PRESSURE AND TIME Pressure ulcers can develop during shorter procedures, but the risk increases the longer anesthetized patients with unprotected bony prominences remain on the OR table.

Pressure ulcers are the painful, red reminders of unprotected bony prominences that remain on the OR table for too long. While no single precaution is 100% effective in preventing pressure ulcers — some patients will suffer skin breakdown no matter how hard you try to prevent it — the right positioning techniques and devices can go a long way toward reducing the risk. Here are 14 simple steps worth considering.

1. Stress good nutrition. Diet impacts risk for pressure ulcer development. Take time during the pre-operative meeting to discuss the importance of nutrition in the weeks leading up to surgery. "Advise patients to take a daily multivitamin, and to make sure they're incorporating protein into a balanced diet, because this helps prevent skin breakdown," says Denise Betcher, RN, MSN, CPHQ, nursing quality specialist at the Mayo Clinic in Scottsdale, Ariz. According to a 2015 report in the journal Advances in Skin and Wound Care, proper hydration can also help ward off pressure ulcers.

2. Keep skin moisturized. Dry skin is more susceptible to pressure ulcers. Advise patients with dry skin to use a moisturizing cream in the leadup to surgery, and to shower only every other day — showering can dry skin out more — and to use a soft sponge for gentle cleansing in the shower in the weeks leading up to surgery, as vigorous scrubbing can make skin more vulnerable to breakdown, according to leading pressure ulcer researcher Courtney Lyder, ND, ScD(H), FAAN, a professor of nursing at UCLA.

"While there's no clinical research on this, it's general knowledge in the field that having good moisture is one of the things that prevents skin breakdown," says Carlos Galeano-Rodriguez, MD, certified wound specialist physician with Vohra Post-Acute Physicians in Pittsburgh, Pa.

GREATEST RISK The most common pressure ulcer sites are bony prominences, any point on the body where the bone is immediately below the skin surface. Examples: pelvic girdle, posterior heel and ankle bone.

3. Turn patients in pre-op. If immobile patients are waiting long in pre-op, turn them at least every 2 hours by 30 degrees — alternating onto their right side, back and left side. When moving from the back to the side, place a pillow behind them, tucked under the sacrum, and place another between the legs to keep the ankles from resting on top of each other and creating pressure. When a patient is on his back, avoid putting a pillow under the knees, as this can increase pressure on the heels. Instead, put a pillow under the calves, so that the heels are lifted. If patients are in such pain that it's not possible to move them by 30 degrees, encourage them to engage in micro turns by subtly shifting their weight. Don't let patients drag themselves in order to shift on their own, as dragging can lead to skin breakdown.

4. Smooth the surface. If a patient will be in a hospital bed before his outpatient procedure, smooth wrinkles out of the sheets, as these can add excess pressure on the skin. Also, limit raising the head of that bed more than 30 degrees, as this can cause the body to be pulled down by gravity while the skin remains fixed, leading to pressure ulcer-causing shear. "If we do raise the head, we gatch the knees to prevent the body from sliding toward the end of the bed," says Mary Paciella, RN, MS, CCRN, ANP, ACNS-BC, PCCN, director of employee health and wellness at Stony Brook (N.Y.) Medicine.

5. Perform a risk assessment. Before surgery, conduct a pressure ulcer risk assessment using the Braden Scale for Predicting Pressure Sore Risk (osmag.net/3oRhSC), which evaluates risk according to 6 categories: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. "But be mindful that this scoring system is geared toward long-term care, not surgical patients," says Joyce Black, PhD, RN, CWCN, FAAN, member of the skin wound advisory team at Nebraska Medical Center in Omaha, Neb. "Nurses need to conduct their own assessment, using their clinical judgement." Is surgery expected to last more than 3 hours? Is the patient older than 62? Does the patient have a BMI of less than 19 or greater than 40? All of these factors increase risk.

6. Assess the skin. Ask patients about previous pressure ulcers, as the skin here is more vulnerable. Look for scars, as this tissue will be vulnerable as well. Take note of discolored areas, or areas that are warm, hard and spongy, as these might be early signs that a pressure ulcer has already started to develop. Once you've identified high-risk spots, dress them with multi-layer soft silicone dressings according to manufacturer instructions, being sure to cover the entire area without wrinkling the adhesive material. While the most common pressure ulcer sites are bony prominences like the pelvic girdle (two-thirds of all pressure ulcers develop here), posterior heel and ankle bone, apply dressings outside of these routine places, if called for. Sometimes overlooked: The weight of adipose tissue in obese patients can lead to pressure ulcers, so pay attention to skin fold areas under the breasts (for both men and women), in the mid-back and behind the neck.

7. Prevent moisture from being trapped against the skin. Because excessively moist skin leads to pressure ulcer-causing friction, continually pad (don't wipe) a patient's perspiration away before surgery. For patients who suffer from incontinence (even a small amount of stress incontinence, which can lead to moisture on the skin), check at least every 2 hours for an incontinent episode and, after each, gently cleanse the skin with water or a pH-balanced cleanser. Moisture-barrier ointments and wicking underpads can also be used to keep moisture from being trapped against the skin. When prepping the skin, be careful not to pour too much, or it may pool around the side of the patient and cause maceration.

8. Invest in a pressure-relieving OR table pad. The standard is 2 inches thick, but experts say 4 inches is a safer bet for preventing pressure ulcers. Stay away from egg crates, which are commonly used but have very tiny pockets of air that compress too easily. And avoid using IV bags under the heel, another common practice, since these also provide inadequate pressure relief. You can use static (non-electric) mattress overlays made of air, foam or gel to provide pressure relief; the overlays can follow the patient into recovery.

9. Relieve pressure during surgery. While it's not always possible to reposition the patient during the case, consider assigning a point person, such as the circulator, who can look for windows of opportunity to make small adjustments, like repositioning temperature probes or a face mask, or making sure that the heels of a patient in the supine position remain suspended off the table throughout surgery to alleviate pressure. This person can make sure any foam or gel cushioning under high-risk areas stays in place. Ask the anesthesia provider to make micro adjustments to the head of a patient in the supine position, if medically advisable, in order to prevent pressure ulcers under the cervical collar.

10. Pay attention to tubing. If pressed against the skin, drainage tubing, oxygen tubing, and catheter or fecal collection tubing can cause pressure on the skin. "We've recently invested in oxygen tubing that's made of a softer silicone, because it results in less pressure," says Ms. Betcher. "And we will put little foam cylinders around this tubing so it's not exerting so much pressure on the ears. It's also important to empty incontinence devices frequently in the OR. The weight of a full bag will tug on the tubing and create more pressure against the skin."

11. Never drag a patient from one surface to another. To reduce the risk of skin shearing and bruising when transferring a patient onto or off of the OR table, never drag a patient. Instead, use a flyboard, hoist sling or an air-assisted transfer system. If this equipment is not available, use a draw sheet, which you can make by folding a top sheet in half lengthwise and rolling one end. Using at least 3 people, roll the patient onto his side and place the rolled end of the sheet underneath the patient's back and hips. Then roll the patient onto his other side, so that you can extend the sheet underneath of him. If there are wheels on either of these surfaces, make sure they are locked. To make it easier, adjust the surface you are transferring the patient onto so that it is a couple of inches lower than the other, if possible, before lifting.

12. Remove the prep. As soon as possible after surgery, remove all prep solution, as wet skin is more susceptible. But don't remove a patient's dressings immediately following surgery. Instead, keep them on until the patient is ambulatory and in street clothes.

13. In recovery, position patients differently. If patients were in the lateral position during the operation, make sure they're supine in PACU. Ask about pain that isn't specific to the surgical site, as this may be an early pressure ulcer indicator. If the patient indicates pain, get him moving — it's possible to ward off an ulcer during the beginning stages by getting the patient off of the area so blood and oxygen can return to damaged tissue.

14. Record pressure ulcer data. Throughout the surgical process, emphasize communication among all team members. Record all pressure ulcer history and risk factors in the patient's chart or whiteboard, and conduct nurse-to-nurse shift reports bedside. Consider setting up a multidisciplinary pressure ulcer prevention task force that meets regularly to discuss specific cases and determine contributing factors. Record this data so that it can be used to conduct common cause analyses. "When it comes to pressure ulcer prevention," says Ms. Black, "you have to go beyond the routine." OSM