Pressure Injury Primer

Patient education, proper positioning and careful post-op monitoring can help prevent poor outcomes.

Pressure injuries (PIs) can range from a minor, localized area of non-blanchable erythema to full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage or bone. These sometimes minor but sometimes devastating injuries can interfere with the patient’s recovery, causing pain and infection that can even result in costly hospital stays.

Pressure injuries can occur less than a few hours after surgery or over the succeeding couple of days. For procedures that are prone to these injuries, prevention requires diligence from both staff and the patient.

Patient prep 

Don’t assume you only need to worry about PIs once the patient goes under the knife. PI prevention protocols should always begin with a preoperative patient skin assessment, says Kimberly Jones, DNP, RN, CNOR, RHCNOC, CER, nurse manager of surgical services, oncology, audiology, wound care, medical specialty clinics and cardiopulmonary rehab at Ascension St. Vincent Mercy Hospital in Elwood, Ind. Her critical access hospital cares for very sick patients while also performing general surgery, orthopedic, podiatry, ENT and urology cases in its two OR suites. “We conduct a verbal skin assessment with all our patients using the Braden Assessment Scale. Those with a score of 12 or less are considered high-risk,” she says. In general, she says, patients who have poor nutritional status, are not as mobile, are very young or elderly, are morbidly obese or are extremely thin tend to be categorized as high-risk. Dr. Jones adds that diseases such as diabetes, peripheral vascular disease and cancer all increase the risk of developing a pressure injury.

Intra-op 101 

The length of the surgical procedure is another prime consideration. Since most cases performed at Ascension St. Vincent Mercy Hospital take 45 minutes or less, the facility rarely utilizes prophylactic foam dressings. “In the chance that we do have cases scheduled for longer, we certainly treat them differently, as they are at a higher risk for pressure injuries,” says Dr. Jones. Shorter cases aren’t an excuse to get complacent, however, as they do not automatically mean PI risk is low, she adds.

Most cases performed at Ascension St. Vincent require the patient to be in the supine position. When employing this position, make sure the patient’s heels and the back of their head are protected. “We make sure that when women come in for surgery, they don’t have their hair pulled up in a ponytail, or at least that they don’t have a ponytail at the crown of their head where they would lay on it,” says Dr. Jones. “If a patient has very thick hair and comes in with a braid, laying on that braid could cause a pressure point on the back of their head, so sometimes we must ask them to take the braid out.” 

Another position with a high risk of creating pressure injuries is the lithotomy position, which is a supine position with the legs separated, flexed and supported in raised stirrups. “We use this position for our urology cases,” says Dr. Jones, who worries about frail male patients undergoing prostate surgery in this position. With lithotomy, there is always a risk of creating a pressure point on the patient’s sacrum. “We will often utilize a bordered foam dressing for pressure ulcer prevention for the sacral area,” notes Ascension St. Vincent Wound Care Nurse Michelle Scholl, WCC. The lithotomy position also places the patient’s hips and knees at risk for nerve injuries, so setting up patients correctly for these types of surgeries is absolutely critical.

The number one cause of pressure injuries post-op is because patients don’t get up and move around. 
Kimberly Jones, DNP, RN, CNOR, RHCNOC, CER 

In many surgeries that require patients to be in the prone position, such as the placement of a bladder stimulator or the removal of a lesion, Dr. Jones says that Ascension St. Vincent teams usually have the patient get into a comfortable position of their own choosing. “Before we get them off to sleep or give them some sort of sedation, we allow the patient to position themselves,” she says. “You’re going to end up with less risk of a pressure injury this way because if it’s uncomfortable for them, they’re not likely to put themselves in that position.”

Post-op persistence

EXTENDED RISK Although intra-op positioning efforts such as those seen here are crucial, close attention must still be paid to pressure injury prevention once the patient is home. 

Even after your patient is out of surgery and beginning to travel the road to recovery, staff still must stay alert to ensure a pressure injury doesn’t occur postoperatively. A primary consideration here is that the patient must be aware of the PI risks and understand what they need to do to avoid them during their recovery.

Ambulating the patient as soon as possible, and then making sure the patient ambulates when they are home, is also important. “The number one cause of pressure injuries post-op is because patients don’t get up and move around,” says Dr. Jones. “Perhaps they had a block in a limb and they don’t feel the need to move it because they can’t feel any pain, or they just don’t feel like getting up and moving around after surgery. For instance, I had a patient that developed a Stage 1 pressure injury on her sacrum. She had cancer. She didn’t want to get up and she just wasn’t in a mental state to understand the importance of getting up and moving around. She didn’t feel good, so she sat in her chair all day long.” 

As a result, patient education should include explicit information on how to prevent post-op PIs. “If a patient can’t get up and move around that well on their own, then you need to pull in family members or care providers and ask them to help make sure the patient is changing positions every couple of hours,” says Ms. Scholl. “It is also important that they have the proper positioning aids available to them, such as foam wedges and pillows, and are taught how to use them properly so they don’t form any additional injuries.” 

Performing frequent skin assessments and using the correct pressure-relieving devices is critical. “If a patient is sitting in a chair or lying in bed, place waffle boots on their feet to prevent any foot or heel pressure ulcers,” says Ms. Scholl. “When a patient is in bed, you can also utilize the 30-degree position elevation on the bed to prevent friction and shearing.”

“We then continue to educate and remind patients of the important steps they need to take during the post-op period,” says Dr. Jones. “We still call our patients 24 to 72 hours after their procedure and stress the importance of getting up and moving around and keeping a close eye on their incision.” OSM