Wadlund, Diana L. MSN, RN, CRNFA, CRNP
Maintaining skin integrity in the acute care setting has always been important, yet development of pressure ulcers continues to be a major problem in the hospital environment. Annually in the United States, 25 million patients treated in the acute care setting develop pressure ulcers resulting in 60,000 deaths.1 Approximately 42% of all hospital-acquired pressure ulcers occur in surgical patients.2
Development of a pressure ulcer can impact the length of hospital stay for a surgical patient, increase costs for both the patient and the healthcare system, and predispose the patient to additional complications such as bacteremia, squamous cell carcinoma, osteomyelitis, and sepsis.3 Additionally, these patients will require further treatment, and are subjected to pain, disfigurement, and loss of income, independence, and, in some cases, loss of life.3
Patients who develop pressure ulcers stay in the hospital 3.5 to 5 days longer than patients who don't.4 Approximately $750 million to $1.5 billion is spent annually to treat perioperatively acquired pressure ulcers.6 As of October 2008, the Centers for Medicare and Medicaid Services no longer reimburse hospitals for pressure ulcers that are not documented as present on admission or that develop during hospitalization.6
The high cost of treatment and the detrimental effects on a patient's life indicate that efforts should be directed at prevention rather than treatment. Preoperative identification of vulnerable patients will prompt nurses to implement measures to prevent excess pressure and manipulate the perioperative environment to control the risk factors inherent there.
What's a pressure ulcer?
The National Pressure Ulcer Advisory Panel (NPUAP) defines pressure ulcers as "localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction."7 Pressure ulcers often develop during times of physiologic stress such as surgery, serious illness, or trauma.3
Localized unrelieved pressure combined with compression, shear, friction, and moisture cause subdermal cellular damage that leads to pressure ulcer development. Pressure ulcers usually develop over bony prominences where there's little subcutaneous tissue and muscle. Pressure from an external source squeezes the tissue between the source and the bone. This external force can be from the weight of equipment resting on or against the patient, positioning devices such as stirrups and leg or arm holders, the surgical team leaning against the patient, or the patient's own body weight.
Once the external pressure has exceeded the normal capillary pressure of 32 mm Hg, the tissue is deprived of oxygen and nutrients causing cellular death.3 Prolonged pressure that goes unrelieved can occlude blood and lymph circulation, interrupting nutrients from getting to the tissue and causing a buildup of waste products leading to ischemia. Ulceration continues the process, and tissue damage can occur even after the pressure is relieved.
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The operative environment presents many challenges, which can affect a patient's ability to endure excess pressure (see Pressure ulcer risk factors in the perioperative patient).
There are many factors that can augment the process of pressure ulcer development in the surgical patient, including shear, pressure, time, and temperature.3
Shear is the folding of underlying tissue when the skeletal structure moves but the skin remains stationary. This causes vascular occlusion, which leads to tissue ischemia.8 Shear reduces the amount of time that tissue can remain under pressure.3
Excess pressure in the surgical environment can be caused by safety straps, positioning devices, surgical equipment such as tourniquets and retractors, and surgical staff leaning on the patient. Even the patient's own body weight can cause excess pressure.
The oxygen consumption of the cell increases as the tissue temperature increases. Intraoperative use of warming blankets could enhance this risk factor.3
Length of surgery is a predictor of pressure ulcer formation for many reasons. The longer a patient is in the OR, the longer the exposure to many risk factors inherent in that environment (see Incidence of pressure ulcer formation by specialty). Of course, as the length of the surgery increases, so does the patient's risk of pressure ulcer development.9 (see Impact of length of surgery on pressure ulcer development). Tissue damage can occur with low pressure for a long time or with high pressure for a short time.
Pressure ulcer stages
The updated staging system published by the NPUAP identifies four stages of pressure ulcer formation. Also included are the definitions and descriptions of deep tissue injury and unstageable pressure ulcers (see NPUAP pressure ulcer stages).1,7
Presentation of surgical pressure ulcers
Presentation as well as progression of pressure ulcers is unique in surgical patients. Ulcers tend to progress from muscle and subcutaneous tissue outward toward the dermis and epidermis. Depending on the patient's skin color, a purple or maroon localized area of discolored intact skin or blood-filled blister occurs as a result of damage to underlying soft tissue. These pressure ulcers present later than typically expected—sometimes as much as several days postoperatively, which may be why the surgical experience is often overlooked as a triggering event.10
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The majority of pressure ulcers can be avoided by practicing two major steps: identifying individuals at risk and implementing appropriate pressure reduction strategies for all patients.11
* Perform a complete medical history. Thoroughly examine the patient's skin.
* Record the patient's general skin condition and anything unusual, such as rashes, contusions, cuts, abrasions, or discolorations.
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* Establish a skin assessment score by using one of the skin integrity assessment tools such as the Braden Scale. This scale is a widely used tool for assessing a patient's risk of developing a pressure ulcer. The scale consists of six subscales: mobility, activity, sensory perception, moisture, nutrition, and friction and shear. The mobility, activity, sensory perception, moisture, and nutrition subscales are scored from 1 to 4. The friction and shear subscale is graded from 1 to 3. The subscale scores are totaled with a range between 6 and 23. The lower the score, the greater the risk.9
* Maximize nutritional status if possible.
* Establish a strategy to maintain temperature as close to normal as possible.
* Ensure that the skin remains free from moisture. Use underpads and don't allow preps and solutions to pool against the skin.
* Be aware of pressure situations and institute appropriate measures.
* Use safety measures when transferring the patient.
* Provide approved pressure-relieving devices and positioning devices on the OR bed.
* Be aware of the forces of friction and shear, and decrease or eliminate these whenever possible.
* Properly position the patient.
* Ensure proper body alignment.
* Use proper transfer techniques.
* Use appropriate, approved positioning devices. Positioning devices should redistribute pressure over areas at risk for pressure ulcer formation.
* Avoid using sheets, blankets, and towels as padding. These are only minimally effective in pressure redistribution and may contribute to friction.10
* Use of foam pads may be ineffective because they quickly compress under heavy body weight areas. However, they've been found to be as effective as gel pads or viscoelastic in situations where there's lighter weight to redistribute.10
* Positioning devices shouldn't be placed under the OR bed mattress. This action will negate the pressure, reducing the effect of the mattress or overlay.10
* When a patient is in the supine position, the best prevention for heel ulcers is to elevate the heels off the OR bed.
* Ensure that pressure-sensitive areas are protected (see Pressure ulcer concerns in common procedures).
* Place transparent dressings over high-risk areas to reduce shearing and friction.
* Use protective padding, films, and dressings whenever necessary to alleviate pressure.
* Avoid intraoperative exposure to moisture. Use underpads whenever necessary to wick moisture away from the skin. Make sure that prep solutions aren't allowed to pool, especially in areas of constant pressure or heat.
* Provide a smooth, even surface for the patient to lie on. Smooth out the sheets before transferring the patient to the OR bed. At a minimum, provide a high-specification mattress or other pressure distribution surface for every perioperative patient.
* Be careful when using temperature regulation devices. Tissue should only be exposed to a maximum temperature of 107.6 °F (42 °C).10
* Place a sheet between the patient and any warming device under the body. Keep heat away from pressure-sensitive areas such as the heels, sacrum, and coccyx.
* Balance the warming benefits with the pressure ulcer risks. As the procedure time increases, consider lowering the maximum temperature and cycling heating periods.
* Remove adhesive and gel interfaces from the skin immediately post-op.
* Assess the patient's skin and record any changes or abnormalities.
* Daily reassessment is necessary due to constant changes in the patient's mobility, nutritional status, and physiologic condition. Nurses should pay special attention to areas at increased risk for pressure ulcer formation such as the sacrum, back, heels, buttocks, and elbows.12
* Assist the patient with early ambulation. Position the patient appropriately and reposition every 2 hours if the patient is confined to bed.
* Completely remove the pressure from any area injured while the patient was in the OR.
* Place the patient on a pressure-relieving device if any of the following criteria are met: over age 40, surgery lasting longer than 2.5 hours, or the patient with vascular disease.3
* Use positioning devices if necessary.
* Cleanse skin routinely and when soiled. Use mild cleansing agents and avoid hot water.
* Keep the head of the bed at the lowest possible elevation.
* Minimize environmental factors such as humidity.
* Be aware of the patient's nutrition and hydration status. Patients with nutritional and fluid deficits may experience weight loss and muscle mass loss, resulting in exposure of bony prominences. There may be reduced blood flow to the skin, which can contribute to breakdown.13,14
Surgical patients commonly enter the perioperative environment full of anxiety about procedures. They don't anticipate being discharged from the OR with pressure-related injuries to their skin and they entrust the surgical staff to care for them properly and safely.
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14. Gibbons W, Shanks HT, Kleinhelter P, Jonas P. Eliminating facility: acquired pressure ulcers at Ascension Health. Jt Comm J Qual Patient Saf. 2006;32:488–496.
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