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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.


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.



• 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.


• 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.



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