OR nurses are skilled in positioning and padding patients to reduce pressure and shearing of the skin and to ensure that a patient's body is in the best possible alignment while giving the surgeon maximum access to the surgical site. In addition, gel pads and state-of-the-art surgical tables with pressure-reducing padding are the norm in most operating rooms today. So why are we still wrestling with the problem of pressure injuries among surgical patients? When we set out to tackle this issue at our hospital, we discovered that one major hurdle to skin safety was the lack of a standard perioperative assessment tool for identifying each patient's risk for skin breakdown. So we decided to create our own.

Identifying risk factors
Staff nurses from all facets of surgical services here at the hospital and our off-site freestanding surgery center took on the challenge of researching the topic and designing a skin assessment tool that would speak to the uniqueness of surgery. We began with a review of the literature, but discovered that there were few articles that truly addressed skin assessment in the perioperative setting. However, we did identify several surgical risk factors for skin breakdown and pressure ulcers. We broke those risk factors into 6 main groups:

• Surgical factors. Length of procedure, positioning and types of surgery.
• Physical limitations. Obesity, emaciation and contractures.
• Medical history. COPD, diabetes and cardiac disease.
• Vital signs. Low blood pressure and high body temperature.
• Abnormal labs. Anemia and high white blood count.
• Additional risk factors. Braden scale < 18, incontinence and pre-existing skin condition.