◙ PRESSURE'S OFF With the right precautions and the right positioning, pressure injuries can be virtually eliminated.

How is that possible?" "It must be a mistake!" "They must have had it before surgery." You may have heard a few of these typical responses when nurses and doctors realize their patients have developed pressure injuries. To transition your staff from doubters to advocates of keeping patients' skin intact, focus on the 5 P's of perioperative ulcer prevention.

1. People. Most of us recognize that a pressure ulcer is "a localized injury to the skin or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear." That's the definition given by the National Pressure Ulcer Advisory Panel (NPUAP). But the panel adds: "A number of contributing or confounding factors are also associated with ?pressure ulcers; the significance of these factors is yet to be elucidated." You need to try to understand and address those other factors, too.

Ask interested nurses in pre-op, the OR and PACU to join certified wound and ostomy care nurses on a skin care task force — ours is known as the Perioperative Pressure Ulcer Prevention (PPUP) team. The interdepartmental approach is essential because each area has a unique role in pressure ulcer prevention. Team members identify the barriers and needs of each department and become champions for change. Bringing nurses from 4 departments together for an evidence-based practice-improvement project boosts interdepartmental communication and cooperation.

2. Practice. Conduct high-level skin assessments before and after surgery. Adopt risk-assessment and skin-integrity communication tools that are handed from pre-op to the OR, and from the OR to PACU. Also train nurses in all 3 departments on how to use the Braden Scale (see "2 Patients, 2 Plans"). Use the tool to record risks and observations, and to document pressure and ulcer prevention interventions.

3. Perception. Educate your staff by providing articles from scientific journals about how ulcers form, and the best practices for prevention. Perioperative nurses want good evidence of need and concrete techniques for change, so also present in-services approximately 3 times a year, with guest speakers, hands-on practice and case studies.

EVALUATING RISK
2 Patients, 2 Plans

◙ HANDLING HEELS Low-profile pillows provide a simple way to prevent heel ulcers.

Use the "Braden Scale For Predicting Pressure Sore Risk" (tinyurl.com/m3p65l6) to help formulate treatment plans that reduce the risk of pressure ulcers. Here are 2 examples you might encounter, along with suggested precautions.

◙ Mr. Adams is a 56-year-old man scheduled for abdominoplasty. He lost 100 pounds after having a lap band placed a year ago. Redundant skin on buttocks and sacrum were noted during pre-op skin inspection and risk assessment. His Braden Scale score is 18.

Risk factors:

• Inadequate nutrition
• Potential for friction/shear injury
• Linens could become wet during surgery due to perspiration and irrigation fluid
• Length of procedure is potentially longer than 3 hours

Plan:

• Moisture management: Absorbent pad on OR table and sacral dressing pre-op
• Reduce friction/shear: Use transfer sheet, avoid "dragging" during transfers. (Sacral dressing also protects skin from friction/shear forces)
• Hand-check redundant skin on sacrum and buttocks during positioning
• Protect heels: Use low-profile pillows under legs to "float" heels
• Perform post-op skin assessment
• Turn patient off his back as soon as tolerated in PACU

◙ Ms. Bates is a 32-year-old woman scheduled for laparoscopic cholecystectomy. Her skin is intact on pre-op assessment. Her Braden Scale score is 23.

Risk factors:

• Friction/shear forces are always a risk when transferring anesthetized patients

Plan:

• Use lateral transfer sheet and avoid dragging
• Perform post-op skin assessment
• Turn patient off her back as soon as tolerated in PACU

— Anne Nowlin, RN, CNOR, and Ann Marie Whaley, RN, CWOCN

At our first in-service, the coordinator of our nurse quality council presented national hospital-acquired pressure ulcer data and compared them with our statistics. Each patient who developed a pressure ulcer in our facility had a drill-down tool completed, so we could see how many patients had come to the OR before developing a pressure ulcer and how many days after the OR experience the pressure ulcer occurred, which indicated whether it was OR-acquired. It was an eye-opening presentation.

The most interactive in-service used a case study of 2 patients who developed intraop pressure ulcers while in our care. It really captured staff interest, because no nurse wants her patient to get a pressure ulcer, and it led to some lively discussion.

Information presented at in-services may be the same for each area, but the question-and-answer periods that follow are department-specific. We've discovered that skin integrity is a topic that nurses in each department readily relate to, and we've incorporated suggestions from every department.

4. Products. One simple, yet very effective practice change is how you cover the OR table. Use a high-quality absorbent underpad to manage moisture for every patient. Because it's strong enough to be used as a drawsheet, eliminate redundant linen between the patient and the OR table surface. If arms are to be tucked in, an additional draw sheet is still required. Suspending heels with low-profile pillows is a simple positioning change that can prevent heel ulcers. Also use a protective sacral dressing for patients who meet your high-risk criteria. Finally, use a lateral transfer device instead of a roller board to reduce shear and friction injuries.

5. Pressure redistribution. Use pressure-redistributing mattresses on your OR tables for all patients at risk for developing pressure ulcers. Also turn patients off the operative side both before and after procedures. This reduces pressure to the area and allows maximum perfusion.

Spreading the word
We're all dedicated to preventing pressure ulcers in the perioperative setting and we're spreading the word to various nursing councils and magnet evaluators, and through an award-winning poster at the 2012 AORN Congress. Several team members have attended conference presentations about prevention of intraoperative pressure ulcers to enhance their effectiveness as champions of this important cause.