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 READING

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

Elsevier Skills Levels of Evidence

• Level I - Systematic review of all relevant randomized controlled trials
• Level II - At least one well-designed randomized controlled trial
• Level III - Well-designed controlled trials without randomization
• Level IV - Well-designed case-controlled or cohort studies
• Level V - Descriptive or qualitative studies
• Level VI - Single descriptive or qualitative study
• Level VII - Authority opinion or expert committee reports