An unacceptable risk
Preventing pressure ulcers remains a priority for periop nurses
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By Debra Anscombe Wood, RN
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EDITOR'S NOTE: Debra Anscombe Wood, RN, is a freelance writer.
Preventing hospital-acquired pressure ulcers has taken on new importance as a nurse-sensitive quality measure, with everyone on the team responsible for decreasing the risk, including perioperative nurses.
“It’s important for perioperative nurses to remember that because our patients are in the operating room and immobile and sometimes put in extreme positions, they are all at risk,” said Lisa Spruce, DNP, RN, CNS-CP, CNOR, ACNS, ACNP, FAAN, director of evidence-based perioperative practice for the Association of periOperative Registered Nurses in Denver.
Spruce recommends completing a risk assessment on every patient. Advanced age, longer length of procedures, nutritional status, certain disease processes, and a higher American Society of Anesthesiologist’s physical status score can make patients more vulnerable to getting a pressure ulcer.

The Munro Pressure Ulcer Risk Assessment Scale and the Scott Triggers are assessment tools for the perioperative setting. Nurses should consider the entire time the patient has been immobile, including time in pre-op and the ED.
In preop, “We probably ought to say, ‘Why don’t you lay on your side?’ or turn them,” Spruce said.
Preventive measures for most patients include a high-specification OR mattress with more than three inches of foam, but some patients may need a gel pad atop that. Additionally, nurses should pad patient’s pressure points or relieve the pressure, such as floating heels off the mattress. Some people will require a foam dressing for the sacrum, elbow and other vulnerable areas. “We want perioperative nurses to do a thorough skin assessment before going into the OR,” Spruce said. That information should be passed along to the nurse receiving the patient postop. And nurses on the units should report the incidence of pressure ulcers to perioperative nurses. Pressure ulcers usually develop 48 to 72 hours after the procedure, so perioperative nurses are often unaware a patient developed a decubiti during surgery, Spruce said. Not knowing when one occurs makes it more difficult to change processes. “Most patients coming in for surgery are expecting to get better,” she said. “Then we give them a pressure injury … that’s painful and sometimes hard to heal. It affects their day-to-day life.”
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Most patients coming in for surgery are expecting to get better. Then we give them a pressure injury …”
— Lisa Spruce, RN
Taking precautions
Nurses have been aware of the dangers of pressure ulcers for decades, but changes in Centers for Medicare & Medicaid Services reimbursement brought it to the forefront in 2008. Then in 2014, the National Pressure Ulcer Advisory Panel offered guidance in prevention of decubiti in perioperative patients. AORN convened a panel of experts and developed a prevention toolkit.
“[Pressure ulcers] are an important concern we all need to have,” Spruce said.
Toolkit available
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Changing processes
Recognizing these dangers of pressure ulcers, Virginia Commonwealth University Medical Center in Richmond made prevention a hospitalwide priority. “The organization at the time was having an epiphany about the need to change the process,” said Linda Currie, MSN, RN, ACNS-BC, CCRN-CSC, clinical nurse specialist in the Cardiac Surgery ICU at VCU. Working with perioperative nurses, the nurse-led CSICU team developed protocols to prevent decubiti in cardiac surgery patients in the ICU. In the OR, the wound care team led the charge to ensure all patients are positioned on gel pads or other specialty mattresses to offload pressure on body parts that cannot be moved or floated during surgery, Currie said. Additionally, perioperative nurses place a heart-shaped, moisture-wicking Mepilex sacrum foam dressing on the sacrum of all surgical patients prior to their being placed on the OR table. Periop nurses also may use Mepilex heel dressings, if patients cannot be positioned to have their heels floated.
Special pillows and mattresses
In the ICU, patients may be placed on a fluidized positioning pillow to prevent occiput pressure. All patients are placed on specialized mattresses that offload pressure, and nurses turn all patients including those who have undergone open heart surgery where their chests remain open and are covered with a large Ioban dressing, Currie said. VCU as a whole conducts monthly surveys to monitor for the incidence of pressure ulcers. Bedside nurses and wound care champions screen daily for pressure points and ways to offload the pressure. “We continue to have good results,” Currie said. “We went for 11 months with zero pressure ulcers on the day of survey.” Since then, a couple of pressure ulcers have occurred, and nurses have looked for the root cause, attempting to differentiate whether unit practice or time in the OR may have contributed, she said. “We are always looking for new places we need to relieve pressure,” Currie said.
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