Pressure Ulcers in the Surgical Patient - Healthcare Associated ...

y Susan Shoemake, BA
and Kathleen Stoessel, RN, BSN, MS
Patient Outcome Improvements
Pressure Ulcers in the Surgical Patient
An Independent Study Guide

Pressure Ulcers in the Surgical Patient
An Independent Study Guide
by Susan Shoemake, BA and Kathleen Stoessel, RN, BSN, MS
Continuing Education Information
The Pressure Ulcers in the Surgical Patient independent study guide has been accredited by
Cross Country University, a Division of Cross Country TravCorps, Inc., a provider of continuing
education in nursing by the American Nurses Credentialing Center’s Commission on
Accreditation. One (1) contact hour for nurses has been awarded for this independent study.
Cross Country University is an approved provider with the Iowa Board of Nursing, Provider
#328. This independent study is offered for 1 contact hour.
Cross Country University is an approved provider with the California Board of Registered
Nursing, Provider #CEP 13345. This independent study is offered for 1 contact hour.
Cross Country University is an approved provider with the Florida Board of Registered Nursing,
Provider #50-3896. This independent study is offered for 1 contact hour.
The Pressure Ulcers in the Surgical Patient independent study guide has been approved by the
Association of Surgical Technologists for one (1) CE credit.
To obtain contact hour credit the applicant must:
Read the educational material printed in this independent study guide
Take the post-test located in the back of the booklet
Complete all information requested on the evaluation form
Submit the post-test and the evaluation form to:
Kimberly-Clark Health Care
Attn: Esther Atkinson
1400 Holcomb Bridge Road
Building 200, 5 th floor
Roswell GA 30076
Post-tests will be graded and, upon passing, a certificate will be issued and sent to the
applicant. Less than passing (less than 75% correct answers) will have the post test returned
and the applicant encouraged to re-read the material, take the test again and re-submit.
Disclaimer
Cross Country University has made reasonable efforts to ensure this educational subject matter
is presented in a scientific, balanced and unbiased way. However, participants must always use
their own judgment and professional opinion when considering future application of this
information, particularly as this may relate to patient diagnostic or treatment decisions. Cross
Country does not endorse or promote any commercial product that may be discussed in this
study guide.
Knowledge Network educational programs are designed to provide clinical education to
healthcare professionals without reference to specific commercial products. This Knowledge
Network independent study guide is provided at no cost through a continuing education grant
from Kimberly-Clark Health Care.
1

Objectives
Pressure Ulcers in the Surgical Patient
An Independent Study Guide
by Susan Shoemake, BA and Kathleen Stoessel, RN, BSN, MS
After completion of this study guide, the participant will be able to:
1. Describe the pressure ulcer classifications.
2. Differentiate between pressure ulcers and burns.
3. Recognize the mechanisms contributing to the formation of perioperative pressure
ulcers.
4. Discuss risk factors associated with the development of pressure ulcers.
5. Describe best practices that may prevent intraoperative pressure ulcers.
Overview
Medical personnel are challenged with preventing skin injury in the perioperative environment
due to prolonged periods of patient immobility, compromised circulatory function under
anesthesia, and preexisting conditions of many surgical patient populations. While great strides
have been made in protecting the patient from skin injury, it is an issue that still needs to be
considered and addressed. These skin injuries may result in extended hospital stay, increased
medical costs, and prolonged morbidity. The healthcare facility may also incur costly financial
and legal ramifications from these injuries. 1,2
In addition to skin tears and burns, pressure ulcers, or pressure injuries, are another type of skin
injury. They are defined as any lesion caused by unrelieved pressure resulting in damage of
underlying tissue. Pressure ulcers, frequently identified in long term care environments, are
also referred to as bedsores, decubitus ulcers, trophic ulcers 3 or ischemic ulcers. 4
In order to identify best practices that will assist in preventing or reducing pressure ulcers,
healthcare professionals need to understand the pathophysiology of these injuries, be able to
properly distinguish the types of injuries that occur, and understand the associated risk factors.
Pressure Ulcers
Pressure ulcers are complex lesions of the skin and underlying structures which tend to develop
when excessive pressure, shear, or friction is applied to soft tissue for an extended period of
time. They are characterized by disintegration or tissue necrosis. 5 Pressure ulcers frequently
develop during serious illness and trauma, including surgery. They vary considerably in size
and severity 6 and are often described as unexplained “burn-like” lesions or inaccurately labeled
as “burns”. 7,8,9,10
While burns result from contact with energy sources, pressure ulcers are a result of localized
unrelieved pressure exacerbated by factors such as compression, shear, friction, and
moisture. 11 Circumstances under which pressure exceeds circulatory pressure is typically
defined as 32 mm Hg. The result is sub-dermal cell damage typically seen at or around bony
2

prominences which extends outward to the surface. These may present within hours following
the surgical procedure or as long as 7 days after the injury has occurred. 7,12,13,14 Conversely,
burns are tissue injuries that initiate directly at the skin surface are visible immediately at the
end of the surgical procedure and penetrate as they advance. 2
Pressure Ulcer Classification
A common method which medical personnel use to determine the severity and treatment
requirements for pressure ulcers is to classify the ulcer according to grading or staging systems
based on the degree of tissue destruction. The stage is determined on initial assessment by
noting the deepest layer of tissue involved. A four-stage classification system, developed by the
National Pressure Ulcer Advisory Council (NPUAC), is used to define pressure ulcers. 15
Stage I Pressure Ulcers
Stage I is characterized by non-blanchable erythema. This is an observable pressurerelated
alteration of intact skin that may include changes in one or more of these areas:
skin temperature (warmth or coolness), tissue consistency (firm or boggy feel), sensation
(pain, itching), or appearance as a defined area of persistent redness in lightly
pigmented skin. In darker skin tones, the ulcer may appear with persistent red, blue or
purple hues. Furthermore, the skin is not broken, but is red or discolored and the
redness or change in color does not fade within 30 minutes after pressure is
removed. 4,16,17,18,19 See Figure 1.
Stage II Pressure Ulcers
Figure 1. Stage I Pressure Ulcers
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Stage II is considered a superficial, partial thickness loss that involves the epidermis and
possibly the dermis. The ulcer presents clinically as an abrasion, blister or shallow
crater. The epidermis or topmost layer of the skin is broken, creating a shallow open
sore. Drainage may or may not be present. 4,16,17,18,19 See Figure 2.
3

Stage III Pressure Ulcers
Figure 2. Stage II Pressure Ulcers
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Stage III, also known as a full thickness skin loss, involves damage to or necrosis of
subcutaneous tissue that may extend down to, but not through, the underlying fascia.
The ulcer presents clinically as a deep crater with or without undermining of adjacent
tissue and the break in the skin extends through the dermis into the subcutaneous fat
tissue. 4,16,17,18,19 See Figure 3.
Stage IV Pressure Ulcers
Figure 3. Stage III Pressure Ulcers
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Stage IV is a full thickness skin loss with extensive destruction, tissue necrosis with
damage to muscle, bone, or supporting structures (e.g., tendon or joint capsule).
Usually a large amount of dead tissue and drainage are present. 4,16,17,18,19 See Figure 4.
Figure 4. Stage IV Pressure Ulcers
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4

Burns
Table 1. Ulcer Staging Criteria Summary 20
Ulcer Stage Criteria
Stage I* Non-blanchable erythema of intact skin; the heralding
lesion of skin ulceration. May also include changes in skin
color, skin temperature, skin stiffness and/or sensation
(pain)
Stage II Partial thickness skin loss involving epidermis and/or
dermis. The ulcer is superficial and presents clinically as
an abrasion, blister or shallow crater.
Stage III Full thickness skin loss involving damage or necrosis of
subcutaneous tissue; may extend down to but not through
underlying fascia. Presents clinically as a deep crater with
or without undermining of adjacent tissue.
Stage IV Full thickness skin loss with extensive destruction, tissue
necrosis or damage to muscle, bone and/or supporting
structures, e.g., tendon, joint capsule.
Additional Pressure Ulcer Categories
There are additional pressure ulcer categories which are not defined by the NPUAC
Stage classification system but may be useful in describing such injuries that do not fit
the established criteria. They include:
“Pre-stage” pressure ulcer: Skin damage that has not reached the Stage I
classification level. These ulcers are labeled reactive hyperemia 17 and are
identified by blanchable erythema. 4
Closed pressure ulcer: Can not be seen on the surface but is in Stage IV beneath
the skin. 17
Purple ulcer: A term used when the ulcer does not meet any of the other
classification criteria. This is more of a “miscellaneous” ulcer or “catch-all”
category. 17
Pressure ulcers and burns may both occur in the intraoperative environment and are often
difficult for clinicians to differentiate upon post-injury inspection; however, they differ in several
ways. A burn is a skin lesion caused by direct contact with thermal, chemical, electrical sources
or radioactive agents that exceed the skin’s tolerance for that energy. 5,21 A distinguishing
characteristic of this type of injury is that it typically presents much earlier after the insult than a
pressure ulcer. 22
Classification of Burn Injuries
Burn injuries have three primary classification levels: 1 st , 2 nd , and 3 rd degree burns. These
classification levels are based primarily on the skin layers affected by the burn. The skin layers
include the epidermis, the thin, outermost layer; the dermis, which provides strength, support,
blood and oxygen to the skin; and the hypodermis or subcutaneous layer, located beneath the
dermis, which provides blood supply to the dermis for regeneration. Figure 5 provides a visual
illustration of these skin layers.
5

Figure 5. Skin Layers
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Table 2. Burn Injury Classification System
Burn Degree (Category) Description
1 st degree (Superficial Burns 23 )
Affect only the epidermal or outer layer of
skin. The burn presents as dry, painful and
reddening, with swelling (erythema), but no
blisters. Mild sunburn is an example. When
lightly pressed, the reddened skin whitens or
blanches. 24,25 Long-term tissue damage is
rare and usually consists of an increase or
decrease in the skin color.
Medical Illustration Copyright © 2006 Nucleus Medical Art, All rights reserved.
www.nucleusinc.com
6

2 nd degree (Partial Thickness Burns)
Superficial
Medical Illustration Copyright © 2006 Nucleus Medical Art, All rights reserved.
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Deep
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reserved. www.nucleusinc.com
3 rd degree (Full Thickness Burns)
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Causes of Burns
Involve the epidermis and part of the dermis
layer of skin. The burn site appears red,
blistered, and may be swollen and painful.
These burns are further subdivided into two
categories: superficial and deep.
7
Characteristics of a superficial dermal
burn include necrosis, which extends to
the upper third of the dermis. The area of
necrosis is separated from the viable
wound by edema.
Deep dermal burns, however, display
necrosis and involve the majority of skin
layers. The area of necrosis is adherent
to the area of injury and there is a smaller
edema layer.
Destroy the epidermis and dermis. Thirddegree
burns may also damage the
underlying bones, muscles, and tendons. The
burn site appears white or charred. There is
no sensation in the area since the nerve
endings are destroyed.
There are several causes for patient burns within the intraoperative environment. Burns have
been found to occur due to contact with various types of energy sources. Chemical, electrical,
or thermal sources are the primary causes.
Chemical Sources
Chemical sources used in the operating room are one cause of patient burns. Many of
these sources involve chemical prepping and degreasing agents 21 such as povidoneiodine
prep solutions. 1,2 These chemical agents may react with the tissue to cause

irritation. The pooling of prep solutions beneath or near the patient and the subsequent
constant contact with the skin is a primary concern, especially if mild heat or pressure is
applied. 21 These burns may also be reactions to chemical interaction with other
substances, either creating new irritants or resulting in exothermic output, often having
the appearance of thermal burns. 21 Prep solutions that are deposited and pooled away
from the intended site are often a preventable source of these risks.
Other chemical sources include: skin contact with ethylene oxide (EtO) under the
condition of improper aeration of EtO-sterilized devices which then come in contact with
the patient 1,2,21 as well as improper electrode (ECG) plating components reacting with
conductive paste. 1,2
Electrical Sources
A second source of burns in the intraoperative environment is electrical energy. This
may include radio frequency devices such as electrosurgery and magnetic resonance
imaging (MRI) field coils 1,2 as well as the electrosurgical unit (ESU). 21
Additionally, if not properly grounded and isolated from tissue contact, AC and DC
sources may be a cause for burns intraoperatively. 1,2 The DC sources may include
batteries, circuit continuity monitors, pacemakers, and nerve and muscle stimulators. 1,2
For instance, the faulty circuitry in the warning circuit of an ESU may allow energy
conduction to the skin, causing a burn to the patient. Most of the new ESU generators
are now isolated and have quality monitoring systems to prevent an alternate path to
ground. Many hospitals, however, still use older equipment that does not have the level
of safety monitoring provided by newer models. Also, electrolysis of skin moisture
produces sodium hydroxide at the negative electrode which can result in full-thickness
skin lesions to the patient. 21
Thermal Sources
Thermal sources, which may cause patient burns intraoperatively if exposure reaches or
succeeds this threshold, are acquired by three primary methods:
- Direct contact 1 (e.g., electrocautery, diathermy, heated irrigation solution bag,
excessively heated cotton blanket, heating pads, unlubricated surgical drill shank,
flash-sterilized surgical instruments, heated probes) 1,2
- Irradiant heat 1 (e.g., radiant warmers, exam and operating lights, fiberoptic light
cables, lasers) 1,2
- Exothermic reactions 1 (e.g., merthiolate on aluminum electrode) 1,2,21
Thermal burns occur when tissue is subjected to a combination of temperature and
exposure time that exceed the tissue’s tolerance threshold. In a landmark study, Moritz
and Henriques established that the threshold for achieving a thermal burn in healthy
adult perfused tissue is impacted by an inverse relationship between the maximum
exposure temperature and the duration of exposure. In their study, “the lowest surface
temperature that was responsible for cutaneous burning was 44 0 C (111.2 0 F) and the
time required to cause irreversible damage to epidermal cells at this temperature was
approximately 6 hours.” 21,26 Data from their findings is illustrated in Table 3.
8

Table 3. Thermal Damage*
Temperature [°C], (°F) Maximum
Exposure Time for
Reversible Injury
(1 st degree burn),
[minutes]
9
Maximum Exposure
Time for Necrosis
(2 nd and 3 rd degree
burns), [minutes]
Notes
40 (104.0) 4113 7883 Extrapolated
41 (105.8) 1918 3675 Extrapolated
42 (107.6) 900 1725 Extrapolated
43 (109.4) 423 810 Extrapolated
44 (111.2) 200 383 Actual Data
45 (113.0) 98 183 Actual Data
46 (114.8) 47 87 Actual Data
47 (116.6) 23 42 Actual Data
48 (118.4) 11 20 Actual Data
49 (120.2) 6 11 Actual Data
50 (122.0) 3 5 Actual Data
*Adapted from Moritz & Henriques
Below 44°C, extrapolated data would indicate that time required to achieve injury
continues to increase as documented in Table 3 above. Based on this information, for
example, extrapolation of this data indicates that a surface temperature of 42°C would
require 900 minutes (15 hours) for a 1 st degree burn to develop and 1725 minutes (28.8
hours) for a 2 nd or 3 rd degree burn to develop.
It is important to properly address and investigate the sources and causes of perioperative skin
injuries. To do this, an investigation into the injury must occur and a report with all pertinent
information must be completed. Unfortunately, many incidents may not be adequately
investigated as a frequent assumption is that all “burn-like” lesions acquired in the perioperative
environment result from one or more of the devices being used during the surgical procedure.
These devices may include but not be limited to hypo/hyperthermia units, radiant warmers, or
electrosurgical units. 2,21 When an injury occurs, all of the devices used during the surgery
should be inspected for defects that may have caused the injury. Often, the inspection reveals
no device defects capable of producing damage. 2 All too frequently, the investigation stops at
this point without considering other causes of the injury. 5
It has been recognized that differentiating by observation alone whether a skin lesion is due to
pressure or a burn is nearly impossible. 27 Therefore using the term “lesion” for any unexplained
injury within the intraoperative environment allows other causes to be considered. This practice
will aid in preventing misdiagnosis and improper treatment. 10
Table 4 describes differences between thermal burns and intraoperatively-acquired pressure
ulcers.

Table 4. Burn and Pressure Ulcer Differentiation
Burn (Thermal)
1 st and 2 nd Degree Burns
Superficial
Pressure Ulcer
(Intraoperatively-Acquired)
Physical Appearance Presents as a painful
reddening of the skin
(appearance of sunburn),
swelling (erythema) and
blanchable redness;
blistering (in 2 nd Stage I: Defined area of
persistent, non-blanchable
redness
Stage II: Abrasion, blister or
degree)
shallow crater
Time of Observation Immediately or soon after
event (

Figure 6. The Pressure Ulcer Development Cycle
Pressure ulcers which originate during the perioperative environment may appear within as little
as a few hours postoperatively. However, the majority typically present one to three days
postoperatively. 17,28,31 These surgically-associated late onset pressure ulcers are often
mischaracterized as energy-related “burns”. 32 Gendron stated that “it is precisely the lack of
recognition of their [pressure ulcers’] true nature that has guaranteed their continuance.” 5
Additional situational factors that augment the risk of pressure ulcer development in the
perioperative setting have been identified. They include shear, pressure, temperature and time
as discussed below.
• The presence of shear may decrease the time that tissue can remain under pressure
before ischemia occurs.
• The sustained high pressure from specific patient positions and/or various devices such
as use of supports and straps, pneumatic tourniquets, and unyielding electrode
adhesives for an extended time (>2-3 hrs) may shorten the time to pressure ulcer
development. 1,2
• Elevated tissue temperatures increase the oxygen consumption rate of the local cells,
thereby shortening the time to death from ischemia.
• The severity of the ulcer is determined by the length of time pressure is applied to any
given location. The probability of developing a pressure ulcer increases with the
duration and intensity of the pressure and shearing force acting upon the tissue during
surgery. 33 See Figure 7.
11

Figure 7. The Accelerated Cycle of Pressure Ulcer Development
Pressure Ulcer Locations
Pressure ulcers are most prevalent in tissues overlying the patient’s bony prominences. 13 In
fact, over 95% of all pressure ulcers develop over bony prominences on the lower half of the
body. 4,29 Studies suggest the most frequent locations for pressure ulcers by percentage are:
Pelvic area, hips and buttocks 65%-67% 4,29
Sacrum/Coccyx 39% 12,34
Heel 36% 12,34
Lower limbs 29%-30% 4,29
The most prevalent bony prominences for pressure ulcers in frequency of occurrence are
illustrated in Figure 8.
12

Figure 8. Most Prominent Pressure Ulcer Locations by Frequency of Occurrence
Additional locations for pressure ulcer formation include the anterior chest. 35 In the prone
position, pressure ulcers frequently develop on the forehead, cheek, female breasts, male
genitalia, ankles and toes. 36
In order to protect patients, identifying the cause(s) of pressure ulcers has become a necessity.
Once identified, preventative measures can be implemented and may help reduce future
occurrences.
The Incidence and Prevalence of Intraoperative Pressure Ulcers on
Patient Outcomes
Surgical patients are more susceptible to developing pressure ulcers than general acute care
patients. This is due to many risk factors only present in the intraoperative environment. The
incidence rate (the number of new cases of disease occurring in a population during a defined
13

time interval; a measure of the risk of disease)for surgical patients ranges from 12-
66%. 7,11,12,13,14,17,20,34,37,38,39 On average, the prevalence rate (a percentage of a population that
is affected with a particular disease at a specified time) for surgical patients is between 3.5-
29%. 10,17,18 Furthermore, there are many opportunities for patients to develop pressure ulcers
depending upon the type of procedure being performed. These specialties have differing
incidence and prevalence rates. See Table 5.
Length of Surgery
Table 5. Incidence and Prevalence by Specialty
Specialty Incidence Rate Prevalence Rate
Cardiac 17-29.5% 6,7,11,12,17 7% 34
Vascular 9.8-17.3% 7,12,17,34
Spinal/Abdominal 36% 12
Orthopedic 15-20.6% 12,29 6.5% 34
Elderly Orthopedic 66% 37
General/Thoracic 27.7% 12 7% 34
Head & Neck 10% 34
Neurologic 5.2% 34
As the length and time of surgery increase, the incidence and percentage of patients with
pressure ulcers also increases. 7 See Table 6.
Table 6. Prevalence Rate Based on Length of Surgery
Length of Surgery Prevalence Rate
3-4 hrs 5.8%-6.0% 12,28,34
4-5 hrs 8.9% 34
5-6 hrs 9.9% 34
>6 hrs 9.9% 34
>7 hrs 13.2% 27,28
Risk Factors for the Development of Pressure Ulcers
Risk factors for pressure ulcers exist in all phases of hospitalization. “From the time the patient
enters the hospital through discharge, all pressure ulcer risk factors need to be examined
individually and addressed in an appropriate medical protocol.” – James G. Spahn, MD, FACS.
In fact, approximately 95% of all pressure ulcers are preventable IF early risk assessment is
performed and appropriate interventions are implemented. 40
Risk factor assessment tools are designed to assist medical personnel in predicting the
likelihood of each patient to develop a pressure ulcer. In general, the more risk factors the
patient has, the more vulnerable he/she is to pressure ulcer development. A study that focused
on surgical patients reported a drastic increase in pressure ulcers developed in those patients
who had multiple risk factors. See Table 7.
14

Table 7. Impact of Surgical Risk Factors on Development of Pressure Ulcers
Number of Percentage of Patients Who
Risk Factors Developed Pressure Ulcers
0 0% 41,42
1 11.4% 41,42
2 39.6% 41,42
3+ 67.9% 41,42
There are a substantial number of risk factors for developing pressure ulcers perioperatively.
Many studies have attempted to identify the most accurate risk indicators for pressure ulcer
development in the surgical patient. Table 8 summarizes these risk factors.
Table 8. Risk Factors for Pressure Ulcers in the Surgical Patient
Temperature Management as a Risk Factor
Most of today’s healthcare professionals would agree that inadvertent hypothermia in the
surgical patient is not optimal, 31 and that unless the specific type of procedure being performed
dictates a period of localized or systemic ischemia, patient temperature should be monitored
15

and normothermia maintained throughout the perioperative process. It has been well studied
and documented that the maintenance of normothermia 7,11 during and directly following the
surgical procedure is very important in creating a positive outcome for the patient. 44 The
benefits of normothermia include:
Decreased incidence of postoperative wound infection 45,46
Reduced rate of morbid myocardial/cardiac events 44,46
Reduced blood loss as well as intra and postoperative transfusion requirements 44,46
Decreased need for postoperative mechanical ventilation 46
Reduced length of hospital stay 44,46
Decreased severity/intensity of postoperative pain 46
Decreased thermal discomfort and incidence of postoperative shivering 47
Shortened immediate postoperative recovery time 47
Reduced thermoregulatory vasoconstriction
Prevented intraoperative complications of hypothermia 47
Improved postoperative patient outcome 47
In an effort to maintain normothermia in surgical patients, various methods have been utilized.
Commonly used methods include: warmed IV fluids, water filled mattresses, convective or
forced-air systems, water-circulating garments and pads, warming blankets, and extracorporeal
circuits. Studies and theory indicate that the method used to manage temperature and the
conditions under which it is used may have both a negative and positive impact on the
development of pressure ulcers.
Negative Impact on Pressure Ulcer Development
Temperatures, both hot and cold, may increase the risk of pressure ulcer development 14,34 by
interfering with cellular efficiency and predisposing the cells to damage. 36
Warming devices used locally at a point of high pressure elevate the tissue temperature,
stimulating an increase in metabolic rate 31 and causing the localized tissue to respond with
increased metabolic demands. 10 This response increases the need for oxygen, nutrients, and
metabolic byproduct removal 6,13,14,29,36,37,48 during a time when the patient may be experiencing
restricted blood flow to that region. 48 As a result, this increased cellular activity can result in a
compromised vasodilatory response that may hasten tissue damage 31 and make the patient
more vulnerable to the development of pressure ulcers.
These risks are heightened in circumstances where the use of temperature produced by the
warming device cannot be uniformly controlled across the surface coverage, or consistently
throughout the application period.
Positive Impact on Pressure Ulcer Development
Although temperature has been identified as a causative agent in intraoperative burns and
pressure ulcers, patient warming devices used during surgical procedures have also been
considered to have a potentially positive impact on pressure ulcers.
Hypothermia increases the risk of pressure damage and wound infection by reducing the blood
flow to the skin, which can result in hypoxia, reduced skin oxygen tension, and therefore, tissue
damage. 8,49 A return to normothermia can restore more normal perfusion to the tissue and
positively impact pressure ulcer relief.
16

As early as 1994, studies have supported the position that warming blankets do NOT play a
statistically significant role in contributing to pressure ulcer development. 49,50 Additionally by
2001, reports and studies concluded that intraoperative warming actually decreases the
incidence of pressure ulcers. 43,49 In one study, Scott reports that intraoperative control of
hypothermia with temperature regulated blankets and warmed IV fluids may reduce the
incidence of postoperative pressure ulcers. 43 The results from that study found an absolute risk
reduction of 4.8% (Range 10.4%-5.6%) 43 and a relative risk reduction of 46% of those who
received warming therapy. 43
This seems to contradict the concern that patient warming devices are a risk factor for
developing pressure ulcers. One reason for this can be attributed to advances in warming
device technology, where manufacturers have improved reliability and refined product design for
patient safety. Warming devices built after 1971 have consistently incorporated backup
thermostats to prevent heating past physiological tolerable limits. 21 In addition, many designs
have moved warming focus away from placement below the patient, and particularly away from
areas which historically were most often involved in documented injury, primarily the bony
prominences of the sacrum and heels, where body pressure is greatest. 21
Highly effective temperature management strategies should be considered directly as part of the
surgical care plan for each case. All factors combined, the benefits of maintaining
normothermia, thus avoiding its adverse consequences, should be weighed and balanced
against the patient’s potential for pressure ulcers.
The Impact of Pressure Ulcers on Surgical Patient Outcomes
Studies indicate that pressure ulcers which occur in the surgical patient may increase the length
of hospital stay, cost of care as well as additional resultant complications.
Length of Stay
The length of stay varies depending upon the type of surgical procedure being performed.
However, the length of stay increases by 3.5 to 5 days on average when a pressure ulcer is
present. 12,28 In some unusual cases, the adjusted length of stay for pressure ulcers may be as
high as 15.6 days 41,42
Cost Factors
Cost factors for pressure ulcer treatment have a tremendous impact on the patient and
healthcare facility. The average range per incident costs $5,000-$60,000, 4,6,7,12,17,20,29,40,41,42
depending upon the severity of the pressure ulcer and the type of treatment required. Actual
cost can reach as high as $90,000 for one incident. 17
Nursing care costs and time can increase by 50% for each pressure ulcer acquired during a
surgical procedure. 17,29 Furthermore, cardiac and vascular surgery patients account for
approximately 45% of the total hospital pressure ulcer treatment costs. 17
A prevalence study conducted at a large U.S. hospital provides actual numbers and not merely
statistical estimates. The average length of stay for those patients acquiring pressure ulcers
17

increased by 6.5 days and cost an additional $12,000 for treatment 17 Unfortunately, the
average reimbursement rate per patient from insurance and Medicare/Medicaid was less than
$1,600. Therefore the hospital was losing more than $10,000 per pressure ulcer incident. 17
In the United States, perioperatively acquired pressure ulcers cost $750 million-$1.5 billion per
year on average. 17,51
Additional Complications
Patients who have pressure ulcers may be predisposed to other complications. Those
complications may include, but are not limited to: bacteremia, 4 squamous cell carcinoma, 4 sinus
tract formation, 4 osteomyelitis, 4,11,20 pyarthroses, 20 amyloidosis, 20 and sepsis. 11,20
Patients with pressure ulcers are impacted emotionally and financially, as well as physically. 17,20
They are subject to pain, discomfort, disfigurement, additional treatment, multiple surgeries,
increased morbidity, increased hospital stay, loss of income, loss of productivity, loss of
independence and possibly even loss of life. 7,20,28
Best Practices for Preventing Pressure Ulcers
In order to prevent pressure ulcers in the surgical patient, healthcare professionals should
develop and employ education and communication initiatives in addition to thorough patient
assessments.
Education and Communication Initiatives
“Heightened awareness and education may be an effective intervention, which alone can
positively influence prevention.” 28
Develop a facility plan for monitoring the incidence of pressure ulcers acquired
perioperatively. 17
- Include preoperative assessment, 17 preventative care, 17 postoperative assessment, 17
and patient follow-up. 17
- Provide an opportunity for annual assessment of the effectiveness of existing
guidelines. 40
Provide frequent education and training to healthcare professionals in the following
areas: 31
Etiology of pressure ulcers 40
Identification of risk factors for pressure ulcer development 31
Appropriate use of risk assessment tools 40
Preventative techniques based on research 40
Periodic schedule for re-education regarding proper body alignment on the
operating room bed, reducing pressure over bony prominences regardless of
the length of scheduled surgical procedure, removing pools of moisture, and
decreasing shear and friction particularly over bony prominences 31
Treatment of pressure ulcers 52
18

Develop a “Surgical Care Plan” or an individual (patient-centered) care plan for
continuity of care and improved communication between the operating room and other
patient care units. 17,40,48,52
- Educate patients and caregivers on the prevention and treatment of pressure
ulcers. 52
- Document and monitor the care plan on a scheduled basis. 48
- Change if adverse conditions or additional risk factors develop. 48
- Communicate the plan to all facility personnel as well as to the patient or a legal
advocate. 48
- Include information such as:
Immobilized for >3 hrs during perioperative (pre and postoperative) time
frame has an ASA score of one, or immobilized for >2 hrs with an ASA score
of 2, 3, 4, or 5 48
Early postoperative self or assisted ambulation, 30 mobilization, aggressive pre
and postoperative dietary considerations, urinary and fecal incontinence
control preventative moisture pooling against the skin, synchronized core of
the shell and core temps, general medical condition and medications should
be reevaluated 48
Pressure ulcer and postoperative skin and self tissue assessments up to 3-7
days after the surgical procedure along with appropriate measures defined to
address the individual risk factors 48
The use of a flotation device that delivers equalized pressure to maintain
proper volumetric support of the soft tissue trapped between the skeletal
press and the support surface, and a device that maintains the calf
configuration to unload the heels 48
“In order to set a benchmark for incidence, a specific patient care plan should be developed and
implemented in every operating room so that patients are at minimal risk for suffering an ulcer.
Once this is implemented, you can establish a prevalence rate, justify your preventative care
measures and determine actual costs for pressure ulcers that are started in the operating room.
The enterostomal therapist or wound care specialist can help determine the facility’s incidence
rate. Prevalence studies should be performed on an ongoing basis to see if the established
preventative measures are effective.” 17
Patient Assessment Strategies
Strategies to prevent pressure ulcers in surgical patients should begin upon admission 20 and be
carried on throughout the hospital stay. 20 Patients should be reassessed at regular intervals,
particularly after a surgical procedure. 20,40 Patient assessment strategies can be divided into 3
phases: preoperative, intraoperative and postoperative. The following is a listing of strategies
grouped by phase.
Preoperative Strategies
Collect information on devices to be used during surgery (for follow-up investigation if
required). 1,2
- Document information on:
Type and location of positioning and/or padding devices 53
Manufacturer 1,2
Lot numbers 1,2
Settings used during the procedures, if applicable
19

Expiration (or “use before”) dates of prep solutions, electrodes, and electrode
gels 1,2
Models 1,2
Hospital control numbers 1,2
Serial numbers of equipment 1,2
Identify patients at risk 7,31,36 by completing an initial risk assessment. 7,19
- Determine general health and risk factors that may identify persons at higher risk of
injury and/or delayed healing. 7,29,40,52
Use one of the various skin integrity assessment tools available such as the
Braden, Norton, or Waterlow Assessment Scales. 29,36,40 (See Appendix B.)
Examine the patient’s skin thoroughly. 1,2
Record a description of the general skin condition and any unusual conditions
(i.e., rashes, reddened or discolored areas, contusions, cuts, abrasions, or
other abnormalities) in the surgical notes. 1,2
- Provide an objective, accurate record of the preoperative risk assessment score and
interventions implemented to reduce the risk. 40
By identifying all contributing factors, measures can be taken to reduce or prevent pressure
ulcers. 29
Maximize nutritional status. 52
- Institute a nutritional support program that corrects malnutrition, 4 preoperatively if at
all possible. 14
- Provide nutrition support thereafter as appropriate. 13
Develop a normothermia strategy to be employed in order to monitor and maintain body
temperature as close to normothermia as possible. 53
- Consider the most appropriate means to achieve normothermia while avoiding the
risks which can be increased by improper device usage.
- Consider when to use/resume/and discontinue temperature device, maximum
temperature, position of heat, and incorporation of active cooling to develop a
warming plan and meet the needs throughout the specific procedure.
- Use core temperature monitoring as it is the preferred measurement technique for
anesthetized intraoperative patients. 53
Minimize skin exposure to moisture so that all dependent skin surfaces will remain dry
during the surgical procedure. 14
- Utilize controlled moisture sources, underpad use, and topical agents that are
moisture barriers. 13
- Eliminate the potential for pooling of preps and solutions against skin, particularly in
areas of constant pressure or heat.
Assess and modify increased pressure situations(e.g., when seated or lying down). 52
- Move and transfer patients safely and effectively. 40
- Arrange for the provision and appropriate use of pressure relieving devices on trollies
and operating room beds. 40
- Use approved pressure relief and positioning devices to combat pressure.
20

Reduce or eliminate friction and shear. 13,14,52
- Allow conscious patients to transfer/position themselves on the operating room
bed. 14
- Use transfer systems, lifting devices 13,40 or turn sheets to assist in lifting and reduce
shear 14 in unconscious patients.
- Minimize pinching, shear, and tightly wrapped restraints against skin.
Avoid massaging over bony prominences 13 or areas that have been damaged by
pressure. 17
Intraoperative Strategies
Protect and position patient properly
- Maintain proper body alignment throughout the procedure. 7,14
- Use proper transfer and turning techniques such as the “log roll” on operating room
table to de-stress skin. 17
- Provide for proper handling, moving and transferring of a patient. 7
- Use positioning aids appropriately. 7
Employ AORN approved devices as needed, knowing that the lowest
pressure is typically achieved when no positioning device is present.
Do not use make-shift positioning devices (e.g., rolled towels).
- Prevent the surgical team from leaning heavily on the patient. 7,22
Protect pressure-sensitive areas when placing a patient in a prone, supine, or lateral
position. 7,40
- Use transparent dressings over high risk areas (bony prominences such as elbows,
sacrum, heels) 14 to reduce shearing and friction. 7
- Properly use protective supplies (e.g., lubricants, protective films, dressings,
padding) 13
- Alleviate pressure on the nerves in order to avoid nerve injury. 7
Ensure adequate peripheral perfusion in pressure areas. 30
- Use pressure relieving supports. 30
- Modulate the distribution of perfusion 54 by allowing the blood flow to be distributed as
evenly as possible.
Minimize skin exposure to moisture intraoperatively. 7
- Use absorbent underpads containing super-absorbant polymers to absorb moisture
from the wet skin surface, if wetness is anticipated. 4
- Avoid the pooling of solutions from prep pads, 7 particularly in areas of constant
pressure or heat.
Smooth out all sheets, pads, and other materials beneath the patient while on the
operating room table.
- Straighten the sheets beneath the patient. 17
- Remove all folds and wrinkles from adhesive materials. 17
- Ensure the surface is dry and wrinkle free. 7,30
- Use a high specification foam theatre mattress or other pressure redistributing
surface as a minimum provision for surgical patients.
21

Consider the following if patient temperature regulators are used (i.e.
hypo/hyperthermia unit operation). 21
- Ensure the backup thermostat is set at a maximum of 42°C. 21
- Avoid exposing tissue to direct heat above 44°C.
- Ensure proper placement of temperature probe and confirm after repositioning the
patient. 21
- Monitor both warming system temperature and patient temperature. 21
- Place a sheet between the patient and water circulating mattresses. 21
- Maintain pressure below that which is required for capillary closure (typically
32mmHg). 10
- Ensure the backup thermostat is set at a maximum of 42°C. 21
- Use anterior surfaces if possible. Keep heat away from primary pressure points such
as the coccyx, sacrum, and heels.
- As procedural time increases, consider strategies to vary or modify the localized
exposure to warmth such as reducing maximum temperature, location of warmth
against the skin, and/or cyclical warming periods. Balance the warming benefits with
the pressure ulcer risk.
Postoperative Strategies
Consider removing adhesive and gel interfaces from the skin immediately following the
surgical procedure.
Record any observed changes or abnormalities. 1
- Assess skin immediately post-op for non-blanchable redness, irritation or tearing.
- Examine the patient’s skin for changes and abnormalities 1 on a defined
postoperative frequency, paying close attention to the areas of bony prominences
where subdermal injuries may arise. 13
- Note ANY observations in the postoperative assessments. 17
Mobilize early after the surgical procedure. 6
Position patients to prevent them from lying directly on their trochanters. 13
Reposition patients who are confined to bed at least once every two hours. 4,13
Provide complete and total relief of pressure for the injured area postoperatively. 17
Consider placing the patient on a pressure relieving device if any of these criteria are
met: 39
- >40 years of age 39
- On operating room table longer than 2.5 hrs 39
- Have vascular disease (e.g., diabetes) 39
Select pressure relief systems that reduce pressure at the interface between the
underlying supporting surface (e.g., dynamic alternating pressure support systems). 4
- Place those patients who are vulnerable to pressure ulcers on a high specification
foam mattress as a minimum.
Use positioning devices to prevent contact with bony prominences. 13
22

Cleanse skin at the time of soiling and at routine intervals.
- Use mild cleansing agents. 13
- Avoid the use of hot water. 13
Maintain the head of the bed at the lowest degree of elevation (30° laterally inclined) 29
consistent with the patient’s medical conditions. 13
Minimize the environmental risk factors such as low humidity (i.e., less than 40%).
Conclusion
Skin injuries in the surgical patient occur all too frequently. All medical personnel have a
responsibility to maintain a safe environment for the patient; therefore, understanding the
pathophysiology of skin injuries and prevention strategies is vital for each member of the team.
As pressure ulcers are one of the more common skin injuries, medical personnel should
understand the impact pressure ulcers have on the surgical patient and follow appropriate best
practices to prevent these injuries. Through careful planning and diligent use of patient
assessment strategies, pressure ulcers in the surgical patient can be eliminated.
23

Appendix A: Glossary
Comorbidity: the presence or effect of all other diseases and/or disorders an individual
patient might have in addition to a primary disease or disorder; existing simultaneously
with and usually independently of another medical condition.
Friction: is the force that resists relative motion of two surfaces in contact.
Incidence: the number of new cases of disease occurring in a population during a
defined time interval.
Negativity: the number of layers of pads and blankets beneath the body.
Prevalence: involves all affected individuals, regardless of the date of contraction;
percentage of a population that is affected with a particular disease at a specific point in
time.
Shear: is a force parallel to a bony surface in which the skin and underlying tissue are
moving in opposite directions causing deep tissue damage; the tearing and splitting of
the layers.
25

Appendix B: Skin Risk Assessment Tools - Predictors of Risk Before
Surgery
Risk assessment scales are often used to predict the occurrence of pressure ulcers. 55
As of 2001, there were at least 40 risk assessment scales in existence and most of
these scales are reflective of various literature reviews, expert opinions, and
modifications of existing scales. 55 Several studies have been conducted to find the
most accurate and reliable scale, to no avail. There are no proven assessment tools
that consistently predict which patients are more at risk for injury. The Risk Assessment
Tool Comparison Chart below illustrates several of the most popular scales and their
assessment criteria.
Items
Risk Assessment Tool Comparison Chart
Braden
Braden Q
Modified Braden Q
Computerized Pressure
Monitoring
Activity √ √ √ √ √ √ √ √
Age √ √
Anti-inflammatories or steroid use √
Build/weight relative to height √ √
Capillary Blood Flow √
Friction and shear √ √ √
General physical condition √ √ √
Hemodynamic state √
Hydration/Fluid Intake √
Hygiene √
Interface Pressure √
Mental state √ √ √ √ √
Mobility √ √ √ √ √ √ √ √ √ √
Moisture (including incontinence) √ √ √ √ √ √ √ √ √ √
Nutrition/blood pigment values √ √ √ √ √ √ √ √
Orthopedic surgery or fracture
√
below waist
Pain √
Predisposing disease √ √
Respiration √
Sensory perception √ √ √ √ √
Sex √
Skin condition (whole body) √ √
Smoking √
Tissue Perfusion and Oxygenation √ √ √
Visual skin type √ √
26
Cubbin & Jackson
Douglas
Gosnell
Laser Doppler Velocimetry
Knoll
Modified Knoll
Norton
Starskid Skin Scale
Waterlow

Developing a skin risk assessment tool is complex. There are an extremely large
number of variables to consider. The tougher challenge still is to decide which of these
variables will truly indicate the risk of a patient developing a pressure ulcer. While none
of these tools have precisely hit the mark, there are three primary scales that are
currently being used - the Norton, Braden, and Waterlow scales. A brief description of
each of these will follow.
Norton
The Norton scale, the first tool developed for predicting the patient at risk, was initiated
in 1962. 56
physical condition of the patient
mental status
activity
mobility
continence
Each of these assessment areas is scored from 1 to 4 with the lower score being the
higher risk, thus a score of 1 is considered very bad, while a score of 4 is good. A
patient is considered at risk for pressure ulcer if the score ≤16. The maximum score for
this tool is 20. 56
27

Braden
The Braden Scale, currently the most frequently used tool, was developed in the mid-
1980s and consists of six items: 56
Sensory perception
Moisture
Mobility
Nutrition
Activity
Friction and Shear
Each item is graded with a score of 1, 2, 3, or 4. The maximum score possible is 23
(best prognosis) and the minimum score is 6 (worst prognosis). 56 A patient is
considered at risk for pressure ulcer if the score ≤16. Although the Braden scale now
has added scoring for low, medium and high risk, the numeric scale is still utilized more
frequently. 56 It is important to note that the breakpoint for determining pressure ulcer
risk using the Braden Scale may vary with patient population. Below is an example of
the Braden Scale.
28

Waterlow
The Waterlow scale, developed from the Norton scale during the 1990s, considers eight
parameters: 56
age and sex
body build (build/weight for height)
appetite
continence of urine and feces
mobility
skin appearance in risk areas
medication
special risks (e.g., disorders associated with tissue malnutrition, neurological
deficits, recent surgery or trauma)
Unlike the Norton and Braden scales, the highest and lowest scores of each item may
vary and each area has a value ranging from 0-3 to 0-5. 56 The Waterlow scale identifies
the patient with the higher score as being at risk for pressure ulcer development
whereas the Norton and Braden scales identify patients with lower scores as being at
risk. When utilizing the Waterlow scale, a score above 19 would place a patient in the
high risk category. 56
29

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33

Pressure Ulcers in the Surgical Patient
Post Test
1. T/F Burns and pressure ulcers both have classification systems.
_____
2. T/F A temperature of 42°C can cause cutaneous burning if exposed to skin for 4
hours.
_____
3. Which of the following is NOT a differentiation factor for pressure ulcers and burns.
A. Pain D. Time of Observation
B. Risks E. All of the above
C. Physical appearance F. None of the above
4. Pressure ulcer development and severity may be affected by which of the following:
A. Ischemia D. Time
B. Vascular Occlusion E. All of the above
C. Pressure intensity F. None of the
5. Approximately _____% of all pressure ulcers are preventable if early risk
assessment is performed and appropriate interventions are implemented.
6. T/F The three perioperative phases in which patients are at risk for development of
pressure ulcers include: preoperatively, intraoperatively, postoperatively.
_____
7. Circle the correct answer. Which of the following is a risk factor in the development
of pressure ulcers?
A. Low systemic blood pressure D. Hypotensive episodes
B. Limited mobility E. All of the above
C. Nutritional status F. None of the above
Match the following best practices with the correct perioperative phase in which they
would be implemented in order to prevent intraoperative pressure ulcers.
8. _____ Use positioning aids appropriately. A. Preoperatively
9. _____ Maximize nutritional status. B. Intraoperatively
10._____ Reposition patients confined to bed C. Postoperatively
at least once every 2 hours.
35

Pressure Ulcers in the Surgical Patient
An Independent Study Guide
Please print clearly and fill in all data to ensure accurate record-keeping.
Name: License State and #:*
Title: SSN:* (if license # not available)
Facility Name:
Home address:
City: State: Zip:
Home Phone: Work Phone:
(*) Either your Social Security Number or License number is required to obtain CE Credit.
Please check appropriate box: RN/LPN Surg Tech Resp Therapist CS Sup/Mgr Other
Evaluation
Date: ___________________________ Facilitator: ________________________________
The evaluation process is important to determine the extent to which this program has met your learning
needs and to measure its overall effectiveness. Circle the number that best reflects the extent of your
agreement with each statement.
Rating Scale: 1=Poor to 5=Excellent
Objectives:
Indicate to what degree the objectives for this program were met.
Poor Excellent
1. Describe the pressure ulcer classifications. 1 2 3 4 5
2. Differentiate between pressure ulcers and burns.
3. Recognize the mechanisms contributing to the formation of perioperative
1 2 3 4 5
pressure ulcers.
4. Discuss risk factors associated with the development of pressure ulcers. 1 2 3 4 5
5. Describe best practices that may prevent intraoperative pressure ulcers. 1 2 3 4 5
Overall Evaluation
Poor Excellent
6. Content 1 2 3 4 5
7. Expertise of authors 1 2 3 4 5
8. Handout materials 1 2 3 4 5
9. Overall quality of the program 1 2 3 4 5
Program Integrity: Indicate your agreement with the following statement
10. The content in this course was presented without bias of any commercial
product or drug.
36
1
2
3
4
5
DisagreeAgree
11. How long did it take you to complete this program? ________________________
12. What other topics would be of benefit to you? ________________________________________
13. Additional comments.
Iowa Nurses Only: Please complete and leave evaluation form with conference coordinator at the conclusion of the conference in
exchange for a Certificate of Completion, or you may submit the evaluation form to the Iowa Board of Nursing.
Florida registered nurses must provide your Florida RN license number.
1
2
3
4
5

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