Pressure ulcers pose a considerable challenge in healthcare, particularly within nursing care, and their prevention stands as a crucial objective in perioperative nursing. Research indicates that a significant portion, ranging from 17% to 29%, of patients in general acute care settings will develop pressure ulcers during their hospital stay. Alarmingly, nearly a quarter of these hospital-acquired pressure ulcers originate during surgical procedures performed in the operating room. This guide aims to provide an in-depth understanding of pressure ulcers, covering:
- Pressure Ulcer vs. Pressure Injury: Clarifying the Terminology
- Comprehensive Pressure Ulcer Stages
- Pressure ulcers vs. Bedsores: Differentiating the Terms
- Understanding Deep Tissue Pressure Injury (DTPI)
- Pressure injury Etiology and Risk Factors
- Advanced Pressure Injury Prevention Devices
Pressure Ulcers vs. Pressure Injury: Clarifying the Terminology
The terms “pressure ulcer” and “pressure injury” are often used interchangeably, but understanding their nuances is essential. A pressure injury is the broader term, encompassing localized damage to the skin and/or underlying soft tissue, typically over a bony prominence, as a result of sustained pressure, pressure combined with shear, or pressure combined with friction. A pressure ulcer, also widely recognized as a bedsore or decubitus ulcer, is a specific type of pressure injury. It is defined as a lesion caused by unrelieved pressure leading to damage of underlying tissues. Essentially, all pressure ulcers are pressure injuries, but not all pressure injuries are necessarily ulcers in the early stages.
Pressure ulcers commonly develop over bony prominences due to reduced tissue tolerance and increased external pressure. These high-risk areas include:
- Back of the head and ears
- Scapulae (Shoulders)
- Elbows
- Sacrum and Coccyx (Lower back and buttocks)
- Ischial tuberosities (Hips)
- Medial and Lateral Malleoli (Ankles)
- Heels
Pressure Ulcer Stages: A Detailed Guide
Studies highlight the significant risk of pressure ulcers in surgical settings. A national study by S. A. Aronovitch revealed that 9% of surgical patients undergoing procedures lasting over three hours developed pressure ulcers. These ulcers often progressed from initial non-blanchable erythema observed post-operatively to more severe stages within days.
Further research by Hoshowsky and Schramm indicated a direct correlation between surgical duration and pressure ulcer risk. Procedures lasting 2.5 to 4 hours doubled the risk, while those exceeding 4 hours tripled the risk of skin changes and quadrupled the risk of pressure ulcer development.
The staging of pressure ulcers is crucial for classifying their severity and guiding appropriate treatment strategies. The National Pressure Ulcer Advisory Panel (NPUAP) staging system categorizes pressure ulcers into four distinct stages, reflecting the depth of tissue damage.
Stage 1 Pressure Ulcer
A Stage 1 pressure ulcer is characterized by non-blanchable erythema of intact skin. This means the skin appears red and when pressed, it does not turn white (blanch). This stage signifies an alteration of intact skin due to pressure. Preceding visual changes, patients may report changes in sensation (pain, itching), temperature (warmth), or tissue firmness. It’s crucial to differentiate Stage 1 from deep tissue pressure injuries, which may present with purple or maroon discoloration.
Key characteristics of Stage 1:
- Intact skin
- Non-blanchable erythema (persistent redness)
- Pain, itching, or changes in temperature or firmness may be present
Immediate interventions for Stage 1:
- Pressure relief: Reposition the patient immediately to alleviate pressure on the affected area.
- Pressure redistribution: Utilize pressure-redistributing surfaces such as specialized mattresses, foam pads, or pillows. Explore patient positioning guides and foam pads for effective strategies.
Stage 2 Pressure Ulcer
Stage 2 pressure ulcers involve partial-thickness skin loss, affecting the epidermis and potentially extending into the dermis. The ulcer presents superficially as an abrasion, blister, or shallow crater.
Key characteristics of Stage 2:
- Partial-thickness skin loss (epidermis and/or dermis)
- Superficial ulcer, resembling an abrasion, blister, or shallow crater
- Pain, swelling, warmth, and redness are common
- May present with serous fluid or purulent drainage
Management of Stage 2:
- Pressure relief: Continue to eliminate pressure on the affected area.
- Wound care: Cleanse the wound gently with water or sterile saline solution. Dry the area carefully.
- Appropriate dressing: Apply a dressing that maintains a moist wound environment and promotes healing, as per healthcare provider recommendations.
Stage 3 Pressure Ulcer
A Stage 3 pressure ulcer is a full-thickness tissue loss injury. It extends through the dermis into the subcutaneous tissue. Damage or necrosis (tissue death) of subcutaneous tissue may occur, potentially reaching down to, but not through, the underlying fascia (connective tissue). Stage 3 ulcers manifest as deep craters, with or without undermining (tissue destruction extending under intact skin edges) of adjacent tissue.
Key characteristics of Stage 3:
- Full-thickness skin loss
- Damage or necrosis of subcutaneous tissue
- Deep crater appearance, possibly with undermining
- May exhibit red edges, pus, odor, heat, and drainage
- Black tissue (eschar) may be present in or around the wound
Clinical interventions for Stage 3:
- Debridement: Medical professionals may need to remove dead tissue (debridement) to promote healing.
- Antibiotics: Infection is a significant concern; antibiotics may be prescribed to combat or prevent infection.
- Specialized dressings: Advanced wound dressings are necessary to manage drainage, protect the wound bed, and promote granulation tissue formation.
Stage 4 Pressure Ulcer
Stage 4 pressure ulcers represent the most severe form, characterized by full-thickness skin and tissue loss with extensive destruction. Damage extends to muscle, bone, tendons, joint capsules, or other supporting structures. Sinus tracts (channels extending from the wound into deeper tissues) and undermining are frequently present.
Key characteristics of Stage 4:
- Full-thickness skin and tissue loss
- Extensive destruction reaching muscle, bone, tendons, or joint capsules
- Sinus tracts and undermining are common
- Signs of infection: red edges, pus, odor, heat, drainage
Critical management for Stage 4:
- Immediate medical attention: Stage 4 ulcers require prompt and aggressive treatment.
- Surgical intervention: Surgery may be necessary for debridement, wound closure, and reconstruction in severe cases.
- Long-term care: These ulcers often require prolonged and complex wound care management, potentially involving specialized wound care teams.
Beyond the Stages: Unstageable and Suspected Deep Tissue Injury
In addition to the four stages, there are categories for pressure injuries that do not fit neatly into the staging system:
Unstageable Pressure Injury
An Unstageable Pressure Injury is a full-thickness tissue loss injury where the extent of tissue damage cannot be determined because it is obscured by slough (yellow or white tissue) or eschar (black, necrotic tissue). Once enough slough and/or eschar is removed to expose the wound bed, the ulcer can be staged (usually Stage 3 or 4).
Suspected Deep Tissue Pressure Injury (sDTI)
Deep Tissue Pressure Injury (DTPI) presents as intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, or purple discoloration, or epidermal separation revealing a dark wound bed or blood-filled blister. Pain and temperature changes are frequently reported. In individuals with darkly pigmented skin, discoloration may appear differently. DTPI results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The injury may evolve rapidly to reveal the actual extent of tissue damage or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle, or other underlying structures become visible, it is then categorized as a full-thickness pressure injury (Unstageable, Stage 3, or Stage 4).
Pressure Ulcers vs. Bedsores: Interchangeable Terms in Practice
While “pressure ulcer” is the clinically preferred term, “bedsore” is a widely understood synonym. Both terms refer to injuries caused by prolonged pressure. Historically, “bedsore” was more commonly associated with immobility due to illness or age, whereas “pressure ulcer” is the broader term used in healthcare settings, encompassing all pressure-related skin injuries, including those acquired in hospitals or during surgery. In practical terms, they are often used interchangeably to describe the same condition.
Pressure Injury Causes and Risk Factors: A Multifaceted Perspective
Pressure injury development is multifactorial, involving both extrinsic and intrinsic risk factors.
Extrinsic Factors (External)
- Pressure: Prolonged pressure, especially over bony prominences, restricts blood flow, leading to tissue ischemia and damage. In surgical patients, pressure is often due to body weight and positioning on the operating table.
- Shear: Shear forces occur when tissue layers slide over each other, causing damage to blood vessels and tissues. Patient movement, repositioning, and sliding down in bed contribute to shear. In surgery, shear can occur with table tilting or patient repositioning.
- Friction: Friction results from surfaces rubbing together, damaging the outer skin layers and increasing vulnerability to pressure and moisture. Dragging or pulling patients across surfaces can cause friction.
- Moisture: Excessive moisture from incontinence, perspiration, or wound drainage macerates the skin, weakening its barrier function and increasing susceptibility to pressure, shear, and friction.
Intrinsic Factors (Patient-Related)
- Immobility: Reduced ability to change position independently increases pressure duration and intensity.
- Malnutrition: Inadequate nutrition compromises tissue health and wound healing.
- Age: Elderly individuals have thinner skin, reduced subcutaneous fat, and decreased physiological reserves, making them more vulnerable.
- Comorbidities: Conditions like diabetes, vascular disease, and neurological disorders impair circulation and tissue integrity, increasing risk.
- Sensory deficits: Reduced sensation may prevent patients from feeling pressure or discomfort, delaying repositioning.
Surgical Specific Risk Factors
- Length of surgery: Procedures exceeding 2.5-3 hours significantly increase pressure ulcer risk due to prolonged pressure exposure.
- Patient position: Certain surgical positions, especially those involving tilting (lateral, Trendelenburg, reverse Trendelenburg), increase shear forces.
- Positioning devices: Improper use or lack of appropriate positioning devices can lead to patient shifting and increased shear.
- Hypothermia: Intraoperative hypothermia has been linked to increased postoperative pressure ulcer incidence. Maintaining normothermia is crucial. Explore the STERIS Patient Warming System for effective temperature management.
- Anesthetic agents: Anesthesia can disrupt normal blood vessel function and reduce tissue perfusion, increasing susceptibility.
- Vasoactive medications: Vasopressors, used to maintain blood pressure, can compromise peripheral circulation and increase pressure ulcer risk, particularly with prolonged use or high doses.
- Type of surgery: Certain surgeries, such as spinal procedures, may have a higher pressure ulcer risk due to patient positioning and surgical duration.
Additional Contributing Factors
- Fluid pooling: Accumulation of fluids on the operating table beneath the patient can lead to skin maceration.
- Rhabdomyolysis: Muscle breakdown due to prolonged pressure can occur in lengthy surgeries.
- Wrinkled sheets: Wrinkles create concentrated pressure points.
- Skin folds: In obese patients, skin folds are prone to pressure and moisture, increasing ulcer risk, especially during positioning and transfers.
Pressure Injury Prevention Devices: Advanced Solutions
Preventing pressure ulcers requires a comprehensive approach incorporating risk assessment, skin care protocols, repositioning schedules, and the use of pressure-redistributing support surfaces and pressure injury prevention devices.
Numerous advanced positioning technologies are now considered standard of care, including:
- Specialized mattresses and overlays: These surfaces redistribute pressure, reducing peak pressure points. Active alternating pressure mattresses cyclically inflate and deflate air cells to further minimize pressure.
- Positioning aids: Foam wedges, pillows, and gel pads provide support and prevent pressure on bony prominences in various positions.
- Heel elevation devices: These devices offload pressure from the heels, a high-risk area.
- Integrated patient positioning systems: Advanced surgical tables with integrated pressure management features offer active pressure redistribution and monitoring capabilities.
Summary: Proactive Pressure Ulcer Prevention is Essential
Operating room-acquired pressure ulcers are preventable adverse events. Recognizing that all surgical patients are at risk is the first step towards effective prevention. While padding bony prominences is important, it is often insufficient on its own. Lower pressure applied over extended periods can still cause tissue damage.
Active pressure management strategies, aimed at maintaining tissue perfusion throughout the surgical procedure, offer enhanced protection. Active support surfaces are easily implemented and can standardize preventative processes, reducing variability in care.
Developing and implementing a specific, proactive patient care plan in every operating room is crucial to minimize pressure ulcer risk. Patients at higher risk or undergoing longer procedures should receive active pressure management. By establishing preventative measures, monitoring prevalence rates, and justifying preventative care, healthcare facilities can effectively reduce the incidence and costs associated with operating room-acquired pressure ulcers, ultimately improving patient outcomes.
Contributors
Lena Fogle BSN, RN, CNOR
Senior Director Global Clinical Solutions, STERIS Healthcare
Lena Fogle is a highly experienced healthcare leader specializing in perioperative environments, program development, process improvement, clinical outcomes, and stakeholder experience.
References
1 Aronovitch, Sharon A. Intraoperatively-acquired pressure ulcer prevalence: A national study. Journal of Wound Ostomy Continence Nursing, 1999, 26(3):130-136.
2 Hoshowsky, VM and Schramm CA. Intra-operative pressure prevention: an analysis of bedding materials. research in Nursing and Health, 1994, 17 (5):333-339.
3 Lim, Kevin Andre S., and Cori Kopecky. The Use of an Alternating Pressure Surface to Reduce Intra-Operative Pressure Injuries in Complex Surgical Cancer Patients.
4 US National Library of Medicine. National Institutes of Health. Pressure Ulcers: Current Understanding and Newer Modalities of Treatment. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4413488/) Accessed 10/22/2018.
5 Merck Manual. Pressure Sores. (https://www.merckmanuals.com/home/skin-disorders/pressure-sores/pressure-sores) Accessed 10/22/2018.
6 Edsberg, L. E., Black, J. M., Goldberg, M., McNichol, L., Moore, L., & Sieggreen, M. (2016). Revised National Pressure Ulcer Advisory Panel Pressure Injury Staging System: Revised Pressure Injury Staging System. J Wound Ostomy Continence Nurs, 43(6), 585-597. doi:10.1097/won.0000000000000281 https://cdn.ymaws.com/npiap.com/resource/resmgr/npuap-position-statement-on-.pdf
7 Edsberg, L. E., Black, J. M., Goldberg, M., McNichol, L., Moore, L., & Sieggreen, M. (2016). Revised National Pressure Ulcer Advisory Panel Pressure Injury Staging System: Revised Pressure Injury Staging System. J Wound Ostomy Continence Nurs, 43(6), 585-597. doi:10.1097/won.0000000000000281 https://cdn.ymaws.com/npiap.com/resource/resmgr/npuap-position-statement-on-.pdf
8 Vasopressors and development of pressure ulcers in adult critical care patients: https://pubmed.ncbi.nlm.nih.gov/26523008/2015 Nov;24(6):501-10.
9 Hwang HY, Shin YS, Cho HS, Yeo JS. Risk factors of pressure sore in patients undergoing general anesthesia. Korean J Anesthesiol. 2007;53:79–84.
10 Luo M, Long XH, Wu JL, Huang SZ, Zeng Y. Incidence and risk factors of pressure injuries in surgical spinal patients: a retrospective study. J Wound Ostomy Continence Nurs. 2019.
11 Effects of warming therapy on pressure ulcers–a randomized trial – AORN J . 2001 May;73(5):921-7, 929-33, 936-8.
