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Hospitals today are currently evaluated by the number of pressure ulcers arising when patients are admitted to the healthcare facility. The Operating Room (OR) is a huge component of this potential health hazard caused by patients being in the same position for more than one hour at a time. Pressure ulcer prevention is paramount to patient care

Introduction

According to the Agency for Healthcare Research and Quality, greater than 2.5 million Americans develop pressure injuries each year (1). Pressure injuries, also called pressure ulcers, are not only expensive to treat once they occur; they also are painful to the patient and can cause other health complications (9).  

Pressure injuries develop when skin and/or the underlying soft tissues are damaged, and typically occur in areas with a bony prominence. Skin disruption can occur from friction or shear and during intense or heavier pressure for a short time or a little pressure over a longer time. Without blood flow and oxygen, the skin and tissues start to break down, become damaged, and redden. Over time, this can lead to excoriation and pressure ulcers (7) 

Operating room (OR) professionals must take steps to prevent pressure ulcers from developing by providing excellent skincare prevention measures and assessments throughout the patient’s surgical procedure (4).  

Common Causes of Pressure Ulcers in the OR 

Since people who have normal mobility can move and adjust themselves when they feel pressure on a specific spot or bony prominence, the development of pressure ulcers is unlikely. However, in patients undergoing surgery for one or more hours, methods for pressure ulcer prevention should be considered since they are immobilized and sedated. 

There are several causes of pressure injuries in the OR. Most have to do with the patient being in one position for an extended period. An example of this might be during a craniotomy, which can last one hour up to ten or more. Keeping the patient free of skin breakdown during this time is key.  

Having the patient lie on a hard operating room table for their procedure is one of the most common causes. Areas with bony prominences can exacerbate skin breakdown after just one hour. Thus, nurses should check and recheck the positioning of the patient and necessary padding before, during, and after the procedure (4).  

Bony prominences are areas where bones may push on the skin due to the limited amount of underlying subcutaneous tissue. Lying in an area with a bony prominence or placing a medical device or equipment over these areas increases the chances of a pressure injury developing. Common trouble spots are the sacrum, back of the head, elbows, shoulder blades, hips, ischial tuberosity, and heels. If the patient is turned prone, areas to watch for potential injury are the forehead, nose, chin, shoulder joints, sternum, breasts for females, dorsal hand, hips, genitalia for males, knees, and top of feet and toes. The lateral position has its own set of problem areas, including the ears, shoulder acromion, greater trochanter of the femur, condyles of the knee, and lateral foot edge against the OR table (2,7). 

The jackknife position, also known as the Kraske position, also increases the risk of pressure ulcers. Some of the areas to consider additional padding when practicing pressure ulcer prevention are against the nose, forehead, shoulder acromion, breasts, genitalia, and condyles of knees, (5). 

Other factors that increase the risk for pressure ulcers include:  

• Nutrition status  
• Increased body mass index (BMI) and obesity 
• Certain health conditions (heart disease, Diabetes)  
• Patient’s age- older skin tends to shear and tear more easily and elasticity is lost with age 
• Smoking- leads to circulation problems and leaves the skin susceptible to injury and breakdown 
• Shearing and friction- this happens when a patient is repositioned in the bed or turning them over to position them for surgery (4, 5, 8) 

Friction happens when the skin is aggressively pulled down on the OR bed to reposition. Shearing is a term that describes two surfaces moving opposite of each other (4). For example, if a nurse is moving a patient up in bed, care is needed to ensure none of the patient’s skin touches the sheet. The skin on the hips and tailbone may be dragged upward or the tailbone may hold it in place. Now we have the body moving upward and the tailbone staying stationary causing skin shear or tears. 

Trendelenburg and Reverse Trendelenburg can increase the risk of shearing due to the patient’s position on the table and the angle of the bed. The surgeon may call for Trendelenburg position, but the patient keeps sliding toward the head of the bed because they have not been strapped in or positioned properly, leading to skin issues after the procedure. If the bed is repositioned, the patient needs to be repositioned. A padded footboard should be on the bed if the surgeon thinks he will use Reverse Trendelenburg at any time during the surgery (5) 

Incontinence is a big problem for immobile people. If an area stays moist for a long period, skin breakdown can also occur. Infection can also set in causing other health issues. Personal hygiene is an important facet of care for all patients, especially those with skin issues (8). Being aware of incontinence and infection is one step of pressure ulcer prevention in the OR.  

Extrinsic factors leading to skin breakdown (factors outside the patient’s body):  

• OR Temperature  
• Medical devices used intraoperatively 
• Type of anesthesia the patient receives  
• Length of time of the procedure  
• How the patient is positioned for the specific procedure (4, 5, 8)  

Performing a preliminary skin assessment before surgery on both low and high-risk patients can be beneficial (3,4). 

Signs and Symptoms of Pressure Ulcers 

There are many characteristics of a pressure sore or ulcer. Learning to recognize these will help the nurse prevent further deterioration of the skin and tissue.  

In the OR, check for reddened and swollen areas where the patient has been lying. First, see if the skin is blanchable, meaning the discoloration will disappear when you press on it. If the skin does not turn white, then it is a problem area that needs further evaluation. Along with redness, the nurse may also find tender areas in and around the primary location. The skin may also be cooler or warmer in those affected areas.  

The ulcers may stay on top of the skin as a reddened area and heal. Some protrude further down into the skin and muscle and can progress down to the bone if not treated promptly (3). These, in turn, can cause the patient great pain and be a source of infection. Skin assessments must be properly performed for each patient so that the severity of each pressure ulcer can be determined, as well as the course of treatment needed. 

It is important to alert the physician to any signs or symptoms of infection in a patient’s skin ulcer. These may range from purulent drainage, patient fever, swelling in the area, and warmth around the specific area of the pressure ulcer (3, 7). Informing the physician is extremely valuable in pressure ulcer prevention.  

Four Stages of Pressure Ulcers 

There are four classifications of skin ulcers ranging from least to the most severe.  

They are as follows: 

Stage 1: 

Skin feels warm and will be red. The patient may complain of itching or burning (6). Stage 1 pressure ulcers may be localized over a bony prominence and will be un-blanchable (2, 7). 

Stage 2:  

Skin starts to blister or have open sores. Pain may be present and discolored skin is seen. This ulcer looks like an abrasion, or it can be a clear blister. Partial-thickness skin loss may occur with the dermis being exposed (2, 4, 7). 

Stage 3:  

Damage is now starting under the skin surface leading to a crater-like look (6). At this stage, full-thickness loss is happening, while the adipose (fat) can be identified in the ulcer as well as slough and eschar if present in the wound. Bone and muscle are not easily identifiable; however, tunneling may be present. Depending on location, the nurse can assess how deep the pressure ulcer goes. For example, if the sore is on the ear, it should be a shallow wound. However, if the sore is on the hip, it can tunnel down to the iliac crest and harm both the muscles and bones in the area (4, 7).  

*** A side note on eschar and patient care: If the wound is classified as a Stage 3 or 4 and is intact, stable, and presents no erythema, the eschar should be left in place and not removed. However, this decision is up to the healthcare provider. A good example of this is eschar found on the heels or elbows. It is a natural defender against organisms and should stay intact (2, 4, 7). 

Stage 4: 

Severe excoriation with a wound, larger than previous assessments. At this point, all tissue – skin, muscles, bones – can be infected, leading to major health risks and full-thickness skin loss (2, 4, 7). 

Unstageable: 

If there is loss of full-thickness tissue and the bed of the wound is filled with slough and/or eschar, no wound classification will be given. The slough and eschar must be cleaned out of the wound before it can be staged. After removal, it can be identified as a Stage 3 or 4 pressure ulcer (2, 4, 7). 

Deep Tissue Injury 

A deep tissue injury is another diagnosis that happens with patients whose pressure ulcers are not responding to treatment. The skin may either be intact or open, but there will be an area that is non-blanchable and consistently red or purple, discolored, and potentially developing a blood blister on top of it (2, 4, 7). 

Measuring Wounds  

When measuring these wounds and ulcers, the nurse should take a vertical measurement from top to bottom at the longest point. The horizontal value should come from measuring across the widest point of the visible wound. A measurement of the deepest point should also be taken. Make sure that all of the measurement values are listed in centimeters (4). 

Documenting Wound Presentation 

To document your findings, list all measurements and observations concerning the ulcer. Other findings might include patient pain level if granulation is seen, swelling, the temperature of the wound, drainage if any, and color, and if tunneling is occurring.  

Pressure Ulcer Prevention in the OR: Effective Methods 

Within the perioperative department, a “skin champion” is someone who goes to hospital pressure ulcer prevention meetings and brings forth pertinent information on how the department can facilitate better outcomes for each patient. These individuals also organize learning drills or small classes where all the OR staff can see each type of wound and describe best how to take care of and prevent them. 

To maximize pressure ulcer prevention for each patient, a detailed skin assessment should take place before a procedure. Patients can answer specific questions about their health, if able, and how long any marks or bruising have been present on the skin. The handoff report should contain those details which place patients in danger of developing a pressure ulcer. 

High-risk patients should include the following items: BMI <19 or >40, history of pressure ulcers, a procedure that lasts three or more hours, and if the patient is bedbound or unable to reposition themselves at any time. Certain procedures also lend to the risk factors; those under trauma, cardiac, vascular, bariatric, or transplants have even higher chances of developing skin ulcers (4, 5).  

As patients are transferred to the OR, the handoff communication should follow them. The preop nurse should also inform the OR of any issues or concerns in the patient’s history and physical. This allows the OR to better accommodate the patient’s needs and further promote pressure ulcer prevention. 

When placed on the OR bed, the patient should be positioned on top of soft foam padded table inserts that provide adequate distribution of weight and don’t allow the patient to sink down to the metal bedframe. While transferring from the patient bed to the OR bed, ensure there is the proper number of staff to help distribute the weight. Four people should be the minimum – head, each side, and feet. Employing a transfer device can be helpful in moving patients to the OR table and back to their own bed. Most ORs use some sort of transfer apparatus, such as a slider board or the hover mat, to facilitate an easy transfer for the patient and staff. 

How do you move your patients? Do you ensure all equipment and devices go with them to their bed? Are all their bony prominences, such as heels, picked up so they are not dragged across the sheets in the transfer? 

When positioning, ensure the bony prominences are sufficiently padded by placing the following:  

• Head on a pillow 
• Foam under elbows and between IV lines and skin 
• Padding under hip bones if needed 

• Pillow under the knees 
• Pillow under feet to allow heels to be off the mattress (5)  

Every two hours, check the positioning of the patient to ensure the promotion of pressure ulcer prevention and that all risk areas are still protected. Anesthesia can assist with patient head movements if they are supine (4,5) 

Types of Padding  

Padding can come in many forms throughout the OR, including: 

• Pillows  
• Blankets 
• Foam padding 

There are many types of foam dressing made specifically for pressure ulcer prevention. A foam dressing is placed on the patient while they are still awake to ensure it covers the target area correctly. This dressing is usually placed on the sacral area, but it can be used on other bony prominences as well.  

A wound matrix is another type of dressing that can assist in healing the pressure wound. The nurse will cut a dry sheet the size of the wound and place it on top of the wound bed. Sterile saline is then added. These dressings are checked weekly and can be used with other dressings to ensure stability. They come in a variety of different sizes and boast a huge reduction in MRSA (4). 

After surgery, communication is key when heading to recovery. The OR nurse should perform a skin assessment after the drapes have been pulled down to ensure no injuries have occurred while the patient is immobile. The Post Anesthesia Care Unit (PACU) nurse should follow up after receiving the skin assessment and watch for any problems that may occur after the surgery. They should then report their findings to the floor nurse taking over the patient’s care. 

Conclusion

Understanding the many factors that lead patients to develop pressure ulcers during their surgical procedure will encourage the OR nurse to look for preventative ways to stop these injuries before they occur. Pressure injury prevention is KEY!  

Training in recognizing patient types, medical history, and current skin assessments will facilitate an uneventful OR and PACU visit. Being able to assess the patient’s skin and determine which skin classification is present also assists with choosing the correct treatment.  

Seeing as these pressure injuries can lead to more serious complications, all perioperative nurses need to be cognizant of the patient’s medical and physical history. With everyone working for the best outcome possible, the occurrence of pressure ulcers should decrease with each passing day. 

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