Nurses key to help prevent


pressure ulcers P


By Debra Anscombe Wood, RN


reventing hospital-acquired pressure ulcers has taken on new importance as a nurse-sen- sitive quality measure, with everyone on the team responsible for decreasing the risk, including perioperative nurses.


“It’s important for perioperative nurses to remember that because our patients are in the


operating room and immobile and sometimes put in extreme positions, they are all at risk,” said Lisa Spruce, DNP, RN, CNS-CP, CNOR, ACNS, ACNP, FAAN, director of evidence-based perioperative practice for the Association of periOperative Registered Nurses in Denver. In preop, “We probably ought to say, ‘Why don’t you lay on your side?’ or turn them,”


Spruce said. Lisa Spruce, RN


Taking precautions Preventive measures for most patients include a high-specification OR mattress with more than three inches of foam, but some patients may need a gel pad atop that. Additionally, nurses should pad patient’s pressure points or relieve the pressure, such as f loating heels off the mattress. Some people will require a foam dressing for the sacrum, elbow and other vulner- able areas. “We want perioperative nurses to do a


thorough skin assessment before going into the OR,” Spruce said. Tat information should be passed along to the nurse receiving the patient postop. And nurses on the units should report the incidence of pressure ulcers to perioperative nurses. Pressure ulcers usually develop 48 to 72


hours after the procedure, so perioperative nurses are often unaware a patient devel- oped a decubiti during surgery, Spruce said. Not knowing when one occurs makes it more difficult to change processes. “Most patients coming in for surgery are


expecting to get better,” she said. “Then we give them a pressure injury … that’s painful and sometimes hard to heal. It affects their day-to-day life.”


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Changing processes Recognizing these dangers of pressure ulcers, Virginia Commonwealth University Medical Center in Richmond made prevention a hos- pitalwide priority. “Te organization at the time was having


an epiphany about the need to change the process,” said Linda Currie, MSN, RN, ACNS- BC, CCRN-CSC, clinical nurse specialist in the Cardiac Surgery ICU at VCU. Working with perioperative nurses, the


nurse-led CSICU team developed protocols to prevent decubiti in cardiac surgery patients in the ICU. In the OR, the wound care team led the charge to ensure all patients are positioned on gel pads or other specialty mattresses to offload pressure on body parts that cannot be moved or floated during surgery, Currie said. In the ICU, patients may be placed on a flu-


idized positioning pillow to prevent occiput pressure. All patients are placed on specialized mattresses that offload pressure, and nurses turn all patients including those who have un- dergone open heart surgery where their chests remain open and are covered with a large Ioban dressing, Currie said. VCU as a whole conducts monthly


surveys to monitor for the incidence of pressure ulcers. Bedside nurses and wound


Linda Currie, RN


care champions screen daily for pressure points and ways to off load the pressure. “We continue to have good results,” Currie


said. “We went for 11 months with zero pres- sure ulcers on the day of survey.” Since then, a couple of pressure ulcers


have occurred, and nurses have looked for the root cause, attempting to differentiate whether unit practice or time in the OR may have contributed, she said. “We are always looking for new places we


need to relieve pressure,” Currie said. Nurses have been aware of the dangers of


pressure ulcers for decades, but changes in Centers for Medicare & Medicaid Services reimbursement brought it to the forefront in 2008. Ten in 2014, the National Pressure Ulcer Advisory Panel offered guidance in prevention of decubiti in perioperative pa- tients. AORN convened a panel of experts and developed a prevention toolkit available at its website, www.aorn.org/guidelines. “[Pressure ulcers] are an important concern


we all need to have,” Spruce said. • Debra Anscombe Wood, RN, is a freelance writer.


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