Pressure Ulcers After Surgery

Preventing, Diagnosing, Staging and Treating Pressure Ulcers

bed sore, pressure sore, pressure ulcer stage 4,
Stage 4 Pressure Ulcer. National Pressure Ulcer Advisory Panel

What is a Pressure Ulcer

A pressure ulcer, also known as a pressure sore or bedsore, is a injury to the skin and potentially the tissues beneath the skin.  This type of injury is caused by pressure on the area, which can be caused by the weight of the body, medical devices or a lack of movement.  Bony areas without fat or muscle under the skin are more likely to develop ulcers than areas with fat and muscle.

  For example, the bridge of the nose is skin over cartilage, and is a high risk area for ulcer formation. 

Surgery patients in particular are at risk for pressure ulcers because they are kept in one position for an extended period of time and are unable to move during the procedure.  An individual who is awake might feel pain or discomfort when laying in one position for too long, and responds to that sensation by moving or adjusting their body position.  An individual who is sedated, being given anesthesia or is too ill to move, cannot do the same. 

Preventing Pressure Ulcers During Surgery

One of the best ways to prevent pressure ulcers from forming is frequent movement, particularly standing and walking, but that is not possible during surgery.  Instead, because the patient remains motionless during general anesthesia, the prevention of ulcers falls to the staff of the operating room and equipment.

 

Many operating rooms now use padded operating tables, which utilize many different materials to provide a soft cushion for the patient to lie upon for an extended period of time.  The operating room staff also pays attention to bony areas, such as the bridge of the nose, which can experience pressure from the breathing mask used during anesthesia.

  For some, the bridge of the nose is padded with a small dressing, for others, a fluffy pad may be placed under an elbow or a hip.  

Preventing Pressure Ulcers After Surgery

After surgery, the prevention of pressure ulcers is the responsibility of both nurses and the patient.  The patient is responsible for taking medications correctly, getting up and walking as soon as possible.  Nurses are responsible for the early identification of patients who are at risk for skin injuries, and putting preventative measures in place, as well as identifying pressure ulcers that do develop as soon as possible.  Nurses are also responsible for the frequent turning of patients who are unable to get out of bed or turn themselves.  Nurses may also pad the feet,  ankles and other bony areas if the patient appears to be at risk for skin damage.  They are also trained to prevent shearing injuries, which is another type of skin injury caused by being moved, by using sheets underneath the patient to reduce friction on the skin.

 

For some patients, special beds may be utilized which can reduce the formation of pressure ulcers.

Risk Factors For Pressure Ulcers

There are many risk factors for pressure ulcers, with the inability to move frequently being one of the most important.  Patients in hospitals who are unable to move themselves are typically turned to a new position at least every two hours to prevent the formation of pressure ulcers.  

Other risk factors include:

  • Diabetes
  • Total time in the operating room (may include multiple surgeries)
  • Age (older patients are more likely to develop ulcers)
  • Use of medications called vasopressors to increase blood pressure
  • Higher risk on the Braden scale, a tool used to determine a patient’s risk level as a surgical candidate
  • Low body mass index (thinner patients are at higher risk, they are less “fluffy” and more “bony”)

Staging of Pressure Ulcers

Staging pressure ulcers is a way a categorizing the severity of the injury.  Different types of pressure ulcers require treatments that vary widely depending on how serious the ulcer has become. Some pressure ulcers are padded with a bandage to stop further damage while others may require one or more surgeries to repair and treat. 

Category/Stage I: Non-blanchable erythema
Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. 

Category/Stage II: Partial thickness
Partial thickness loss of skin presenting as a shallow open ulcer with a red pink wound bed. May also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister.

Category/Stage III: Full thickness skin loss
Full thickness tissue loss. Fat may be visible but bone, tendon or muscle are not exposed. The depth of a Category/Stage III pressure ulcer varies by location. The bridge of the nose, ear, head and ankle bone do not have fatty tissue and can be shallow. In contrast, areas of fat deposits can develop extremely deep Category/Stage III pressure ulcers. 

Category/Stage IV: Full thickness tissue loss
Full thickness tissue loss with exposed bone, tendon or muscle.  The depth of a Category/Stage IV pressure ulcer varies by anatomical location. T Exposed bone/muscle is visible or can be easily felt.

Unstageable/Unclassified: Full thickness skin or tissue loss – depth unknown (this category is used in the United States)
Full thickness tissue loss in which actual depth of the ulcer is completely obscured by tissue called slough or eschar in the wound.  Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined.

Sources:

NPUAP Pressure Ulcer Stages/Categories. National Pressure Ulcer Advisory Panel. Accessed September, 2015. http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/

Patient Specific and Surgical Characteristics in the Development of Pressure Ulcers. American Journal of Critical Care.  Accessed September, 2015.  http://www.aacn.org/wd/Cetests/media/A1221021.pdf

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