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MMaintaining skin integrity in the acute care setting
has always been important, yet development of pres-
sure 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 complica-
tions 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, indepen-
dence, 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 bil-
lion 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 fric-
tion.”7 Pressure ulcers often develop during times
www.ORNurseJournal.com March OR Nurse2010 27
1.9ANCC CONTACT HOURS
skin integrityin theOR
Maintaining
By Diana L. Wadlund, MSN, RN, CRNFA, CRNP
RO
XA
NN
AV
ILLA
of physiologic stress such as
surgery, serious illness, or
trauma.3
Localized unrelieved pressure
combined with compression,
shear, friction, and moisture
cause subdermal cellular dam-
age 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 exter-
nal 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 nutri-
ents 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.
Risk factors
The operative environment pre-
sents 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
ShearShear is the folding of underlying tissue when the
skeletal structure moves but the skin remains stationary.
28 OR Nurse2010 March www.ORNurseJournal.com
Maintaining skin integrity in the OR
Localized unrelieved pressure combined with
compression, shear, friction, and moisture,
cause subdermal cellular damage that
leads to pressure ulcerdevelopment.
Pressure ulcer risk factors in the perioperative patient
Preoperative risk factors Intraoperative risk factors Postoperative risk factors
• Age (elderly)
• Smoking
• Nutritional status
—Decreased serum albumin
—Decreased serum protein
—Decreased lymphocyte count
—Decreased muscle mass
—Obesity
—Dehydration
—Low body mass index (BMI)
• Comorbidities (diabetes mellitus,
hypertension, anemia, respiratory,
neurologic, vascular, or heart
diseases)
• Impaired mobility
• Hypotension
• Fever
• Type of surgery
• Prolonged hypothermia
• Use of warming blanket (specifically
when placed under the patient)
• Use of anesthetic agents
• Impaired sensorium
• Hemodynamic factors (hypotensive
episodes, extracorporeal circulation,
blood loss)
• Time on OR table
• Position during surgery
• Position changes during surgery
• Intensity and duration of pressure
• Exposure to moisture during surgery
• Length of time it takes
the patient to return to a
normothermic state
• Positioning during
recovery
• Mobility
Adapted from Shoemaker S, Stoessel K. The Clinical Issue: Pressure Ulcers in the Surgical Patient. Kimberly-Clark Health Care Education Knowledge
Network; 2007.
www.ORNurseJournal.com March OR Nurse2010 29
This causes vascular occlusion, which leads to tissue
ischemia.8 Shear reduces the amount of time that tis-
sue can remain under pressure.3
PressureExcess pressure in the surgical environment can
be caused by safety straps, positioning devices, sur-
gical equipment such as tourniquets and retractors,
and surgical staff leaning on the patient. Even
the patient’s own body weight can cause excess
pressure.
TemperatureThe oxygen consumption of the cell increases as the
tissue temperature increases. Intraoperative use of
warming blankets could enhance this risk factor.3
TimeLength 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 develop-
ment.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 out-
ward 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 under-
lying 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
Perioperative prevention
The majority of pressure ulcers can be avoided by
practicing two major steps: identifying individuals at
risk and implementing appropriate pressure reduc-
tion strategies for all patients.11
Preoperative strategies• Perform a complete medical history. Thoroughly
examine the patient’s skin.
Incidence of pressure ulcer formation by specialty
Procedure Incidence rate Prevalence rate
specialty No. of new case Percentage of
during a defined population affected
time interval at a specific time
Cardiac 17-29.5 7
Vascular 9.8-17.3
Spinal and 36
abdominal
Orthopedic 15-20.6 6.5
Elder 66
orthopedic
General and 27.7 7
thoracic
Head and neck 10
Neurologic 5.2
Data represented in table are in percentage.
Adapted from Shoemaker S, Stoessel K. The Clinical Issue: PressureUlcers in the Surgical Patient. Kimberly-Clark Health Care Education
Knowledge Network; 2007.
Impact of length of surgery onpressure ulcer development
Length of surgery (h) Prevalence rate (%)
>3 5.8-6.0
>4 8.9
>5 9.9
>6 9.9
>7 13.2
Adapted from Shoemaker S, Stoessel K. The Clinical Issue: PressureUlcers in the Surgical Patient. Kimberly-Clark Health Care Education
Knowledge Network; 2007.
30 OR Nurse2010 March www.ORNurseJournal.com
Maintaining skin integrity in the OR
• Record the patient’s general skin condition and
anything unusual, such as rashes, contusions,
cuts, abrasions, or discolorations.
• 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, sen-
sory 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 solu-
tions 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.
Intraoperative strategies• 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
NPUAP pressure ulcer stages1,7
Pressure ulcer Pressure ulcer stage
stage description
Deep tissue injury Dark or discolored area of
intact skin or a blood-filled
blister. May be painful,
firm, mushy, or at a differ-
ent temperature than the
surrounding tissue. Often
will open to reveal deep
layers of tissue.
Stage I Redness on intact skin that
doesn’t blanch.
May heal and remain intact
with appropriate interven-
tion.
Stage II Open ulcer—shallow, par-
tial thickness, with a pink
wound bed
OR
Intact or ruptured serum-
filled blister
Stage III Full-thickness ulcer—
May have exposed subcu-
taneous tissue, necrotic
tissue and undermining.
Muscle, tendon, bone not
visible.
Depth will vary according
to location.
Stage IV Full-thickness ulcer-
exposed muscle, tendon,
or bone.
May have necrotic tissue
and undermining, and risk
for osteomyelitis due to
exposed bone.
Depth will vary with location.
Unstageable Full-thickness ulcer
Wound bed covered with
necrotic tissue
Can’t be staged due to
inability to visualize the
depth of tissue loss
Art courtesy of Anatomical Chart Company.
www.ORNurseJournal.com March OR Nurse2010 31
• 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 solu-
tions 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 transfer-
ring the patient to the OR bed. At a minimum,
provide a high-specification mattress or other
pressure distribution surface for every periopera-
tive patient.
• Be careful when using temperature regulation
devices. Tissue should only be exposed to a
maximum temperature of 107.6 ºF (42 ºC).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, con-
sider lowering the maximum temperature and
cycling heating periods.
Postoperative strategies• 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 spe-
cial 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
Pressure ulcer concerns in common procedures10
Common Procedures Prominent
surgical areas of pressure
positions concern
Supine Chest Sacrum/coccyx
Abdomen Heels
Pelvis Elbows
Face/neck/mouth Thoracic spine
Extremities Lumbar area
Occiput
Scapulae
Prone/ Back/spine Iliac crests
jackknife Posterior Shins
leg/knees Dorsum of the foot
Toes
Anterior shoulders
Genitalia
Forehead/eyes/
ears/chin
Lithotomy Obstetrics Sacrum/coccyx
Genitourinary Heels
Gynecology Elbows
Occiput
Scapulae
Shoulders
Lateral aspect
of the leg
Hips
Lateral Chest Dependent side of:
Lung Face
Kidney Ear
Hip Shoulder
Axilla
Hip
Arms
Legs
Ankles
Feet
Surgical patients commonly enter the periopera-
tive 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. OR
REFERENCES
1. Black JM, Clark LD. Pressure ulcers and how to prevent them: questions and answers on the treatment of pressure ulcers. ManagingInfection Control. 2007;October:34-39.
2. Fowler E, Scott-Williams S, McGuire JB. Practice recommendationsfor preventing heel pressure ulcers. Ostomy Wound Manage. 2008;54(10):42-8, 50-2, 54-7.
3. Shoemaker S, Stoessel K. The Clinical Issue: Pressure Ulcers in the SurgicalPatient. Kimberly-Clark Health Care Education Knowledge Network; 2007.
4. Price MC, Whitney JD, King CA, Doughty D. Development of a riskassessment tool for intraoperative pressure ulcers. J Wound Ostomy Con-tinence Nurs. 2005;32(1):19-30.
5. Sanders W, Allen RD. Pressure management in the operating room:problems and solutions. Managing Infection Control. 2006;6(9):63-72.
6. Hospital-acquired conditions (present on admission indicator). TheCenter for Medicare and Medicaid Services. http://www.cms.hhs.gov/HospitalAcqCond.
7. National Pressure Ulcer Advisory Panel. NPUAP updated pressure
ulcer staging system. 2007. http://www.npuap.org/documents/PU_Definition_Stages.pdf
8. Heizenroth P. Positioning the patient for surgery. In: Alexander’s Careof the Patient in Surgery. 13th ed. St. Louis: Mosby; 2007:159-186.
9. Sewchuk D, Padula C, Osborne E. Prevention and early detection ofpressure ulcers in patients undergoing cardiac surgery. AORN J. 2006;84(1):75-96.
10. Association of periOperative Registered Nurses. Recommendedpractices for positioning the patient in the perioperative practice setting.Standards, Recommended Practices and Guidelines. AORN, Inc.: Denver,CO;2009:525-548.
11. Watson-Geer PS. Prevention of pressure ulcers in the surgical pa-tient. AORN. 2009;89(3):538-552.
12. Comfort EH. Reducing pressure ulcer incidence through BradenScale Risk Assessment and support surface use. Adv Skin Wound Care.2008;21(7):330-334.
13. Reddy M, Gill SS, Rochon PA. Preventing pressure ulcers: a systemicreview. JAMA. 2006;296:974-984.
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.
Diana L. Wadlund is a nurse practitioner and registered nurse first assistant
at Surgical Specialists, Paoli, Pa.
The author has disclosed that she has no significant relationship with or
financial interest in any commercial companies that pertain to this educa-
tional activity.
32 OR Nurse2010 March www.ORNurseJournal.com
Maintaining skin integrity in the OR
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