The Perioperative Patient for Registered Nurses

Risk of Pressure Injury

Before arriving in the OR, the perioperative nurse needs to perform an assessment to check the patient’s pre-existing skin condition. The nurse can then assess the patient’s risk of developing a pressure injury and implement preventative interventions.

Patient positioning is a crucial factor in patient outcomes. Proper positioning requires knowledge of anatomy and physiology and familiarity with patient positioning equipment. The patient’s position is determined by the type and approach of surgery along with the surgeon’s preference.

Different points on the body to see what the pre-operative risk factors are for pressure injury (select the + hotspots in the image to reveal information).

Positioning Considerations

Changes occur to the physiological and anatomical condition when positioning the patient. Factors that can affect these changes are:

  1. The surgical table/OR bed
  2. Padding
  3. Positioning devices used
  4. Type of anesthesia given
  5. The surgical procedure

These factors impact the following systems:

(ORNAC, 2021; Fawcett, 2020)

Extrinsic Risk Factors

Different physical forces can injure the skin and underlying tissues when positioning a patient and maintaining that position. Other extrinsic factors that increase the risk of a pressure injury include inadequate protection or padding, an extended length of time on the OR table, and even the use of positioning aids/devices.

Intrinsic factors can increase the patient’s risk for pressure injury as they decrease tolerance to pressure and foster skin breakdown. These factors can be pre-existing, including the patient’s age, body sizes such as obesity or a thin build, and if they smoke. Other factors include diabetes mellitus, vascular disease, peripheral vascular disease, infection, malnutrition, impaired sensory perceptions, and incontinence. Intrinsic factors can also be induced during surgery such as hypotension, certain medications such as steroids or vasopressors, low hemoglobin or hematocrit, and impaired mobility from being under general anesthesia.

(ORNAC, 2021 & Fawcett, 2019)

Skin Risk Assessment Tool

One of the first things to prevent a patient’s skin injury is to assess their risk. There are different skin risk assessment tools, but the Munroe Pressure Ulcer Skin Assessment Scale is often used to assess the patient’s risk of skin injury during the pre-op, intraoperative, and post-op stages. Those patients identified as “at risk” can have additional interventions in place to reduce injury.

Munroe Pressure Ulcer Skin Assessment Scale for Perioperative Patient

(Fawcett, 2019)

Stages and Definition of Pressure Injury

Stage 1 Skin is intact but is non-blanchable erythema usually over a localized bony prominence. Stage one may present differently in darker pigmented skin.

Stage 2 Partial-thickness loss with dermis exposed as a shallow or open ulcer. Wound bed is pink or red and moist. Also present may be a serum-filled blister intact or ruptured. Adipose tissue and deeper tissues are not visible.

Stage 3 Full thickness tissue loss. Adipose tissue may be visible and granulation tissue with epibole (rolled wound edge) are also often present. There may be tunneling and undermining. Fascia, muscle tendon, and ligament, cartilage is NOT exposed.

Stage 4 Full thickness tissue and skin loss with exposed bone, tendon, muscle. Slough and eschar may be present and undermining and tunneling is often present.

Unstageable When the injury cannot be confirmed because slough or eschar obscure and conceal a full-thickness skin and tissue loss. If the slough or eschar is removed, a stage 3 or 4 stage injury is revealed

Deep Tissue Pressure Injury (DTPI) Localized intact skin, either deep red, purple or maroon discolouration, non-blanchable or can be a blood-filled blister with epidermal separation. May be difficult to detect in darker pigmented skin.

Medical Device- Related Pressure Injury Injury related to pressure from a medical device used for diagnostic or therapeutic purpose. Injury should be staged using the staging system.

Mucosal Membrane Pressure Injury Mucous membrane injury with history of using medical device. These injuries are unable to be staged.

(ORNAC,2021& Fawcett, 2019)

🧩 Practice Activity: Medical Device and Vulnerable Areas

Choose one or multiple responses to answer the question. Select “Check” when you feel confident in your answer.

Match the medical device listed into the corresponding vulnerable area associated with the device (devices may be under multiple vulnerable areas):