Pressure Ulcers in the Operating Room

Pressure Ulcers
in the Operating Room
Robert B. Dybec RN, MS, CPSN, CNOR
SOBECC
9th Annual Congress
Sao Paulo, BR
July 19, 2009
Overview
• Pressure Ulcers: prevalence,
description, staging, treatment options
• Pressure Ulcers in the O.R.
• Padding and Positioning
• Special Considerations and Challenges
Pressure Ulcers
Localized injury to the
skin and/or underlying
tissue usually over a
bony prominence as a
result of pressure,
shear, friction or some
combination of these.
Pressure Ulcer
Prevalence
In the United States, the prevalence of
pressure ulcers ranges from
3.5 - 29% among hospitalized patients,
2.4 - 26% among those in long-term care,
10 - 12.9% for clients in home health care.
Millions!!
Pressure Ulcers
Estimated health care costs associated with
pressure ulcers:
$5,000,000,000.00
Five Billion dollars per year for 1.5 million
patients in the United States. (2006)
Patho-physiology of
Pressure Ulcers
Pressure Ulcer
Staging
• Suspected Deep Tissue Injury
• Stage I
• Stage II
• Stage III
• Stage IV
• Unstageable
Suspected Deep Tissue
Injury
• Purple or maroon localized area of
discolored intact skin OR blood-filled
blister due to damage of underlying soft
tissue from pressure and/or shear.
• The area may be preceded by tissue
that is painful, firm, mushy, boggy,
warmer or cooler as compared to
adjacent tissue.
Further Description of
Deep Tissue Injury
• May be difficult to detect in people with
•
•
•
dark skin.
May include a thin blister over a dark
wound bed.
May further evolve and become covered
by thin eschar.
May evolve rapidly exposing additional
layers of tissue even with optimal
treatment.
Suspected Deep Tissue Injury
Stage I
•
•
Intact skin with nonblanchable redness of
a localized area
usually over a bony
prominence. Darkly
pigmented skin color
may differ from the
surrounding area.
The area may be
painful, firm, soft,
warmer or cooler as
compared to adjacent
tissue.
Blanchable Erythema
• NOT a STAGE I pressure ulcer
Stage I Pressure Ulcer
Stage II
•
•
Partial thickness
loss of dermis
presenting as a
shallow open
ulcer with a red
pink wound bed.
May also present
as an intact or
open/ruptured
SERUM filled
blister.
Stage II
• Presents as a shiny or dry shallow ulcer
•
WITHOUT slough or bruising.
This stage should NOT be used to
describe skin tears, tape burns, perineal
dermatitis, maceration or excoriation.
Stage II Pressure Ulcer
Stage II Pressure Ulcer
NOT a Stage II
Pressure Ulcer
Not a Stage II
Stage II Pressure Ulcer
Not a Stage II – skin tear
The Interaction of Friction and Moisture
Moisture Lesions not Pressure Ulcers
Stage III
•
Full thickness
tissue loss.
Subcutaneous fat
may be visible.
Slough may be
present but does
not obscure the
depth of the
tissue loss. May
include
undermining and
tunneling.
Stage III Further
Description
• Bone / tendon not visible
• Depth varies by anatomical location:
bridge of nose, ear, occiput, malleolus
do not have subcutaneous tissue.
areas of significant adiposity can
develop deep Stage III pressure
ulcers.
Stage III Pressure Ulcer
Stage III
Stage III Pressure Ulcer
Stage IV
• Full thickness
•
tissue loss with
exposed bone,
tendon, or
muscle.
Osteomyelitis
may be
possible
Stage IV Pressure Ulcer
Stage IV Pressure Ulcer
Stage IV Pressure Ulcer
Unstageable
• Full thickness tissue loss in which the
base of the ulcer is covered by slough
(yellow, tan, gray, green, or brown)
and/or eschar (tan, brown, or black).
Unstageable (continued)
• Until enough slough and/or eschar is
•
removed to expose the base of the
wound, ……the stage cannot be
determined.
Stable eschar (dry, adherent, intact
without erythema or fluctuance) on the
heels serves as “the body’s natural
(biological) cover” and should NOT be
removed.”
Unstageable
Unstageable
Unstageable
Location
Most Common Location
for Skin Damage
Second Most Common Location
25% of all Pressure Ulcers
Pressure Ulcer Prevention
Turn and Position every 2 hours
Turning Initiatives - reminders
- red light green light
- 2 hour alarms
- back to basics
Pressure Ulcer Treatment
• PREVENTION
• Pressure redistribution
• Nutrition
• Incontinence management
• Cleansing
• Dressings
• Debridement (enzymatic, sharp)
• Dermis / Porcine / Bovine Products
• VAC – (vacuum assisted closure)
• Surgery (grafts and flaps)
Pressure Ulcer Treatment
Dressings
Tegagel wound filler Tegasorb (hydrocolloid)
Tegaderm
Tegagen
Op-site (occlusive)
Adaptic
Xeroform
Acticoat
Silverlon
Aquacel Ag
Mepilex Ag
Hydrofera Blue
Biobrane Allevyn Mepilex Mepitel
Alginate Fiber pad / rope Polyurethane pads
Websites - 3m / Molnlycke / Smith & Nephew / Hollister
Hospital Acquired Pressure
Ulcer Initiatives – U.S.A.
• Institute for Healthcare Improvement
•
•
•
5 Million Lives Campaign
Joint Commission – NPSG
State DOH reporting requirements
Federal – CMS reimbursements
Private – Govt. ?
Hospitals and POA
• Oct 1, 08
– Pressure ulcers present on admission (POA) must be
identified by the provider
• Provider=physician or qualified health care practitioner
legally accountable for establishing patient’s diagnosis
▪ Stage and location must be noted
• If not identified as “POA”, it’s a “Hospital Acquired
Condition”
– i.e. pressure ulcer is considered to have developed after
admission
– Hospital will not be paid for pressure ulcers that develop
during hospitalization
Pressure Ulcer in the O.R.
We are treating Pressure Ulcers in the
Operating Room but……..
Pressure Ulcer in the O.R.
…..we are causing them also!
O. R. Acquired Pressure Ulcers
Communication
Operating Room
Wound Care Dept.
Pressure Injuries
Postoperative
Pressure Ulcer History
The Age of Ambulatory Surgery
• Statistics???
• 25% Postoperative Pressure Ulcers
•
O.R. induced
Presenting 3 – 7 days post-op
Pressure Injuries
Postoperative
Pressure Ulcer History
The Old Days
• Long term bed rest after surgery
• Turning patients
• Poor bedding materials
Pressure Injuries
Patient develops a pressure ulcer
conservative treatment fails or
condition worsens
pressure ulcer requiring surgery
comes to the O.R.
Pressure Injuries
Patient comes to the
Patient develops a
O.R. for surgery
pressure ulcer postop
Pressure ulcer
requires surgery
Conservative treatment
fails or condition worsens
Perioperative Nursing
AORN
Standards and Recommended Practices
• Positioning of Patients in the
Perioperative Setting
Pressure Ulcers
• Caused by pressure and shear
force
• AORN Recommends Padding /
Positioning devices maintain
Normal Capillary Interface Pressure
of 32mm Hg or less
Positioning Products
• Eggcrate Foam, Blankets, Sheets, etc.
• Providers view them as inexpensive
• Many Institutions re-use – risk of:
– Infection
– Patient Injury
– Lawsuit
Viscoelastic Polymer
(called “gel”)
•
•
•
•
•
•
•
•
In use for 30+ years
Reusable ( cost savings )
Proven pressure reduction / relief
Radiolucent
Fire Retardant
Tissue equivalent
No bottoming out
Latex Free
Pressure Reduction
Pressure Reduction
O.R. Bedding Materials
Pressure Reduction
Pressure Reduction
Hospital Initiatives
Gastrointestinal Lab
Electro-physiolgy Lab
Radiology CT Scan / MRI
Cardiac Catheterization Lab
Special Procedures
Orthopedic Floor
Assessment
• Pre-Operative
Considerations
Pre-Operative
• Medical History (Pre-existing disease)
• Physical Health / Mental Health
• Actual Weight / Height
• Skin Condition / Nutritional Status
• Pre-planning with Anes. & Surgeon
• Type and length of procedure
• Position
Pre-operative Assessment
• Skin Condition / Nutritional Status
Provide baseline assessment of skin
condition pre-operatively. Pre-existing
areas of concern, patient on vasopressors.
• Type, Length and Position needed for
the Surgical Procedure
Important information that will impact on
the intraoperative interventions.
Assessment
• Intra-Operative
• Post-Operative
Intraoperative
• Trauma to the Skin
worse if wet
Beware of fluids
pooling under patient
-Saline, Povidine, Sweat
Electrode jelly, Blood
Post-operative Assessment
• Skin Condition
Physical examination of the patient at the
end of the procedure. Check side of
patient that was in contact with the O.R.
table. Particular attention is given to
checking obvious pressure points.
Areas of concern are documented, the
surgeon and Recovery Room are notified.
Suspected Deep Tissue Injury and Stage I
Skin Injuries
• True Pressure Injury
• Reactive Hyperemia
• Allergic Response
Skin Injuries
• Reactive Hyperemia:
•
•
Skin WILL blanch under finger pressure
True Pressure Injury:
WILL NOT blanch with pressure
Allergic Response/Reaction:
ESU ground pad, EKG Electrodes,
Tapes and Adhesives, etc.
Position is Everything!
A Team Effort
For the benefit of the Patient
•
•
•
Nursing
Anesthesia
Surgeons
Peripheral Nerve Injuries
The Most Devastating
Complication to an Elective
Procedure
Mechanism of Position
Related Peripheral
Nerve Injury
• Compression
• Stretching
• Combination of Both
Resulting in Ischemia to the Nerve
Peripheral Nerve Injuries
Factors Increasing the
Likelihood of Injury
AORN article
Retrospective study
• Patient Age
• Time on O.R. table
Positioning Assist Devices
O.R. Table Attachments
• Armboards
• Stirrups
•
•
•
- Candy cane (Lollipop)
- Heel/Calf (Allen type)
- Knee Support
Straps – Safety Belts
Kidney Rests
Lateral Positioning Devices
Positioning Assist Devices
Non-Attached Accessories
• Padding Material:
•
•
•
•
-Gel Pads
-Foam Pads/Eggcrate
Sand Bags
Bean Bags
Blankets – Pillows – Sheets
Doughnuts
Challenges
• Obesity
• Geriatrics
• Pediatrics
The Obese Surgical
Patient
The Bariatric Surgical
Patient
Co-Morbid Medical
Conditions
• Diabetes
• Hypertension
• Hyperlipidemia
• Cardiac Disease
• Sleep Apnea
• Neuropathy
• Osteoarthritis
• Heartburn (GERD)
• Depression
• Stress Incontinence
• Menstrual Irregularity
• Renal Failure
Preoperative Planning
• Equipment Selection
Specialty Equipment
Pressure Reduction
• Foam products
- Ineffective
• Sand Bags/Rolls
- Increase risk of
injury
• Use appropriate size
positioners that
provide pressure
reduction/relief
Avoiding Injury
To self and staff
•
•
•
•
•
Adequate number of personnel
Good body mechanics
Common sense
Communication
Transfer equipment
Avoiding Injury
To patient
l
l
l
l
Appropriate equipment
O.R. table and accessories
Positioning and padding devices
Proper instrumentation
Special Considerations
The Geriatric Patient
Geriatric Patients
New Considerations
•
•
•
•
•
•
•
Osteoporosis
Heart Disease
Pulmonary Diseases
Rheumatoid Arthritis
Osteoarthritis
Total Joint Implants
Fragile Skin
Special Considerations
The Pediatric Patient
The Pediatric Surgical Patient
•
•
•
•
•
•
•
Premature infant
Neonate
Infant
Toddler
Pre-school child
School-age child
Adolescent
- GA 38 weeks or less
- Newborn to 6 weeks
- 6 weeks to 11 months
- 12 months to 3 years
- 4 to 5 years
- 6 to 12 years
- 13 to 18 years
Pediatric Patients
• Cannot use traditional support
•
devices.
-Safety straps, Armboards, etc.
Padding required
• Child should be
attended to
at all times!!
Pediatric Positioning
•
•
•
•
Physiologic differences
Size differences
Equipment requirements (latex free)
Pre plan with Surgeon and Anesthesia
Contractures
Creative Positioning
Nurses Liability
Most Important
Documentation!
WHO – positioned
WHAT – devices were used
WHICH – position the patient was in
WHERE – special attention was given
WHEN – patient was checked intraoperatively
Positioning OK’d by Surgeon & Anesthesia
Remember
• Communication O.R. / Wound Care
• Evaluate all Surgical Patients Pre and Post-op
• Documentation
• Use products for padding and positioning that
are proven to reduce, relieve and redistribute
pressure.
Summary
• Pressure Ulcers: prevalence,
description, staging, treatment
• ORAPUs
• Padding and Positioning
• Special Considerations and
Challenges
Obrigado