Pressure Ulcer Reduction for Surgical Patients
by Diane Pogmore and Mary Jo Steiert
The incidence of new pressure ulcers in acute care patients is 7 percent. However, perioperative acquired pressure ulcers are 66 percent of that total. Surgical procedures that require difficult patient positioning or procedures that require the patient to be in the same position for a long period of time are adding to the increased incidence of pressure ulcers in patients. Pressure ulcers have been identified as a major education initiative for perioperative nurses by Association Of Registered peri Operative Nurses(AORN).
The presentation and progression of pressure ulcers is unique for surgical patients. They may begin as burn-like lesions. Changes may appear in hours, but typically changes take place within 72 hours following surgery. The appearance of ecchymotic (bruised) areas on the skin which may or may not blister and necrosis may occur within two to six days. When the vasculature is compromised, skin may present as a mottled irregular pattern that may resolve or result in a full thickness wound.
The delay in visualizing any of these events may contribute to the surgery being overlooked as the triggering event in the development of pressure ulcers.
Of course the best treatment option is to avoid the possibility of pressure ulcers developing. The cost of treating hospital-acquired pressure ulcer in surgical patients is estimated to be between $750 million and $1.5 billion.
Pressure ulcers that occur during surgery are acute injuries which develop rapidly. They are the result of the compression of tissues that cause ischemia and necrosis during serious illness, trauma and surgery. Major causes in the OR are because of loss of the blood volume and the shunting that occurs during surgery and with trauma patients. The cold OR environment contributes to the body shunting blood away from the skin and into the trunk of the body to protect vital organs. Surgical patients are vulnerable without aggressive intervention before the surgical procedure begins.
Other risk factors for surgical patients are:
- Dehydration from being NPO, pain medications, anesthetic agents, use of several layers between the patient and the OR bed and prolonged immobility.
- Patients that may have a predisposition are those undergoing extracorporeal circulation for cardiovascular procedures, elderly patients with femoral neck fractures, obese patients, underweight patients, patient position and those exposed to additional fluids from irrigants and blood loss.
During the preoperative assessment, it is important to identify unique patient considerations that may require additional precautions for procedure-specific positioning:
- morbidly obese patients
- patients with chronic diseases
- existing pressure ulcers
- emergency surgeries
The intraoperative assessment should assure the OR table is of sufficient size to support the patient, and lifting is used instead of dragging the patient from surface to surface. Pressure points should be monitored when possible as well as monitoring pooling of fluids. Skin should be kept dry and layering of materials minimized. An assessment of appropriate use of warming blankets over mattresses should be included.
Gel pads should be used rather than foam pads as positioning devices.Gel is preferred for the following reasons:
- promotes proper patient positioning
- Reduces the risk of unwanted conditions such as ulcers, pressure sores, nerve damage, excess bleeding, breathing difficulties and skin breakdown.
- Gel table pads are superior to the former standard of sandbag and foam products (which are not therapeutic)
- Gel has a greater acquisition cost but significantly outperforms foam and other positioning options and is a reusable product.
Recent changes made in the OR at TMCA include:
- Continued efforts to maintain normothermia
- Gel table pads and other devices for positioning
- Sahara OR sheets are being used to provide greater absorption of fluids
- Education for perioperative staff on positioning bariatric patients and the use of devices
The biggest component for success is working together for the benefit of the patient. Collaboration will accelerate action, promote teamwork and will provide measurable results for improvement in safe care for our patients.