Prevention of Pressure Ulcers

in the Surgical Patient

2.5 PATINA S. WALTON-GEER, RN-BC, MSN, CWCN, CFCN

T
he development of pressure ul- treat them when they occur. The Institute
cers (PUs) is of enormous con- for Healthcare Improvement has initiated
cern in all health care settings. A interventions to help hospitals reduce
PU is any lesion (ie, localized area of PUs through the use of evidence-based
tissue necrosis) caused by unrelieved practices to improve patient care.6
pressure or pressure in combination According to Graves et al, any patient
with friction or shear that results in affected by PU development will require
damage to the skin or underlying tis- a longer hospital stay.7 Brown’s research
sue.1,2 An ulcer often develops when indicates that there is a link between
soft tissue is compressed between a hospital-acquired PUs and mortality.8
bony prominence and an external sur- Reddy et al estimate that approximately
face for a prolonged period.2-4 60,000 patients will die each year from
Pressure ulcers can occur any time hospital-acquired pressure ulcers and
body tissue is compromised causing skin that the cost of treating these wounds is
breakdown. Monitoring and maintaining approximately $11 billion per year.9
skin integrity is an essential component The Centers for Medicare and Medi-
of defining a patient’s health status and caid Services will no longer reimburse
evaluating the quality of nursing care.5 It health care facilities if a health care-
is incumbent upon all health care provi- associated PU develops or is not docu-
ders to work not only to decrease the in- mented as present on the patient’s ad-
cidence of PUs, but also to effectively mission to the facility.10 Placing financial
responsibility for PU development on
the health care facility should intensify
ABSTRACT the focus on reducing PU incidence.
Pressure ulcers (PUs) are a serious health care It is important to look at all areas
problem, and it is crucial to assess how patients within health care to decrease the possi-
acquire pressure ulcers after admission to a bilities of PU development whenever
health care facility. In the OR, factors related to po- possible. There are many times during
sitioning, anesthesia, and the duration of surgery, which patients are put at increased risk
in addition to patient-related factors, all can affect for developing PUs, including during
PU development. surgery. Literature reviews reveal that
PUs are discussed predominantly in re-
This article reviews current practices, including gard to long-term care, intensive care,
AORN recommended practices, regarding pres-
sure ulcer prevention efforts for surgical patients.
All surgical patients should be considered at-risk indicates that continuing education contact
for pressure ulcer development; therefore, perioper- hours are available for this activity. Earn the con-
tact hours by reading this article and taking the
ative departments should develop and implement examination on pages 549–550 and then com-
strategic plans for pressure ulcer prevention. pleting the answer sheet and learner evaluation
on pages 551–552. The contact hours for this ar-
Key words: pressure ulcer, health care-acquired con- ticle expire March 31, 2012.
ditions, surgical patients, wound prevention. AORN
J 89 (March 2009) 538-548. © AORN, Inc, 2009. You also may access this article online at
http://www.aornjournal.org.

538 • AORN JOURNAL • MARCH 2009, VOL 89, NO 3 © AORN, Inc, 2009
Walton-Geer MARCH 2009, VOL 89, NO 3

TABLE 1
Stages of Tissue Breakdown1,2
Type of injury Length of pressure Resolution
Hyperemia Occurs when pressure is applied for Resolves within 1 hour
less than 30 minutes

Ischemia Occurs after 2 to 6 hours of unrelieved May require up to 36 hours

pressure to resolve

Necrosis Develops after 6 hours of unrelieved May require a vascular surgeon

pressure with microvasculature and/or wound care team consult
collapse and thrombosis

Ulceration Occurs within 2 weeks of necrosis May require a vascular surgeon

and/or wound care team consult

1. Pressure ulcers. Landon Center on Aging. http://www2.kumc.edu/coa/Education/AMED900/Pressure

Ulc.htm. Accessed December 28, 2008.
2. Pieper B. Mechanical forces: pressure, shear, and friction. In: Bryant R, Nix D, eds. Acute & Chronic
Wounds: Current Management Concepts. 3rd ed. St Louis, MO: Mosby Elsevier; 2007:205-234.

and rehabilitation settings however, with little based on three causes: pressure, extrinsic fac-
focus on acute care settings including the surgi- tors, and intrinsic factors.2,4
cal environment.7,11-14 Even though a large PRESSURE. Pressure can be defined by its inten-
amount of information is available to educate sity and its duration. Pressure ulcers are caused
health care providers and help them imple- by compression of soft tissue between a bony
ment policies, procedures, protocols, and nurs- prominence and an external surface such as a
ing care plans to decrease the number of health bed or chair. When the external pressure exceeds
care-associated ulcers, the incidence of PUs normal capillary filling pressure of approximate-
continues to climb.3,7,12 This article reviews the ly 32 mmHg, local blood flow is occluded, caus-
causes of and risk factors for PUs and intraop- ing tissue ischemia and subsequent necrosis of
erative methods for pressure redistribution and skin and subcutaneous tissues. Muscle is more
prevention of ulcers that could occur during sensitive to pressure than skin; underlying tis-
surgical procedures. sue may become necrotic by the time a lesion
presents on the skin surface.3,17
ETIOLOGY OF PRESSURE ULCERS Tissue breakdown occurs in stages (Table 1).
An intraoperatively acquired PU may resem- Tissue damage may become apparent within
ble, and is often documented as, a burn. Ac- several hours after surgery or may not appear
cording to AORN’s “Recommended practices for up to three days. Therefore, a PU that results
for positioning the patient in the perioperative from surgery may not be noticed until the pa-
setting,” an intraoperatively acquired PU usual- tient’s recovery period.3,18 An inverse relation-
ly develops outward on the muscle of a bony ship may exist between the duration and inten-
prominence and has a purplish discoloration.15 sity of pressure. Low-intensity pressure over a
Depending on the patient’s skin color, a purple long period can initiate the tissue breakdown
or maroon localized area of discolored intact process, as can high-intensity pressure for a
skin or blood-filled blister occurs as a result of short period of time.3,17
damage to underlying soft tissue.2,4,16 According Tissue tolerance is the condition or integrity
to the National Pressure Ulcer Advisory Panel of the skin and supporting structures that in-
(NPUAP) and the Wound, Ostomy, and Conti- fluences the skin’s ability to tolerate pressure.3
nence Nurses Society (WOCN), PUs develop Pressure risk factors for skin damage include

AORN JOURNAL • 539

MARCH 2009, VOL 89, NO 3 Walton-Geer

immobility, sensory deficit, mental status affect tissue perfusion include

changes, and “bottoming out.”2,19 Immobility is • certain medications (eg, steroids, vasoactive
the limitation of the patient’s ability to reposi- medications);3,20
tion. Sensory deficit is the patient’s limited abili- • presence of comorbid diseases (eg, cancer,
ty to sense the need to reposition. This could be cardiovascular and peripheral vascular de-
caused by neuropathies, spinal cord lesions, ficiencies, diabetes mellitus, neurological or
stroke, coma, or chemical restraints. Mental and respiratory disease);3,20
cognitive changes may prevent pressure sensi- • extracorporeal circulation;21
tivity. Patients may not be able to move prompt- • impaired regulation in body temperature;3,20
ly or may be too confused to follow common • fractures;3
movement patterns. Bates-Jensen defines bot- • low hemoglobin and hematocrit levels;3,20
toming out as when the pressure-relieving de- • nutritional deficiencies;3,11
vice no longer prevents direct pressure on the • obesity;22
surface from which the patient needs to be pro- • low serum protein (ie, prealbumin or total
tected.19 This can be evaluated by sliding a hand albumin plus globulin);3
between the pressure-redistribution device and • smoking;3,20 and
the prominence exposed to the pressure.19 • low systemic blood pressure.3,20
EXTRINSIC FACTORS. Extrinsic factors include shear,
friction, and moisture. Shear is defined as the POSITIONING
applied force that can cause an opposite, parallel Positioning is a crucial component of surgi-
sliding motion in the planes of an object. Shear cal care. Positioning for a surgical procedure
is affected by the amount of pressure that is ex- depends on the surgeon’s preference, the
erted.3,16 This tends to occur in larger occluded anesthesia care provider’s needs, the proce-
areas of vascular supply. An example is pulling dure being performed, the need for exposure
skin in one direction and the bone in another. of the surgical site, and the patient’s predis-
Friction is defined as a superficial, mechanical posing conditions.5,15,23
force directed against the epidermis, resulting in Positioning is recognized as a balance be-
increased susceptibility to ulceration.3 For exam- tween the position a patient can physically
ple, this can occur when a patient is dragged assume and those that are physiologically toler-
across a sheet during repositioning or when a ated. A patient’s body must be positioned ade-
patient self-repositions. Another extrinsic factor quately on an OR bed and proper body align-
occurs when the layer of skin (eg, stratum ment must be maintained to lessen the potential
corneum) becomes overhydrated, causing weak- risk of skin injuries. Factors to be taken into ac-
ness of the collagen or elasticity of the skin. This count during the preoperative interview before
leads to maceration of the skin, resulting in tis- sedation and positioning occur include
sue damage. All of these extrinsic factors can • preexisting conditions;24
cause tissue damage, especially in older adult • decreased ranges of motion;24
patients, patients with spastic movements, and • previous surgical procedures;24
patients who use braces or appliances that can • presence of joint prostheses;24
rub against the skin. • fractures;24 and
INTRINSIC FACTORS. Many patients undergoing • the patient’s age, height, and weight.23,24
surgery, especially older adults, have numer- A surgical patient should be positioned prop-
ous risk factors that can result in PUs. Intrin- erly during the intraoperative phase of surgery
sic risk factors causing skin damage affect the to lessen possible injuries. Physiological injuries
ability of the skin and supporting structures that are short-term (ie, resolving in 24 to 48
to respond to pressure and shear forces. In- hours) or long-term can occur during surgery.
trinsic factors include advanced age, anaero- Some injuries are modifiable and others are not.25
bic waste products, nutritional deficiencies, The incidence of modifiable injuries can be de-
and steroid administration that affect collagen creased by proper positioning during surgery to
synthesis and degradation. Other factors that lessen the probability of adverse physiological

540 • AORN JOURNAL

Walton-Geer MARCH 2009, VOL 89, NO 3

responses, while providing access to the surgical quate to safely transfer or position the patient
site, the patient’s airway, IV sites, and monitoring preoperatively or intraoperatively. Transferring
devices.23,24 Maintaining optimal physiological is accomplished with a lateral transfer device
conditions lessens the risk for complications (eg, slide boards, air-assisted transfer devices)
both intraoperatively and postoperatively. that reduces friction and shear. Perioperative
When a patient has inadequate arterial blood team members should place proper padding
flow, improper positioning can cause complica- around the patient’s body to help prevent skin
tions with blood pressure, decrease tissue perfu- breakdown, especially on high-risk areas, de-
sion and venous return, and cause thrombus pending on the position (Tables 2, 3, 4, 5, and 6).
formation. The patient’s skin is at increased risk Pressure-relieving devices should be used to
of tissue damage when the patient’s body decrease possible ischemic changes as a result
weight is not distributed evenly on the OR bed of pressure when a patient must remain in a po-
or if poor tissue perfusion is present.23,24 sition for several hours. Rolled sheets and tow-
Safety is the primary concern when determin- els are not to be used beneath overlays. This de-
ing a patient’s position for a procedure. The creases the effectiveness of the overlay and
number of personnel and devices must be ade- causes pressure. It is important to monitor the

TABLE 2
Common Surgical Positions—Supine1
Applicable Vulnerable
Description procedures anatomy
• Patient lies on back with face toward the • Anterior chest • Occiput
ceiling. (eg, open heart) • Scapulae
• Ankles are uncrossed. • Abdomen • Arms
• Arms are padded at sides in neutral position or • Pelvis • Elbows
on padded arm boards at less than a 90-degree • Face, neck, and • Thoracic vertebrae
angle with palms up. mouth • Lumbar area
• Head and upper body are in alignment with • Extremities • Sacrum and coccyx
hips. • Heels
• Legs are parallel.
• If patient is pregnant, a wedge should be 1. Recommended practices for positioning the patient
placed under patient’s right side to shift the in the perioperative setting. In: Perioperative Stan-
uterus to the left and relieve compression on dards and Recommended Practices. Denver, CO:
the aorta and vena cava. AORN, Inc; 2008:497-520.

Heels

Thoracic Lumbar Sacrum and

Occiput Arms and vertebrae coccyx
Scapulae area
elbows
Kurt Jones

AORN JOURNAL • 541

MARCH 2009, VOL 89, NO 3 Walton-Geer

quantity of pads, blankets, and warming blan- points and assist in decreasing the risk of ad-
kets placed on top of or beneath a patient. Use verse physiological responses.15
of too many pads or blankets can cause the cap-
illary pressure to rise over 32 mmHg, which in- ANESTHESIA
creases the risk for poor tissue perfusion at that Together, positioning and anesthesia put the
area of pressure, causing the patient to be at risk patient in a compromised state. Anesthesia af-
for PU development.15 fects how the patient is positioned. It also
Patients should be repositioned during sur- blocks a patient’s sensitivity to pain and pres-
gery if they are at high risk for skin break- sure, causing tissue damage vulnerability. All
down. For example, a patient in the lithotomy agents used in anesthesia can depress the auto-
position may have to be repositioned after nomic nervous system, causing some degree of
prolonged surgery. AORN’s “Recommended vasodilatation that is reflected in a lowering of
practices for positioning the patient in the pe- blood pressure that causes a decrease in tissue
rioperative setting” suggests that a patient perfusion. The compounded effect of anesthesia
should be repositioned every two hours to and the cold OR bed causes decreased perfu-
prevent continuous pressure on pressure sion.23,24 According to a study performed by

TABLE 3
Common Surgical Positions—Prone1
Applicable Vulnerable
Description procedures anatomy
• Begins in the supine position. • Back and spine • Forehead, eyes,
• After induction of anesthesia, patient is log-rolled • Posterior legs ears, and chin
into the prone position (ie, face down). • Anterior shoulders
• Patient may be placed on a positioning device. • Breasts
• Head is placed on a padded headrest. • Iliac crests
• Head and cervical alignment is maintained. • Genitalia
• Arms are at the patient’s sides or on padded arm • Knees
boards at less than a 90-degree angle. • Shins
• Chest rolls may be used to accommodate chest • Dorsum of the feet
movement and lower abdominal pressure. • Toes
• Protection is provided for patient’s forehead, eyes, 1. Recommended practices for positioning the patient
chin, breasts, genitalia, knees, and shins. in the perioperative setting. In: Perioperative Stan-
• Toes are allowed to extend over the end of the bed or dards and Recommended Practices. Denver, CO:
are raised off the bed with padding under the shins. AORN, Inc; 2008:497-520.

Anterior shoulders
Forehead, Knees Dorsum of
eyes, ears, the feet
chin
Toes

Breasts Iliac Genitalia

(women) crests (men) Shins
Kurt Jones

542 • AORN JOURNAL

Walton-Geer MARCH 2009, VOL 89, NO 3

Lindgren et al,26 patients having epidural or necrosis. In acute and chronic settings, it is sug-
spinal anesthesia were more likely to develop gested that patients who are immobile be
pressure ulcers than patients having general turned at least every two hours.3,15,18 The dura-
anesthesia. Other contributing factors in the tion of the surgical procedure is a significant in-
study were low body mass, poor nutritional sta- dicator in the risk of tissue damage. Reposition-
tus, low albumin levels, and decreased blood ing a surgical patient, except for the heels, arms,
pressure. Changing the position of a patient un- and head, is rarely possible intraoperatively.14
dergoing anesthesia, regardless of what vasoac- O’Connell24 demonstrated that procedures last-
tive medications are used, can decrease blood ing longer than four hours triple the risk of tis-
pressure, putting skin integrity at risk. sue damage. Even the healthiest patient can be
at risk for tissue damage if a surgical procedure
SURGERY DURATION lasts longer than four hours.
Most tissue can only withstand excessive Length of a surgical procedure is not al-
pressure for brief periods. Prolonged exposure ways the primary predictor of PU develop-
to pressure can initiate events resulting in tissue ment. Other factors could complicate or influ-
ischemia, which may lead to tissue anoxia and ence the course of the procedure, resulting in

TABLE 4
Common Surgical Positions—Kraske/Jackknife1
Applicable Vulnerable
Description procedures anatomy
• Begins in the supine position. • Rectum • Forehead, eyes,
• After induction of anesthesia, patient is log- • Anus ears, and chin
rolled into the prone position. • Anterior shoulders
• OR bed is then flexed to a 90-degree angle. • Breasts
• Head and cervical alignment is maintained. • Iliac crests
• A padded headrest and chest rolls are used. • Genitalia
• Arms are at sides of bed or on arm boards at • Knees
less than a 90-degree angle. • Shins
• Toes are allowed to extend over the end of the • Dorsum of the feet
bed or are raised off the bed with padding • Toes
under the shins.
1. Recommended practices for positioning the patient in the perioperative setting. In: Perioperative Standards
and Recommended Practices. Denver, CO: AORN, Inc; 2008:497-520.

Forehead, Anterior Shins

eyes, ears, shoulders
chin

Toes

Dorsum of
Iliac Genitalia
Breasts the feet
crests (men) Knees
(women)
Kurt Jones

AORN JOURNAL • 543

MARCH 2009, VOL 89, NO 3 Walton-Geer

longer time spent on the OR bed. Periopera- bed, hypotension and the type of procedure
tive nurses and surgeons must address immo- increase the patient’s susceptibility to PU de-
bility if the patient will remain in one position velopment.3,18 The skin of the older adult is
for several hours. most likely to sustain tissue injury because it
is less elastic with a thinner dermis and has
VULNERABLE SURGICAL PATIENTS less collagen, muscle, and adipose tissue.
Patients who are 65 years of age or older These characteristics make older patients not
experience the highest incidence of PU devel- just susceptible to pressure problems with the
opment. The incidence of PUs in surgical pa- skin, but also to increased bruising, skin tears,
tients can be as high as 45%.2,3 In older adult infection, impaired thermoregulation, and
patients, there is a greater incidence of preop- slow healing.24
erative variables (ie, extrinsic and intrinsic fac-
tors) occurring that result in physiological SURGICAL PRESSURE REDISTRIBUTION
changes to the skin and ultimately, PU devel- Rather than focusing on pressure reduction
opment.2,3 During the intraoperative phase of and pressure relief, support surfaces redistrib-
surgery, which includes the time on the OR ute pressure.16 These devices are designed to

TABLE 5
Common Surgical Positions—Lithotomy1
Applicable Vulnerable
Description procedures anatomy
• Patient begins in the supine position then legs • Obstetrics and • Occiput
are slowly and simultaneously raised and gynecological • Shoulders
placed in stirrups or leg holders that are at an procedures • Scapulae
even height. Legs are not in contact with the • Genitourinary • Hips
stirrup posts. procedures • Sacrum/coccyx
• Patient’s buttocks are at the break in the proce- • Lateral aspect of
dure bed. the legs
• Arms are on arm boards at less than a 90-degree • Heels
angle with the
palms up. Arms
are tucked at sides
only if this is sur-
gically necessary.
• Heels are in the
lowest possible
position.
Shoulders and
• After surgery, the
scapulae
patient’s legs
are lowered
slowly and Heels
simultaneously.
Lateral
1. Recommended practices aspect of
for positioning the patient the legs
in the perioperative set-
ting. In: Perioperative Sacrum and
Standards and Recom- coccyx
mended Practices. Occiput
Denver, CO: AORN, Inc; Hips
Kurt Jones
2008:497-520.

544 • AORN JOURNAL

Walton-Geer MARCH 2009, VOL 89, NO 3

prevent PUs or to promote reduction of inter- bottoming out. If punctured, gel overlays are
face tissue pressure. capable of self-repair. One study found that
Several types of pressure redistribution sup- gel overlays helped to prevent both skin
port surfaces are available. One type is an over- changes and PU development in the older
lay, which is placed directly on the mattress or adult population, including those with chron-
on the bed frame as a replacement for the stan- ic health comorbidities or vascular disease
dard foam OR mattress. Foam, static air, gel, and and those experiencing extended surgical
dynamic air are common types of overlays, and times (ie, longer than two hours).27
all are latex free. Foam overlays are available in Dynamic-air overlays have a mechanical
a variety of sizes, depths, densities, and con- pump alternating inflation and deflation.
struction. Static-air overlays allow air to ex- These types of overlays include alternating
change through multiple chambers when a pa- pressure mattresses, low-air-loss beds, and air-
tient lies on the overlay. This type of overlay fluidized mattresses. Alternating-pressure mat-
must be reinflated periodically. tresses produce alternating high and low pres-
Gel overlays (ie, visco-elastic polymer) pre- sures between the patient and the mattress
vent shearing, support weight, and prevent with diminishing periods of high pressure.

TABLE 6
Common Surgical Positions—Lateral1
Applicable Vulnerable
Description procedures anatomy
• Patient begins in the supine position and is log- • Chest • Dependent side of
rolled onto the nonoperative side with assistance • Lung face and ear
of positioning devices. • Kidney • Dependent shoulder
• Solid positioning devices (eg, bean bags) should • Hip • Arms
be avoided as they compromise circulation and • Dependent axilla
increase risk of ulceration. • Dependent hip
• Patient’s dependent leg is flexed and the top leg • Legs
is straight with padding (eg, a pillow) between • Dependent knee
the legs. • Ankles
• Spinal alignment is maintained. • Feet
• A headrest or pillow is used for the patient’s head.
• The dependent arm is on a padded arm board. 1. Recommended practices for positioning the pa-
The upper arm is on a padded arm board or is tient in the perioperative setting. In: Periopera-
supported with padding and a pillow is placed tive Standards and Recommended Practices.
between the arms. Denver, CO: AORN, Inc; 2008:497-520.

Note: In this illustration, the bed has been cracked for a kidney procedure.

Arms
Ankles
and feet

Dependent Dependent hip

shoulder Legs
Dependent side of Dependent knee
and axilla
the face and ear Kurt Jones

AORN JOURNAL • 545

MARCH 2009, VOL 89, NO 3 Walton-Geer

Low-air-loss mattresses are air sacs through tioning devices, and risk factors (Table 7).
which warm air passes. Air-fluidized mattresses SKIN ASSESSMENT. The perioperative nurse
contain small silicone-coated beads; warm air should perform a thorough skin assessment of
under pressure sets the beads in motion to stim- each surgical patient. This establishes a preop-
ulate circulation and evenly distribute weight.7 erative baseline to compare with the patient’s
Dynamic-air overlays are not often used intra- postoperative status. The preoperative nurse
operatively because of the possibility of body should check thoroughly for any skin compli-
movement, electrical problems, and asepsis.15 cations (eg, rash, maceration, infection, break-
Mackey28 reviewed three OR trials that indi- down, dermatitis, incontinence, lymphedema)
cated that the use of air and gel pressure over- and look for signs of venous insufficiency21
lays on the OR bed might be beneficial in reduc- (eg, aching, cramps, pain, tiredness, paresthe-
ing the incidence of PU for high-risk surgical pa- sia in the legs that worsens with standing or
tients.28 Reddy et al9 reviewed 59 randomized walking and is relieved by rest and elevation).
controlled trials that addressed impairment of A Braden or Norton Scale can be used to vali-
mobility, skin integrity, and nutrition in relation date the patient’s skin integrity and provide a
to PU development. Strategies to address mobil- comparison of preoperative and postoperative
ity impairment included the use of a support skin status. These scales can determine preop-
surface, mattress overlays on the OR bed, and eratively whether the patient is at high risk for
specialized foam and specialized sheepskin PU development, depending on the parame-
overlays. Reddy’s review reaffirmed that mat- ters being assessed. These assessments can
tress overlays on the OR bed may decrease the provide evidence that would suggest the need
incidence of postoperative PUs along with ade- to take more proactive steps before surgery to
quate nutrition, moistening the skin, and reposi- help prevent possible tissue damage and PU
tioning.9 More current and unbiased research is development.
needed to address the effectiveness and defi- Pressure ulcer development does not neces-
ciencies of surgical pressure redistribution sup- sarily start in the OR. Many factors that can
port surfaces. contribute to tissue fragility begin before sur-
gery. It would be appropriate, therefore, to
SURGICAL CONSIDERATIONS thoroughly assess the patient’s skin when per-
AND RECOMMENDATIONS forming the preoperative physical examina-
All surgical patients should be considered tion (eg, nutrition, hydration) and laboratory
at risk for PU development because of the un- tests (eg, hemoglobin, total albumin, prealbu-
controllable length of surgery and the effects min), all of which are important in evaluating
of anesthesia on the patient’s hemodynamic skin integrity. For example, if a patient has
state along with the use of vasoactive medica- been immobile or unable to react to ischemic
tions during surgery. Classifying all surgical pain before surgery, the patient is at increased
patients as “at risk” for PU development is an risk for skin breakdown. Perioperative nurses
appropriate preoperative intervention to suc- should emphasize evaluating skin integrity
cessfully help reduce the incidence of possible before surgery. More research needs to be per-
PU development. The preoperative assess- formed to help support the preoperative and
ment should include details of the patient’s postoperative use and effectiveness of a skin
skin status along with a risk assessment not- assessment for surgical patients.
ing whether the patient is a high-risk candi- CONSIDERATIONS FOR SUPPORT SURFACES. Pressure re-
date for PU development based on the pro- distribution devices should be used for all sur-
posed procedure and intrinsic and extrinsic gical patients. The use of pressure redistribu-
factors. Perioperative nurses should develop tion support surfaces has been proven to be ef-
nursing guidelines and protocols and individ- fective in decreasing PU formation, especially
ualized nursing care plans based on the pa- among high-risk populations.9,14,27,28 For surgery,
tient’s condition, the type and length of the research supports the use of a static-air mat-
surgical procedure, the required surgical posi- tress in the OR. Gel overlays have been shown

546 • AORN JOURNAL

Walton-Geer MARCH 2009, VOL 89, NO 3

TABLE 7
Nursing Care Plan to Prevent the Development of
Intraoperatively Acquired Pressure Ulcers [PNDS code]
Outcome Outcome
Diagnosis Nursing interventions indicator statement
Risk for injury • Verifies the patient’s identity, allergies, NPO The patient’s skin The patient
[X29] status, informed consent, and laterality [I26, remains intact, is free from
I123, I124, I143]. nonreddened, and signs and
• Identifies physiological status (eg, skin in- free of blistering; symptoms
tegrity, sensory impairments, musculoskeletal motion, sensation, of physical
status) [I66, I90]. and circulation are injury
• Implements protective measures to prevent maintained or acquired
injury (eg, appropriate positioning, adequate improved during during the
padding of pressure points, safety devices) the perioperative periopera-
[I11, I72-I78, I90]. period. tive period
• Evaluates for injury [I136-I143, I152]. [O1].

Ineffective • Identifies baseline tissue perfusion [I60]. The patient does The patient
tissue • Identifies risk factors for ineffective tissue not exhibit signs has
perfusion [X61] perfusion (eg, venous stasis) [I15]. or symptoms of wound/
• Maximizes mechanical prophylaxis by venous stasis. tissue
• assisting the patient in donning thrombo- perfusion
embolic disease (TED) stockings properly, consistent
• educating the patient about the impor- with or
tance of TED stockings and the signifi- improved
cance of wearing them as prescribed, and from
• suggesting that the patient use stock- baseline
inettes or socks under foot pumps for levels estab-
comfort. lished pre-
• Administers pharmacologic agents as ordered. operatively
• Maintains continuous surveillance [I128]. [O11].
• Evaluates postoperative tissue perfusion [I46]
and response to venous stasis prophylaxis.

to provide a reduction in pressure but not as search then should be translated into better ed-
effectively as air mattresses. More research ucation to improve the competency of periop-
needs to be done to help identify preventative erative team members and to help develop
techniques, supplies, and equipment. and implement policies and procedures, where
Nurse managers should assess the support needed, to decrease the vulnerability for PU
surfaces used throughout the hospital, includ- development. More evidence-based research in
ing in the emergency department (ED). Many this area will encourage practice changes that
patients are transported to the ED in ambu- will in turn help decrease PU development,
lances on hard surfaces. Patients then are trans- improve patient comfort, decrease patient
ferred onto stretcher mattresses that do not pro- mortality, and lower health care costs.
vide the pressure redistribution needed to help
prevent PU development. Often, patients in the Acknowledgment: The author acknowledges
ED are left on that surface waiting for admis- Michelle M. Byrne, PhD, RN, CNOR, associate
sion for many hours. Patients may already have professor of nursing and coordinator of the MS
adversely affected tissue because of this exten- Nursing Education Program, North Georgia
sive and long-term pressure. College and State University, Dahlonega, GA,
More research is needed to address the pre- for her support and mentorship during the devel-
vention of PUs in surgical patients. The re- opment of this manuscript.

AORN JOURNAL • 547

MARCH 2009, VOL 89, NO 3 Walton-Geer

REFERENCES 16. Nix DP. Support surfaces. In: Bryant R, Nix D,

1. Ayello EA, Baranoski S, Lyder CH, Cuddigan J. eds. Acute & Chronic Wounds: Current Management
Pressure ulcers. In: Baranoski S, Ayello EA, eds. Concepts. 3rd ed. St Louis, MO: Mosby; 2007:235-248.
Wound Care Essentials: Practice Principles. 2nd ed. 17. Lee BY, Ostrander LE. Noninvasive evaluation of
Philadelphia, PA: Lippincott Williams & Wilkins; the cutaneous circulation. In: Lee BY, ed. The Wound
2007:254-286. Management Manual. New York, NY: McGraw-Hill;
2. Pressure ulcer stages revised by NPUAP. Nation- 2005:131-140.
al Pressure Ulcer Advisory Panel. http://www 18. Price MC, Whitney JD, King CA, Doughty D.
.npuap.org/pr2.htm. Accessed December 27, 2008. Development of a risk assessment tool for intraop-
3. Pieper B. Mechanical forces: pressure, shear, erative pressure ulcers. J Wound Ostomy Continence
and friction. In: Bryant R, Nix D, eds. Acute & Nurs. 2005;32(1):19-30.
Chronic Wounds: Current Management Concepts. 19. Bates-Jensen BM. Pressure ulcers: pathophysi-
3rd ed. St Louis, MO: Mosby; 2007:205-234. ology and prevention. In: Sussman C, Bates-Jensen
4. Position statement: Pressure ulcer staging. Wound BM, eds. Wound Care: A Collaborative Practice Manu-
Ostomy and Continence Nurses Society. http://www al for Health Professionals. 3rd ed. Philadelphia, PA:
.wocn.org/pdfs/WOCN_Library/Position_State Lippincott Williams & Wilkins; 2007:336-373.
ments/PressureUlcerStaging.pdf. Accessed Decem- 20. Posthauer M. Introduction to wound diagnosis.
ber 27, 2008. In: Sussman C, Bates-Jensen BM, eds. Wound Care:
5. Montalvo I. The National Database of Nursing A Collaborative Practice Manual for Health Profession-
Quality IndicatorsTM (NDNQI®). The Online Journal als. 3rd ed. Philadelphia, PA: Lippincott Williams &
of Issues in Nursing. 2007;12(3). http://www.nurs Wilkins; 2007:52-71.
ingworld.org/MainMenuCategories/ANAMarket 21. Sewchuk D, Padula C, Osborne E. Prevention
place/ANAPeriodicals/OJIN/TableofContents/Vol and early detection of pressure ulcers in patients un-
ume122007/No3Sept07/NursingQualityIndicators dergoing cardiac surgery. AORN J. 2006;84(1):75-96.
.aspx. Accessed January 30, 2009. 22. Nixon J, Cranny G, Iglesias E, et al. Randomised
6. Relieve the pressure and reduce harm. Institute for controlled trial of alternating pressure mattresses com-
Healthcare Improvement. http://www.ihi.org/IHI pared with alternating pressure overlays for the pre-
/Topics/PatientSafety/SafetyGeneral/Improvement vention of pressure ulcers: PRESSURE (pressure reliev-
Stories/FSRelievethePressureandReduceHarm.htm. ing support surfaces) trial. BMJ. 2006;332(7555):1413.
Accessed January 28, 2009. 23. Phillips NF. Positioning, prepping, and draping
7. Graves N, Birrell F, Whitby M. Effect of pressure the patient. In: Phillips NF, ed. Berry and Kohn’s Operat-
ulcers on length of hospital stay. Infect Control Hosp ing Room Technique. St Louis, MO: Mosby; 2004:470-511.
Epidemiol. 2005;26(3):293-297. 24. O’Connell MP. Positioning impact on the surgi-
8. Brown G. Long-term outcomes of full-thickness cal patient. Nurs Clin North Am. 2006;41(2):173-192.
pressure ulcers: healing and mortality. Ostomy 25. Intraoperative nursing management. In:
Wound Manage. 2003;49(10):42-50. Smeltzer SC, Bare BG, Hinkle JL, Cheever KH, eds.
9. Reddy M, Gill SS, Rochon PA. Preventing pressure Brunner & Suddarth’s Textbook of Medical-Surgical
ulcers: a systematic review. JAMA. 2006;296(8):974-984. Nursing. 11th ed. Philadelphia, PA: Lippincott
10. Hospital-acquired conditions (present on ad- Williams & Wilkins; 2006:417-435.
mission indicator). The Centers for Medicare and 26. Lindgren M, Unosson M, Krantz AM, Ek AC.
Medicaid Services. http://www.cms.hhs.gov/Hos Pressure ulcer risk factors in patients undergoing
pitalAcqCond. Accessed January 28, 2009. surgery. J Adv Nurs. 2005;50(6):605-612.
11. Baumgarten M, Margolis D, Localio AR, et al. 27. Hoshowsky VM, Schramm CA. Intraoperative
Extrinsic risk factors for pressure ulcers early in the pressure sore prevention: an analysis of bedding
hospital stay: a nested case-control study. J Gerontol materials. Res Nurs Health. 1994;17(5):333-339.
A Biol Sci Med Sci. 2008;63(4):408-413. 28. Mackey D. Support surfaces: beds, mattresses,
12. Ayello EA, Lyder CH. Protecting patients from overlays—oh my! Nurs Clin North Am. 2005;40(2):
harm: preventing pressure ulcers in hospital pa- 251-265.
tients. Nursing. 2007;37(10):36-40.
13. Padula CA, Osborne E, Williams J. Prevention
and early detection of pressure ulcers in hospital- Patina S. Walton-Geer, RN-BC, MSN,
ized patients. J Wound Ostomy Continence Nurs. CWCN, CFCN, is a wound and foot care
2008;35(1):65-75. nurse clinician at AnMed Health Outpatient
14. Dybec RB. Intraoperative positioning and care of
the obese patient. Plast Surg Nurs. 2004;24(3):118-122.
Wound and Foot Care Clinic, Anderson, SC.
15. Recommended practices for positioning the pa- Ms Walton-Geer has no declared affiliation that
tient in the perioperative setting. In: Perioperative could be perceived as a potential conflict of
Standards and Recommended Practices. Denver, CO: interest in publishing this article.
AORN, Inc; 2008:497-520.

548 • AORN JOURNAL

 Examination 2.5
Prevention of Pressure Ulcers
in the Surgical Patient
PURPOSE/GOAL
To educate perioperative nurses about prevention of intraoperatively acquired pressure ulcers
(PUs).

BEHAVIORAL OBJECTIVES
After reading and studying the article on preventing PUs in surgical patients, nurses will be able to

1. discuss the etiology of PU development,

2. describe factors that contribute to the development of intraoperatively acquired PUs,
3. identify surgical patient populations that may have an increased risk of developing PUs, and
4. describe methods available to help prevent PUs in surgical patients.

QUESTIONS
1. Local blood flow is occluded when the 2. friction.
external pressure exceeds normal capil- 3. overhydration of tissue.
lary filling pressure of approximately 4. shear.
a. 32 mmHg. a. 1 and 3
b. 64 mmHg. b. 2 and 4
c. 86 mmHg. c. 2, 3, and 4
d. 92 mmHg. d. 1, 2, 3, and 4

2. Underlying tissue may become necrotic 5. When a patient has inadequate arterial
by the time a lesion presents on the skin blood flow, improper positioning can
surface because 1. cause blood pressure complications.
a. muscle rests directly on bone. 2. decrease tissue perfusion.
b. muscles have less vascular supply than 3. decrease venous return.
skin. 4. result in thrombus formation.
c. muscle is more sensitive to pressure a. 1 and 2
than skin. b. 3 and 4
d. muscles have more vascular supply than c. 1, 3, and 4
skin. d. 1, 2, 3, and 4

3. Necrosis occurs when unrelieved pressure 6. According to AORN’s “Recommended

is applied for practices for positioning the patient in the
a. less than 30 minutes. perioperative setting,” the OR team should
b. two to four hours. reposition the patient every __________ to
c. four hours or more. prevent continuous pressure on pressure
d. six hours or more. points.
a. 30 minutes
4. Extrinsic risk factors for tissue damage b. hour
include c. two hours
1. comorbid diseases. d. three hours

© AORN, Inc, 2009 MARCH 2009, VOL 89, NO 3 • AORN JOURNAL • 549
MARCH 2009, VOL 89, NO 3 Examination

7. All agents used in anesthesia can b. 1, 2, 3, and 4

1. cause a decrease in tissue perfusion. c. 2, 3, 4, 5, and 6
2. cause some degree of vasodilatation. d. 1, 2, 3, 4, 5, and 6
3. depress the autonomic nervous
system. 9. The highest incidence of PU development
4. lower blood pressure to some degree. occurs in patients who are
a. 1 and 3 a. younger than 10 years of age.
b. 2 and 4 b. 50 years of age or older.
c. 1, 2, and 3 c. 65 years of age or older.
d. 1, 2, 3, and 4
10. Gel overlays (ie, visco-elastic polymer)
8. Anatomical sites that are vulnerable to 1. allow gel to exchange through multiple
pressure ulcer development when a pa- chambers.
tient is in the jackknife position include 2. are capable of self-repair.
1. dorsum of the feet. 3. prevent bottoming out.
2. eyes, ears, and forehead. 4. prevent shearing.
3. genitalia and breasts. 5. support the patient’s weight.
4. knees. a. 2 and 3
5. occiput. b. 1, 4, and 5
6. sacrum. c. 2, 3, 4, and 5
a. 1 and 5 d. 1, 2, 3, 4, and 5

The behavioral objectives and exam- This program meets criteria for CNOR and CRNFA recertification, as well
ination for this program were prepared as other continuing education requirements.
by Rebecca Holm, RN, MSN, CNOR, AORN is accredited as a provider of continuing nursing education by the
clinical editor, with consultation from American Nurses Credentialing Center’s Commission on Accreditation.
Susan Bakewell, RN, MS, BC, direc- AORN recognizes this activity as continuing education for registered
tor, Center for Perioperative Educa- nurses. This recognition does not imply that AORN or the American
Nurses Credentialing Center approves or endorses products mentioned
tion. Ms Holm and Ms Bakewell have in the activity.
no declared affiliations that could be
AORN is provider-approved by the California Board of Registered Nurs-
perceived as potential conflicts of inter- ing, Provider Number CEP 13019. Check with your state board of nurs-
est in publishing this article. ing for acceptance of this activity for relicensure.

550 • AORN JOURNAL

 Answer Sheet 2.5
Prevention of Pressure Ulcers Event #09100
Session #1115
in the Surgical Patient

lease fill out the application and answer form

P on this page and the evaluation form on the back
of this page. Tear the page out of the Journal or make
photocopies and mail with appropriate fee to:

AORN Customer Service

c/o AORN Journal Continuing Education
2170 S Parker Rd, Suite 300
Denver, CO 80231-5711
or fax with credit card information to
(303) 750-3212.
Additionally, please verify by signature that you
have reviewed the objectives and read the
article, or you will not receive credit.

Signature ______________________________________
1. Record your AORN member identification number in
the appropriate section below. (See your member
card.)
2. Completely darken the spaces that indicate your an-
swers to examination questions 1 through 10. Use blue
or black ink only.
3. Our accrediting body requires that we verify the time
you needed to complete this 2.5 continuing education
contact hour (150-minute) program. ______
4. Enclose fee if information is mailed.
AORN (ID) #_________________________________________
Name_______________________________________________
Address _____________________________________________
City ___________________________________________________ State __________ Zip __________
Phone number _______________________________________
RN license #____________________________________________ State __________
Fee enclosed ___________________________________________
or bill the credit card indicated ■ MC ■ Visa ■ American Express ■ Discover
Card # __________________________________ Expiration date _____________________

Signature _______________________________________________________________ (for credit card authorization)

Fee: Members $12.50 A score of 70% correct on the examination is required for credit.
Nonmembers $25
Participants receive feedback on incorrect answers.
Program offered March 2009 Each applicant who successfully completes this program
The deadline for this program is March 31, 2012 will receive a certificate of completion.

© AORN, Inc, 2009 MARCH 2009, VOL 89, NO 3 • AORN JOURNAL • 551
2.5 Learner Evaluation
Prevention of Pressure Ulcers
in the Surgical Patient
his evaluation is used to determine the
T extent to which this continuing education
program met your learning needs. Rate these
items on a scale of 1 to 5.
PURPOSE/GOAL
To educate perioperative nurses about preven-
tion of intraoperatively acquired pressure ul-
cers (PUs).
OBJECTIVES
To what extent were the following objectives of
this continuing education program achieved?
1. Discuss the etiology of PU development.
2. Describe factors that contribute to the de-
velopment of intraoperatively acquired
PUs.
3. Identify surgical patient populations that
may have an increased risk of developing
PUs.
4. Describe methods available to help pre-
vent PUs in surgical patients.

CONTENT
b. an AORN Journal I obtained elsewhere.
To what extent
c. the AORN Journal web site.
5. did this article increase your knowledge
15. What factor most affects whether you take
of the subject matter?
an AORN Journal continuing education
6. was the content clear and organized?
examination?
7. did this article facilitate learning?
a. need for continuing education contact
8. were your individual objectives met?
hours
9. did the objectives relate to the overall
b. price
purpose/goal?
c. subject matter relevant to current posi-
TEST QUESTIONS/ANSWERS tion
To what extent d. number of continuing education contact
10. were they reflective of the content? hours offered
11. were they easy to understand? What other topics would you like to see ad-
12. did they address important points? dressed in a future continuing education arti-
LEARNER INPUT cle? Would you be interested or do you know
13. Will you be able to use the information someone who would be interested in writing
from this article in your work setting? an article on this topic?
a. yes Topic(s): __________________________________
b. no __________________________________________
14. I learned of this article via Author names and addresses: _______________
a. the AORN Journal I receive as an AORN __________________________________________
member. __________________________________________

552 • AORN JOURNAL • MARCH 2009, VOL 89, NO 3 © AORN, Inc, 2009