Now more than ever, you need to refocus your attention on preventing complications resulting from the improper positioning of patients during surgery. Beginning in October, Medicare won't reimburse for extra care associated with treatment of such preventable injuries as pressure ulcers and nerve injury. Here are four tips to follow.

1. Continually assess the patient
Before positioning a patient for surgery, assess him and identify factors that may interfere with his ability to maintain the prescribed position for the duration of the procedure. Some risk factors that affect a positive outcome include age, height and weight, nutritional status, skin condition and range of motion, respiratory and circulatory status, and immunocompromised patients, such as diabetics or those undergoing steroid, chemotherapy or radiation treatments. Assessment in the OR should be continuous. The circulating nurse is the patient advocate. If there's a change in the patient's position during the procedure, the circulating nurse must re-assess the patient for possible injury from equipment or extremity movement that may cause harm.

2. Measure the patient's risk
The primary nursing diagnosis associated with positioning is to reduce the risk of perioperative injury, such as post-op nerve damage, impaired skin and tissue integrity, impaired circulation and compromised respiratory process. The Braden Scale for Predicting Pressure Sore Risk (www.bradenscale.com/braden.pdf) lets you reliably score a patient's level of risk for developing pressure ulcers. The AORN recommended practices (2008) say you should take additional precautions to decrease the risk of pressure ulcers in patients with Braden Scale scores of less than 20.

3. Anticipate a patient's position
If the surgeon has informed the circulating nurse of a position that differs from those on his preference list, the intuitive nurse will organize and gather positioning devices best suited for that position, such as gel pads, pillows and blanket rolls, before the patient arrives in the operating suite.

• Supine. In this position, the most common for surgical procedures, pressure is concentrated on the occiput, shoulders, elbows, back, sacrum, coccyx and heels. Using a pressure-reducing OR mattress and providing additional padding to bony prominences help minimize skin and tissue injury in this position. Research suggests that polymer elastomer gel pads are more effective than regular foam mattress pads in reducing pressure areas, and that air-support surfaces (pads that have static or dynamic systems) are more effective than gel pads, according to Rothrock in the textbook Alexander's Care of the Patient in Surgery (Mosby, 2007).
• Semi-Fowler position (beach chair). This position is often used for head and neck, open shoulder and arthroscopic shoulder procedures. In addition to the pressure areas noted in the supine position, extra support and padding is needed for the calcaneus (heel bone), coccyx and ischial tuberosities. Use a pillow or sling to support the non-operative extremity and restrain it on the patient's lap. You could also position the arm on an arm board and secure it with Velcro straps. When using a table accessory for shoulder surgery, secure the patient's head with a padded head-positioner. All team members should be aware of the head immobilization process. Throughout the procedure, the patient's head must remain in proper body alignment and the patient's eyes and ears must be protected. Anesthesia personnel should be especially attentive to the patient's respiratory process and ensure that the endotracheal tube remains in the proper position during positioning and throughout the case.

• Lithotomy position. Rectal, genito-urinary and gynecological procedures usually require the lithotomy position, in which the patient's legs are placed in stirrups. Many types of stirrups are available for lithotomy positioning, including candy cane, boot-type and knee crutch. The pressure areas of concern in this position are the same as those in the supine position, except there is less pressure on the lower extremities. Monitor increased pressure in the lumbar, sacral and coccyx areas of the spine. Of greater concern is the development of neuropathies as a result of the patient's lower extremities being placed in the stirrups. Researchers have determined that well-padded positioning devices and carefully timed positioning of the lower extremities are important factors in avoiding injury and neuropathies. In addition, they found a strong coincidence of neuropathies when the procedure was more than two hours long.
• Trendelenburg position. The Trendelenburg position is used in pelvic surgeries to assist the surgeon with visualization by lowering the patient's head and upper body. The patient's legs may be positioned in stirrups, or the patient may be positioned in the supine position with his knees placed over the knee-break in the table. This position can cause respiratory, vascular and other physiologic changes in the patient. However, the main concern with pressure injury is related to shearing stress. Shear force is created when the skin of the patient remains stationary while the deep fascia and skeletal structures move in parallel motion. The pressure creates perpendicular force. Additionally, the force of gravity causes stretching and tearing of the skin and underlying structures, which may lead to ischemia and tissue necrosis.
• Prone position. The prone position is used for pain-management procedures such as epidural and facet injections. Since these procedures often require only conscious sedation rather than general anesthesia, they have few post-op pressure injuries associated with them. In the prone position, areas of concern for pressure injury include the cheeks, ears, eyes, elbows, breasts, genitalia, knees and toes. Special head positioners made of foam or gel are recommended for the positioning of the patient's head to reduce the possibility of facial injury. In addition, it is important to prevent nerve and shoulder injury to the patient by ensuring that a team member is responsible for each of the patient's arms during the prone positioning process. Each arm should be kept close to the body and brought into position without rotating the shoulders, with the palm of the hands facing down. Then place the patient on padded arm boards with the arms slightly flexed. Position the upper arms at an angle of less than 90 degrees to prevent brachial plexus nerve damage.

4. Document
OR nursing documentation includes pre-op and post-op skin condition, types of positioning devices used, where they were used and the names and titles of all team members involved in the positioning process. In the event of an untoward occurrence, everyone involved in the event should be made aware of the injury. Then the nurse should file an incident or occurrence report.

Ounce of prevention
In a fast-paced ambulatory surgical setting, it's important that you use all possible preventative measures when positioning the patient. Creating cultural change in the OR in order to prevent patient injury should be a goal in all institutions. We must continue to seek out processes that will improve safety in all aspects of patient care. In the OR, we must encourage vigilance in positioning patients for surgery in order to prevent pressure injuries while they are in our care.