RISK FOR PERIOPERATIVE-POSITIONING
At risk for inadvertent anatomical and physical changes as a result
of posture on equipment used during an invasive/surgical procedure
• Muscle weakness
disturbances from anesthesia
ASSESSMENT FOCUS (Refer to comprehensive assessment parameters.)
• Physical regulation
• Risk management
• Pharmacological function
The patient will
• Maintain effective breathing patterns.
• Maintain adequate cardiac output.
• Have surgical positioning that facilitates gas exchange.
• Not show evidence of neurologic, musculoskeletal, or vascular
• Maintain tissue integrity.
SUGGESTED NOC OUTCOMES
Aspiration Prevention, Blood Coagulation; Circulation Status; Neuro-
logical Status; Respiratory Status: Ventilation; Thermoregulation; Tissue
Integrity: Skin & Mucous Membranes; Tissue Perfusion: Peripheral
INTERVENTIONS AND RATIONALES
Determine: Document and report the results of the preoperative
nursing assessment. Identify factors predisposing patient to tissue
injury. This information guides interventions.
Perform: Use the appropriate mode of patient transportation
(stretcher, patient bed, wheelchair, or crib) to ensure patient safety.
Make sure an adequate number of staff members assist with
transferring patient—obtain at least two for moving patient onto an
operating room bed and at least four for moving anesthetized
patient off operating room bed. Adequate stafﬁng enhances safety.
Check the operating room bed before surgery for proper function-
ing. Intraoperative bed malfunction can result in increased anesthe-
sia time and a more difﬁcult surgical approach.
Ensure proper positioning (follow institutional policies):
– Check patient’s neck and spine for proper alignment to avoid
– Check that patient’s legs are straight and ankles uncrossed.
Crossed ankles cause pressure on tissue, vessels, and nerves.
– Place a safety strap 29 (5 cm) above patient’s knees, tight
enough to restrain without compromising superﬁcial venous
return. Applied too tightly, the safety strap may cause venous
thrombosis or compression of tibial, peroneal, or sciatic nerves.
– Secure patient’s arms at his sides with a draw sheet, with palms
down, making sure that no part of the arm or hand extends
over the mattress. Hyperextension can cause injury to the
brachial plexus. Supination of palms minimizes pressure.
Apply eye pads if patient’s eyelids don’t remain closed or if
surgery is being performed on his head, neck, or chest. If allowed to
remain open, the eyes may dry out and become infected. Corneal
abrasions may result from drapes and other foreign material rubbing
against the eyes.
If surgery is expected to last more than 2 hr or if patient is pre-
disposed to a pressure injury, place padding under his occiput,
scapulae, olecranon, sacrum, coccyx, and calcaneus to protect poten-
tial pressure points. Apply a padded footboard to support patient’s
feet. Avoid plantarﬂexion, and prevent stretching of the tibial nerve
and subsequent foot drop.
Assess patient position following each positional change to ensure
proper body alignment and adequate padding and support.
Inform: Tell patient about positioning measures planned to reduce
Attend: Assure patient that careful positioning of the body will be
carried to reduce worry about possible injury.
Manage: Consult with a physical or occupational therapist if special
protective equipment is needed to ensure safety for the patient.
SUGGESTED NIC INTERVENTIONS
Circulatory Care: Mechanical Assist Device, Circulatory
Precautions; Infection Control: Intraoperative; Positioning: Intraoper-
ative; Skin Surveillance; Surgical Precautions; Temperature
Millsaps, C. C. (2006, January). Pay attention to patient positioning! RN,