While pressure ulcers are more commonly associated with long-term care,extended periods of uninterrupted pressure and friction during surgicalprocedures also put patients at risk for these injuries. Even though theaverage incidence rate (both inpatient and outpatient) is only about eightpercent, there?s no reason that this should ever be a problem in yourfacility. In the following pages, we?ll tell you what you need to know toprotect your patients.
Types of Pressure Ulcers
Pressure ulcers are lesions on the surface of the skin that occur as aresult of pressure and damage to the underlying tissue. The pressure impedesblood flow to the tissue for a period of time, causing tissue decay. Thereare four stages of pressure ulcers according to the degree of tissue damage.
Stage I: Observable pressure-related alteration of intact skin when comparedto adjacent tissue and may include one or more of the following: skintemperature (warm or cool), tissue consistency (firm or boggy), andsensation (pain or itching). Most pressure ulcers that develop during asurgical procedure are stage I cases.
Stage II: Partial skin loss of the epidermis and dermis. The skin is erodedor blistered or has shallow craters.
Stage III: Full skin loss, possibly down to, but not through, the fasciallayer, causing deep craters.
Stage IV: Extensive tissue loss. Muscle, bone, and supporting structuresshow.
Although this may seem like a very rare complication during an ambulatoryprocedure, many patients are potentially at risk. And anytime a patient hashigh-risk conditions and the intraoperative factors are "right," there is achance that a patient could develop these ulcers.
Patient risk factors
Age. Elderly patients have less elastic, smaller, more calcified bloodvessels. All of these factors hinder blood flow, especially to theextremities. When this happens, patients are more likely to develop pressureulcers.
Body size. There is an inverse relationship between time and pressure, andobese patients put more weight and pressure on their bony prominences. Thegreater the pressure, the shorter the time the patient can endure it. Morbidly obese patients (the National Institute of Health defines obesity ashaving a body mass index of 30 and above) are particularly at risk.
Nutritional status. Patients who are malnourished are at an increased riskfor developing pressure ulcer, and they may also have a difficult timehealing. One sign of malnutrition is low albumin levels, which indicates alow level of protein in the blood. A normal albumin level is between 3.5-4.5mg/dl. Patients with levels under 3.0 are considered at risk. If you thinka patient may be malnourished, you may want to test his or her serum albuminlevel or serum protein level. If you are using anesthesia, your pre-op bloodwork should already include a complete blood count (CBC). A TotalLymphocytic Count (TLC) can be calculated by multiplying the patient?s whiteblood cell count by his/her total lymphocytes and dividing that by onehundred should give you a good measure of the patient?s nutritional status. Patients with a score lower than 2000 should be considered at risk.
Diabetes or hypertension. When a surgical patient has any kind of diseasethat would cause diminished circulation, he or she is at risk for pressureulcers. If a patient is diabetic or has hypertension, especially if this iscombined with any of the above risk factors, he or she is considered to beat risk. According to the American Heart Association, hypertension wouldinclude anyone with a blood pressure reading of 140/90 or higher.
Intraoperative risk factors
Length of surgery. The longer the procedure, the longer the patient remainsin the same position and the greater the risk of developing a pressureulcer, which should be a concern during longer procedures such as plastics,orthopedics, and gynecology. Studies have proven that two-hour proceduresput patients at risk, but depending on how susceptible the patient is andthe intraoperative factors, such as the case I mentioned, patients havedeveloped ulcers during procedures that last only a half-hour to an hour.
Moisture. Pooled moisture from prep solutions may change the skin?s pH andremove protective oils, making the skin more susceptible to pressure ulcerdevelopment. When you prep the patient, use only as much prepping solutionas you need to do the job, and be careful that the solution doesn?t poolunder the patient (if this happens, change the linens).
Skin shearing and friction. Shear is a problem if patients are repositioned,even slightly, after they have been anesthetized. Shearing occurs when theouter layer of skin slides across a surface and the underlying tissues shiftor move, causing them to become damaged. This can happen if the patient ispulled or moved without being lifted. If you need to reposition thepatient, use a lift sheet instead of dragging the patient.
Intraoperative hypotension. Anesthesia usually lowers a patient?s bloodpressure, sometimes to the point of hypotension. When this happensespecially with patients who normally have high blood pressure, the bloodvessels have a difficult time delivering oxygen to the tissue. To preventthis, the anesthesiologist or nurse anesthetist should carefully monitor thepatient?s blood pressure and O2 saturation.
Warming blankets. While keeping patient warm has been proven to reduce thechance of pressure ulcers, it?s not a good idea to keep a warming blanketunder the patient. Because the area is already warm, less blood will travelto that spot, depriving the tissue of oxygen. If you need to use warmingblankets, use them on top of the patient rather than under him or her.
Inappropriate cushioning devices. Many OR tables only have a one-inch foamcovering, and for many at-risk patients, this will not be enough protection,especially at the bony prominences. Pillows, blankets, and foam padding mayproduce minimal pressure relief, but towels and sheets do not reducepressure and they may cause more friction.
Because particular procedures call for specific positions, nurses do nothave a lot of choice when it comes to better positioning. However, thereare many cushioning devices on the market that can reduce the risk ofpatients developing pressure ulcers. Here are some common positions andareas that may be at affected.
Supine Position. When patients are in the supine position pressure soresmost commonly occur on the heels, sacrum and ischium, the back of the skull,and the shoulder blade. These areas should be protected with cushioningpads. (Because the supine position allows for optimal access to the airwayfor the anesthesiologist and also allows easiest access to the body in theevent of an emergency, most procedures are done in the supine position.)
Lateral Position. Cushion the ear, shoulder, thigh, knee, ankle, and footwhen patients are positioned laterally. (Some procedures done in the lateralposition include: pneumonectomies, certain unilateral orthopedic proceduressuch as hip fracture repair, hip replacement, and other procedures requiringaccess to one side or the other of the thoracic cage.)
Prone Position. In the prone position, use pads under the face, chest, andfeet to prevent wounds on the nose, forehead, chest, feet, and toes. (Someprocedures done in the prone position include: neurologic or orthopedicprocedures on the back or spine such as laminectomies, kyphoplasties,diskectomies; pain management procedures such as facet blocks and lumbarsympathetic blocks under fluoroscopic guidance; hemorrhoidectomy in thejack-knife position; and some types of plastic surgeries such as back/flankor buttock/hip liposuction.)
Lithotomy Position. Pad the lateral or posterior knees and ankles to preventpressure (Many gynecology procedures are done in the lithotomy position.)
Detection and Treatment
Before discharging the patient check for any change in the skin particularlyover bony prominence. Any change in skin color (it can be red, pink, purple,or blue) should be an indicator, as well as warmth or sensitization. Howeverin some cases an intraoperative pressure ulcer may not appear until 24 to 48hours after the procedure. So during the follow-up phone call, you shouldask them if they are experiencing any soreness anywhere other than theoperative site, and ask them if they have noticed any change in skin coloror warmth.
In many cases intraoperative pressure ulcers will typically resolvethemselves. If the skin is still intact, keep pressure off the area andkeep the skin moisturized. If the tissue has begun to break down avoid usingan occlusive dressing until the pressure ulcers has fully demarcated andkeep pressure off the area. Once the wound has demarcated use of use anocclusive dressing on the wound is appropriate.