What are the types of Fowler's position?

Patient positioning is vital to a safe and effective surgical procedure. Fowler’s position is the most common position for patients resting comfortably, whether in-patient or in the emergency department. Also known as sitting position, Fowler’s patient positioning is typically used for neurosurgery and shoulder surgeries. Variations of the Standard Fowler’s Position include Low Fowler’s Position, Semi Fowler’s Position, and High/Full Fowler’s Position.

With numerous applications, Fowler’s position is used for patients who have difficulty breathing because, in this position, gravity pulls the diaphragm downward allowing greater chest and lung expansion.² Learn more about Fowler’s position use cases in common medical procedures, and the differences between the positions.

What is Standard Fowler’s Position

Standard Fowler's position, also known as sitting position, is typically used for neurosurgery and shoulder surgeries. The bed angle is between 45 degrees and 60 degrees. The legs of the patient may be straight or slightly bent. This position is often used for head, chest, and shoulder surgeries.

Standard Fowler’s position is the preferred position to combat respiratory distress syndrome. Due to the positioning of the bed, Standard Fowler's position allows for better chest expansion, improving breathing by facilitating oxygenation.³ Other advantages include an increase in blood and cerebral spinal fluid drainage and improved hemostasis.

What is Semi Fowler’s Position

In Semi Fowler’s Position, the patient is usually on their back. The bed angle is between 30 degrees and 45 degrees. The legs of the patient may be straight or bent.

Semi Fowler’s Position can be used when the patient faces difficulty breathing or is undergoing breathing treatments and when drainage occurs after an abdominoplasty. Due to the positioning Semi Fowler’s position is the preferred position during childbirth to improve the comfort of the mother.⁴ Also, patients experience less nausea in this position compared to patients lying down.

What is High/Full Fowler’s Position

In High Fowler’s position, the patient is usually seated upright with their spine straight. The upper body is between 60 degrees and 90 degrees. The legs of the patient may be straight or bent. This Position is commonly used when the patient is defecating, eating, swallowing, taking X-Rays, or to help with breathing.

High Fowler’s position is usually prescribed to elderly patients as it is scientifically proven to aid in the digestion process and help the patient overcome breathing problems.³ Resting in a High Fowler’s position for an extended period can cause discomfort and increase the development of pressure ulcers.

Contradictions of Fowler’s Position

Positioning of the patient is primarily for reasons of anatomical exposure for the surgical procedure. In instances where the patient does not tolerate the sitting position well, adjustments can be made to accommodate any intolerances of the patient. For Example, patients with pressure ulcers in the lower back or buttocks may not be able to tolerate the sitting position.

Additional measures to reduce pressure and contact of the injured area with hard surfaces may be needed. These can include extra padding, changing angles, employing tilt to remove pressure where the injury is lateral. Additionally, patients with previous spine surgery may have range of motion limitations that make this position contraindicated. Patients should be assessed for their ability to tolerate this position and for any intrinsic patient factors that may pose any additional risk to the patient.

Patient Positioning Considerations for Fowler’s Position

Fowler’s position can be achieved in many different ways using either the native sections of a general surgical table or through the addition of surgical table accessories and positioning aids. Common surgical table accessories & positioning aids used when employing Fowler’s position include Beach Chair positioners or foam body positioners.

Beach Chair Positioners are most often used for High Fowler’s positioning in orthopedic shoulder procedures (total shoulder replacement, shoulder arthroscopy, rotator cuff, etc.). Beach Chairs often have removable left & right back sections that provide surgical site access to the patient’s shoulder. It is also common for Beach Chairs to have a lateral support that is employed to keep the patient positioned upright and restricts lateral torso movement during the rigors of upper extremity procedures.

Limb Positioners are commonly used in collaboration with Beach Chairs when employing High Fowler’s positioning in orthopedic shoulder procedures. Basic limb positioners can include arm and elbow positioners for neutral positioning of the patient’s operative arm for surgical site access or the non-operative arm(s) to get them out the surgeon’s way. More advanced limb positioners allow the surgical team to position the patient arms in unique, spatial positions that enable surgical site access to the shoulder across a spectrum of shoulder joint procedures. OR staff can also employ advanced limb positioners for positions other than Fowlers; for instance, in lateral patient position to enable suspended arm positioning for orthopedic shoulder procedures.

Multi-position armboards are similar to basic limb positioners in that they facilitate neutral positioning of the patient’s operative arm for surgical site access or the non-operative arm(s) to get them out the surgeon's way to access the target anatomy.

Neurosurgical headrests and head positioners are commonly used in Semi-Fowler’s and High Fowler’s positioning to attain surgical site access to the patient’s skull, facial and neck anatomy. The general table is often positioned using native table sections (no Beach Chair used) to achieve the desired Fowler’s position. The native head section of the surgical table is often removed, and the desired anterior or posterior positioning accessories are attached to facilitate immobilization of the head and surgical site access.

Gel and foam positioners are often used across all Fowler's positioning variations. Common positioning aids that support the patient across Fowler's positions include headrest donuts, face masks (for Beach Chairs), arm cradles, wedge positioners (for the legs or feet), heel & ankle cradles, and egg-crate foam sheets to protect or bolster key anatomical areas. Pre-operative patient assessments are always advised to assess the patient’s skin, body morphology, bony prominences, and any special anatomical areas that need unique consideration during surgery. See STERIS's Healthcare Knowledge Center article on Pressure Management to learn more.

Conclusion

One of the most common patient positions, the Fowler’s position provides better surgical exposure and improved breathing. Surgical staff should consider risks and complications associated with the Fowler’s position such as:

• a decrease in the return of blood to the heart
• venous embolism
• air or gas inside the skull
• an increased potential for airway loss
• an increased risk for nerve damage and facial edema

Variations to the Fowler’s position include the Standard Fowler’s, Low-Fowler’s, Semi-Fowler’s, and High-Fowler’s position.

Regardless of what position is being used for a patient during a procedure, it’s important to follow best practices for positioning.¹ Surgical Staff should always refer to their facility's positioning policies, procedures, and training when positioning a patient.

• Have an adequate number of personnel, devices, and equipment available during positioning activities helps to ensure patient and personnel safety.
• Respect the patient’s dignity and privacy during positioning: only necessary personnel in the room when the patient is exposed.
• Maintain the patient in a natural neutral alignment. Keep the patient’s head and neck in a neutral position without extreme lateral rotation and avoid hyperextending.
• Verify the patient's complete body is in physiologic alignment and that the hands, fingers, feet, and toes are protected from surgical table articulations.
• Operating Room staff should always use safe body mechanics during transfers and positioning.
• Ensure that the patient is not in contact with any metal portions of the surgical table or positioning devices.
• Never exceed the weight limits for the table or the accessories used and always follow the manufacture’s guidelines and recommendations when using the surgical table and accessories.
• Inspect all equipment, pads, and accessories before use and replace them as needed.

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References

¹Guideline for positioning the patient. (2017). AORN Journal, 105(4), P8-P10. doi:10.1016/s0001-2092(17)30237-5

² https://nurseslabs.com/patient-positioning/#fowlers_position

³ https://www.topregisterednurse.com/fowlers-position/

⁴ https://nurse.plus/nclex-terminology/terms-abbreviations/semi-fowlers-position/