Patient Positioning: Obese Patients
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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
Use caution when placing a patient with a body mass index greater than 40 kg/m2 in the Trendelenburg position.1
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 Class 3 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.3
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.1,6,9
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
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
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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).
Rationale: The use of mechanical devices and graduated compression stockings reduces the risk of deep vein thrombosis.2
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
Rationale: This type of mattress reduces the risk of pressure injury by changing its load distribution in response to an applied load.1
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
Rationale: Maintaining correct body alignment while supporting the patient’s arms and legs and joints decreases the potential for injury during the transfer.1
Rationale: Adequate assistance protects perioperative team members from self-injury.
Do not pull or drag the patient.
Do not cross the ankles.
Rationale: Elevating the patient’s head, neck, and shoulders facilitates optimal airway alignment (Figure 1).9
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
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
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 room bed.1
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.
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 room bed.6
Rationale: Using arm cradles prevents the arms from sliding down the side of the OR or procedure room bed and contacting the bed edge or rigid attachments.
Rationale: Tucking too tightly causes pressure that interferes with monitoring devices and invasive lines.
Rationale: Correct arm placement eliminates pressure on the ulnar nerve.
Do not use rolled blankets.
Rationale: Rolled blankets do not disperse body weight when compressed and become a source of localized pressure.1
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
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 room 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.
Rationale: Ensuring that the patient’s body is in physiologic alignment decreases the potential for injury.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
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.
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
Stanton, C. (2022). Guideline for positioning the patient. AORN Journal, 115(5), p5-p7. doi:10.1002/aorn.13680
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