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Pressure Ulcers in the Perioperative Setting

3 Contact Hours
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This peer reviewed course is applicable for the following professions:
Advanced Practice Registered Nurse (APRN), Certified Nurse Practitioner, Certified Registered Nurse Anesthetist (CRNA), Clinical Nurse Specialist (CNS), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Midwife (MW), Nursing Student, Registered Nurse (RN), Registered Nurse Practitioner, Respiratory Care Practitioner, Respiratory Therapist (RT)
This course will be updated or discontinued on or before Tuesday, May 7, 2024

Nationally Accredited

CEUFast, Inc. is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation. ANCC Provider number #P0274.


≥ 90% of participants will know the recent changes in terminology to the pressure injury classification system and the revised 5 stage pressure injury classification system.


After completing this continuing education course, the participant will be able to meet the following objectives:

  1. List the two types of forces associated with causing pressure injuries.
  2. Classify and stage fluid-filled blisters over pressure points correctly.
  3. Differentiate between stage 2 and stage 3 ulcers.
  4. Classify unstageable pressure injuries correctly.
  5. List the three principles which underlie risk reduction for perioperative pressure injuries.
CEUFast Inc. and the course planners for this educational activity do not have any relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

Last Updated:
To earn of certificate of completion you have one of two options:
  1. Take test and pass with a score of at least 80%
  2. Reflect on practice impact by completing self-reflection, self-assessment and course evaluation.
    (NOTE: Some approval agencies and organizations require you to take a test and self reflection is NOT an option.)
Author:    Berthina Coleman (MD, BSN,RN)


Pressure injuries, formerly described as pressure ulcers, are one of the most commonly observed adverse events among hospitalized patients (Padula et al., 2018). Pressure injuries are defined as a localized area of injury to the skin and underlying soft tissue. This injury usually occurs over a bony prominence and is caused by either pressure or a combination of pressure and shear forces (Haesler et al., 2007). Other names for pressure ulcers include bedsores, pressure sores, and decubitus ulcers. Decubitus ulcers, loosely translated from Latin, means ulcers one gets from lying down.

The incidence and prevalence of the disease are national and global indicators of disease burden and whether adequate care is currently being provided. Point prevalence is defined as the number of pressure injury cases at a specific point in time, usually denoted as a specific day. The incidence rate is defined as the number of new pressure injury cases within a specific person-time (Edsberg et al., 2016). Establishing a global prevalence and incidence of pressure injuries helps clinicians and policymakers understand the extent and impact of the condition.

Why Should we Care?

Hospital-acquired pressure injuries remain preventable. However, approximately 2.5 million people in the U.S. develop a pressure injury in healthcare facilities yearly (Edsberg et al., 2016). Pressure injuries can lead to extensive damage, including chronic wounds and up to 60,000 deaths yearly (VanGilder et al., 2017). In comparison, in 2016, about 63,600 deaths were related to drug overdose (Hedegaard, 2017), 56,000 people died of influenza between 2015 to 2016 (2015-2016 U.S.) (CDC, 2020). and 47,000 people committed suicide in 2017 (CDC, 2019). Despite these numbers, pressure injuries receive much less attention than other causes of death.

Pressure injuries have been linked to increased risk of pain and disability, prolonged hospitalization, and risk of nosocomial infection, which all result in increased morbidity and mortality. (Ferris et al., 2019). Pressure injuries have also been associated with high financial costs for healthcare facilities. Claims submitted by Medicare beneficiaries demonstrated that caring for patients with chronic pressure injuries costs the system approximately $22 billion yearly (Nussbaum et al., 2018).

Recently, the US Centers for Medicare and Medicaid Services reduced reimbursement related to hospital-acquired conditions, which include pressure injuries. Hospitals have thus been forced to bear the full financial burden of these hospital-acquired conditions. A single hospital-acquired pressure injury can cost a hospital anywhere between $500 and $70,000 (Haesler, 2014).

A more recent study published in 2019 denoted that the average cost of healthcare-associated pressure injuries was $10,708, representing the incremental cost associated with increased length of stay secondary to the pressure injury. After accounting for all the patients within Stages 1 through 4, the estimated national cost burden was $26.8 billion based on the 2.5 million reported cases (Mervis et al., 2019).

Recent Updates

In 2016, the National Pressure Ulcer Advisory Panel (NPUAP) appointed a task force to review the definition and stages of pressure injury. The goal of the revision was to fully incorporate an up-to-date understanding of the etiology of pressure injuries and to fully explain the anatomical features absent or present in each stage of the injury (Edsberg et al., 2016). Essentially creating a new system that is easier for clinicians to use.

To begin the review, the task force appointed by the NPUAP created draft definitions from a literary review. These definitions were then reviewed by a multidisciplinary panel consisting of educators, clinicians, researchers, and members of the public from around the world. These definitions were the focus of the multidisciplinary conference held in April 2016 by NPUAP. Two notable changes from the conference were using the term injury rather than ulcer and changing the stages from Roman numerals to Arabic numerals (Edsberg et al., 2016).

Only pressure injuries should be staged with the NPUAP Pressure Injury Staging System. Non–pressure-related ulcers and wounds should be characterized based on the etiology of the wound or ulcer. The following are examples:

  • Venous leg ulcers (Clinical Etiology Anatomy Pathophysiology Classification System)
  • Diabetic foot ulcers (Wagner Classification System)
  • Burn classification (total body surface area)
  • Skin tears (International Skin Tear Advisory Panel)
  • Adhesive and tape injuries (Medical Adhesive Related Skin Injury categories, MARSI) (Edsberg et al., 2016)

When diagnosing a pressure injury, it is crucial to ensure that the injury is caused by actual pressure or shearing forces. Clinicians must have a basic understanding of anatomy to accurately use the NPUAP staging system to assess the extent of tissue damage. Pressure injury staging should only occur after the wound bed has been adequately exposed and cleansed to perform an accurate visual assessment. When performing pressure injury staging, it is important to identify factors that distinguish pressure injuries from other wounds and injuries.

Ulcer versus Injury

Miriam-Webster defines an ulcer as a break in the skin or mucous membrane with loss of surface tissue, disintegration, and necrosis of epithelial tissue (Merriam-Webster, n.d.) According to Langley and Brenner, an injury is defined as bodily damage caused by the transfer of energy and also the absence of energy. Examples of injuries caused by the absence of energy include hypothermia (Edsberg et al., 2016).

Note that after the NPUAP 2016 conference, the term ulcer was preserved for stages of pressure injuries that present as an ulcer. The decision to switch from the term ulcer to injury was arduous, based on months of discussions. Ultimately it was decided that the term ulcer did not properly describe the presentation of a Stage 1 Pressure Injury, also known as a Deep Tissue Pressure Injury. Note that tissue injury can occur before the development of an ulcer. In short, ulcers cannot occur without tissue injury, but tissue injury can occur without an ulcer (Edsberg et al., 2016).

Roman Numerals versus Arabic Numerals

Ultimately, the multidisciplinary committee opted to change from Roman numerals to Arabic numerals to avoid confusion with other initials used in medicine, such as Stage IV and intravenous (IV) (Edsberg et al., 2016).

Costly Ramifications of Pressure Injuries

Too often, when we think about pressure injuries, we conjure up an image of frail elderly patients in the nursing home who cannot turn themselves. However, hospital-acquired pressure injuries are a reality, a costly one at that.

The cost associated with pressure ulcers is not a problem unique to the United States; similar statistics are noted worldwide. For example, in the United Kingdom (U.K.), the prevalence of pressure injuries is 3.1 per 10,000 (Cullum et al., 2014). The costs associated with these pressure injuries are about 4% of the total health budget in the U.K., which is between 1.4 to 2.1 billion pounds (Bennett, 2004).

Pressure ulcers are the second most common reason for civil lawsuits related to medical malpractice. Only second to wrongful death lawsuits (Petrone, 2017). The Center for Medicare and Medicaid Services (CMS) includes stages III and IV pressure ulcers on its "never events" list for nonpayment in hospitalized patients. It is considered an error in care management, implying that CMS will not process any payments for any stage 3, stage 4, or unstageable pressure ulcers acquired after the patient has been admitted into a healthcare facility (PSNet, n.d.). Therefore, the cost of these pressure ulcers is passed unto the hospital or the healthcare facility.

Numerous studies on pressure ulcers have concordantly concluded that the cost of prevention is less expensive than the cost of treatment of a pressure ulcer. More than likely, the cost of pressure ulcers will continue to increase as life expectancy increases and the percentage of seniors increases. However, there is an agreement that not all pressure ulcers are avoidable, and there is a category of ulcers that are classified as "unavoidable" pressure ulcers (Edsberg et al., 2019).

Risk Factors

The causes of pressure ulcers are multifactorial; to name a few include:

  • Restricted or limited mobility
  • Pressure from a hard surface
  • Friction from being unable to move well in bed or a chair
  • Shear from involuntary movements
  • Poor nutrition
  • Comorbidities such as depression
  • Dementia
  • Diabetes mellitus
  • Peripheral arterial disease

Pressure ulcers have also been associated with poorly fitted medical equipment such as braces or casts.

Immobility is a well-known risk factor for developing pressure injuries, particularly in perioperative and recovery settings where patients are temporarily sedentary.

Perioperative setting risk factors include:

  • hypotensive episodes during surgery
  • low core body temperature during surgery
  • reduced postoperative mobility (NPUAP, 2014)

Other perioperative risk factors include:

  • surgical position
  • duration of surgery and anesthesia
  • anesthesia type (patients who had surgery under general anesthesia had lower rates of perioperative pressure ulcers compared to other types of anesthesia
  • the total time of diastolic blood pressure < 50mmHg, and the use of positioning devices

Other risk factors are patients with severe illness, patients who are malnourished, or those with neurological impairment. Of note, the superficial skin is less susceptible to pressure-induced damage than deeper tissues; thus, the external appearance may underestimate the extent of a pressure-related injury. Up to 70% of pressure ulcers occur in adults over 65. Pressure ulcers in younger patients often occur in patients with a severely debilitating illness or neurological impairment.

In certain populations, such as the cardiac surgery population, pressure injuries have been reported as high due to longer times under anesthesia and compromised cardiovascular systems. Transplant and oncologic cases are sometimes also at increased risk.

Classification of Pressure Injuries

According to the NPUAP, a pressure ulcer is localized damage to the skin and underlying soft tissue, usually over a bony prominence or related to a medical device. The injury could present as an ulcer or with intact skin, which may or may not be painful. The injury can occur due to intense pressure, prolonged pressure, or pressure in combination with shear forces. Several factors affect the patient's skin and soft tissue's ability to withstand pressure and shear forces. These include the underlying condition of the soft tissues, comorbid conditions, nutrition, perfusion, and microclimate.

Stage 1

Stage 1 is intact skin with non-blanchable erythema. This stage may appear differently in darkly pigmented skin and may not present as erythema. It may be painful and of a different color, firmness, and temperature than adjacent skin. Usually located over bony prominences (Edsberg et al., 2016).

Stage 2

Partial-thickness skin loss with exposed dermis. The wound bed usually appears pink or red, meaning it is viable. Alternatively, a Stage 2 injury may present as an intact, open, or ruptured serum-filled skin blister. Note that granulation tissue, scar, or eschar are not present. Also, adipose tissue or deeper soft tissues are not visible in this stage. These injuries occur due to adverse microclimate and shear in the skin, usually over the pelvis and heel. Injuries in this stage do not include incontinence-associated dermatitis, moisture-associated skin damage, and traumatic injuries. If a stage 2 injury is suspected, the history or presence of pressure or shear forces must be confirmed. Stage 2 injuries heal by re-epithelization, not by granulation tissue formation. A viable dermis is pink, red, or shiny and blanchable. It does not contain granulation tissue (Edsberg et al., 2016).

Stage 3

Full-thickness skin loss contains an exposed layer of adipose tissue and may include granulation tissue and rolled wound edges, also known as epibole. Slough or eschar may be visible. Tunneling or undermining may be present within the wound bed. The fascia, ligament, bone, tendon, or muscle are not exposed. Accurate staging primarily depends on accurately assessing the extent of damage and the visible tissue layer. Appropriately assessing the anatomic layer is critical because the sacrum and the buttock may have very different depths of injury (Edsberg et al., 2016).

In the past, the slough was considered nonviable tissue. It is now considered an inflammatory exudate of neutrophils, bacteria, fibrin, and proteinaceous tissue. The inflammatory exudate comprised of slough is usually produced secondary to biofilm. If biofilm build-up is not controlled, the slough will continue to build up after debridement (Edsberg et al., 2016).

Slough is usually moist, soft, cream, or yellow-colored, while eschar is thick, dry, leathery, and usually black or brown. Note tunneling and undermining may be present (Edsberg et al., 2016).

Stage 4

Full-thickness tissue loss with exposed or directly palpable bone, tendon, cartilage or muscle in the ulcer bed (Edsberg et al., 2016).


Finally, if slough or eschar prevents adequate evaluation of the tissue loss, the wound must be characterized as an unstageable pressure injury. The slough or eschar must be debrided to stage the pressure injury fully (Edsberg et al., 2016).

Imaging studies do not play a major role in diagnosing or staging pressure ulcers unless there is suspected osteomyelitis. In cases of suspected osteomyelitis, plain films, C.T. scans, and MRI can be used to ascertain the full extent. MRI has the highest sensitivity and specificity for diagnosing osteomyelitis.

Prevention and Management

Risk Assessment Tools

Several risk assessment tools are currently used to identify patients at increased risk for pressure injuries. The goal is to standardize assessment and minimize variations reported by nurses with different clinical backgrounds and years of experience.

The Braden Scale

Braden Scale is a well-established predictor of pressure injury development that evaluates friction and shear forces, skin moisture, sensory perception, nutrition, activity, and mobility. A 2016 review by Putnam reported that the Braden Scale offered the best sensitivity and specificity for detecting pressure injuries compared to the Norton Scale, Waterlow Scale, and clinical judgment.

The Braden scale is extremely useful for detecting patients at risk for pressure injuries. However, it does not consider specific perioperative risk factors such as time on the operating table, core body temperature, type of anesthesia, etc.

Munro Pressure Ulcer Risk Assessment Scale

This scale can be implemented in all patients across the preoperative, intraoperative, and postoperative settings. It is a comprehensive scale that includes more than 15 evidence-based risk factors for pressure injury development, namely; hypotension, body temperature, skin moisture, patient positioning, duration of perioperative care, support devices used in the intraoperative phase of care, physical status, anesthesia, blood loss in the postoperative phase of care.

Scott Triggers Tool

This tool is based on the use of four evidenced-based predictors of perioperative pressure ulcers, namely, body mass index, age or serum albumin, estimated surgery time, and American Society of Anesthesiologists' physical status classification score. High-risk patients are identified, which should trigger clinical providers to implement adequate measures to reduce the patient's risk.

Adoption of Perioperative Specific Pressure Injury Scales

Due to the widespread use of the Braden Scale for generalized inpatients, which most nurses are familiar with, the adoption of a perioperative specific pressure injury scale had to be developed with a specific focus on educating not just perioperative nurses but also floor nurses. Education on the perioperative pressure injury scale is not just limited to nursing staff but also surgeons and anesthesia team personnel. Also, if a patient does develop a pressure injury in the postoperative setting, the perioperative team should be informed so that adjustments can be made in subsequent patients.

Although dressings could be used as an adjunct to pressure injury prevention strategies, they cannot replace them. Specifically, Mepilex and Allevyn dressings were shown to reduce the forces of friction on tissues. Also, Mepilex dressings were shown to mitigate the shear forces on a tissue. Finally, it was noted that the size of the dressing plays a role in reducing or redistributing stress on tissues.

Interventions to Reduce Risk

The three principles which underlie risk reduction for perioperative pressure injuries are to relieve, reduce, or redistribute pressure. In the perioperative setting, nurses should identify bony prominences and pressure points that must be padded using support devices to decrease the pressure as much as possible. Note that the type of surgery will dictate the required patient positioning, length of surgery, time under anesthesia, and available equipment.

Lastly, individual patient risk factors can also be optimized to mitigate risks, such as nutrition status and hydration. Note that risk reduction strategies can be implemented in the preoperative, intraoperative, and postoperative settings. It has been suggested that patients should be positioned differently in the preoperative and perioperative setting to decrease pressure on pressure points or redistribute pressure points. For example, raising the heels increases the pressure on the sacrum, while lowering the knees will decrease pressure on the sacrum (Mervis et al., 2019).

If a pressure injury does occur, it is important to perform a root cause analysis to correctly identify the risk factors which may have contributed to the development of the pressure injury.


Pressure redistribution is a critical component of pressure injury prevention. This redistribution can be accomplished by frequent repositioning and optimal patient positioning. Repositioning is performed to avoid long-standing periods of locally sustained pressure. Traditionally, this repositioning has been performed every 2 hours. However, this was omitted from the most recent guidelines from the NPUAP published in 2016 due to the lack of supporting evidence (Mervis et al., 2019).

The angle of incline is also a specific risk factor for pressure injuries. The higher the angle of incline, the greater the risk because this increases the amount of shear and frictional forces. For example, the 30-degree lateral tilt position has been proposed as more appropriate than the 90-degree lateral or supine positions (Mervis et al., 2019).

Support Surfaces

Special support equipment such as overlays and mattresses are intended to reduce both shear and pressure forces. Note that compared to standard mattresses, continuous low pressure or alternating pressure support systems decrease the incidence of pressure injuries. A continuous low-pressure support system will conform to the patient's body shape, while an alternating pressure device will mechanically vary the pressure over time. Continuous low-pressure systems can be water-filled, bead-filled, or might be a high specification foam mattress. Alternating pressure devices have numerous air-filled components that can inflate or deflate to vary the pressure across different body sites. So far, no significant difference in preventing pressure injuries has been found between alternating pressure devices and continuous low-pressure devices (Mervis et al., 2019).


Nutritional deficiencies have been shown to promote skin breakdown and negatively impact tissue healing. The importance of nutrition as a critical factor in assessing operative risk cannot be overemphasized. However, traditional markers of malnutrition such as pre-albumin and albumin are not always reliable because they can be impacted by other factors such as hydration status or liver function. More comprehensive tools incorporating history and physical are now favored (Mervis et al., 2019).


Prophylactic dressings could protect intact skin from friction and shear forces and prevent skin maceration. Examples of dressings include foams, hydrocolloids, or films. Topical agents such as fatty acid creams can be used for pressure injury prevention. The goal of ointment and cream application is to decrease frictional forces well maintain healthy skin (Mervis et al., 2019).

Staff Engagement

Documentation of loss of skin integrity or breakdown, rashes, or incontinence has proven helpful in follow-up and continued monitoring of patients at risk. Pressure injury documentation must include a picture in the medical record.

One of the major challenges with implementing any pressure injury prevention program is staff engagement because learning a new staging and documentation program can be difficult and time-consuming for the staff. This challenge can be addressed by creating incentive programs and allowing the staff flexibility in the time available to complete training modules.

Another challenge with implementing a pressure injury prevention program includes increasing the number of wound care nurses in charge of follow-up patients with pressure injuries or at risk for pressure injuries. Increasing staff education has also been shown to be helpful.

Sometimes patients with a stage I injury, who are correctively identified as being at risk intraoperatively, are lost on follow-up because those concerns are not communicated to the recovery nurses and eventually floor nurses and may go unnoticed until the patient develops a stage 2 or 3 ulcers.

Standardizing perioperative reports reminds nurses to mention a skin assessment as part of a routine report to the receiving floor. After a long case, nurses may neglect to mention stage 1 or 2 ulcers on a cardiac surgery patient coded four times during the procedure. Often, the receiving nurse may incorrectly view that information as excessive and not important at the current time.

The crux of any successful intervention is the education of the staff and frequent reassessment to monitor progress. Also, it is important to identify areas of staff miseducation that can be addressed. An example of inappropriate nursing interventions that may increase the patient's risk includes layering bed linen, which can contribute to developing hospital-acquired pressure ulcers.

The basis of any intervention must include a complete skin assessment, which should include skin temperature, color, turgor, moisture status, and integrity. The pinnacle of any proper skincare program is keeping the skin clean and dry while avoiding excess dryness and scaling as the primary goal. Excess moisture increases friction and contributes to shearing, thus making the skin more susceptible to breakdown. Excess moisture may arise from other sources, including sweat and drainage from nearby wounds. Additionally, chemicals in urine and feces may irritate the skin, so a good toileting program is also critical.

Clinical Scenario

You are a nurse working in the Cardiac ICU, and you are taking care of a status post coronary artery bypass graft patient. The operating nurse reported that the patient had been in the operating room for 5 hours. After the procedure, the patient presents to the CICU for postoperative care. After performing a complete assessment and physical, you notice blanchable erythema over the sacrum and fluid-filled blisters over the bony prominences of the elbow. You are tasked with staging the pressure injuries.


As a CICU nurse, you should recognize that cardiac patients are particularly at risk for pressure injuries and should be proactive about identifying and actively managing pressure injuries. You correctly identify that the fluid-filled blisters over the elbows are stage 2 pressure injuries. You provided that feedback to the operating room staff, who decided to further investigate the incident by performing a root cause analysis. The redness on the sacrum remains blanchable at this time; thus, it is not a pressure injury but a high-risk area that should be closely monitored. You should document the injuries in the patient's medical record and ensure that this information is part of the end-of-shift record to the oncoming staff members.


The agency for healthcare research and quality (AHRQ) has given several key components of any successful pressure ulcer reduction and prevention policy. These include:

  • Staff education on best prevention practices
  • Standardized forms for documenting ulcer appearance and interventions
  • One or more members of the nursing team designated as a skincare champion
  • Minimizing barriers to obtaining necessary supplies such as special mattresses and overlays, obtaining additional expertise through consultations, and using audits and feedback.

In the On-Time Pressure Ulcer Prevention Program proposed by the AHRQ, clinical decision support addressing various risk factors, including nutritional status, weight, and moisture, has resulted in a lower incidence of pressure ulcers. The NPUAP recommends consultation for surgical repair of stage 3 or 4 pressure ulcers that do not close with usual treatment or if more rapid closure is required (NPUAP, 2014). Also, improving arterial blood flow is beneficial in preventing pressure ulcers or helping pressure ulcers heal.

In conclusion, from a nursing perspective, several actions could be implemented to prevent hospital-acquired pressure ulcers in the preoperative, intraoperative, or postoperative setting. However, any system-wide effort would have to be multidisciplinary, including adequate staffing with a focus on education and continuous efforts to reeducate staff on implementing successful interventions.

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Implicit Bias Statement

CEUFast, Inc. is committed to furthering diversity, equity, and inclusion (DEI). While reflecting on this course content, CEUFast, Inc. would like you to consider your individual perspective and question your own biases. Remember, implicit bias is a form of bias that impacts our practice as healthcare professionals. Implicit bias occurs when we have automatic prejudices, judgments, and/or a general attitude towards a person or a group of people based on associated stereotypes we have formed over time. These automatic thoughts occur without our conscious knowledge and without our intentional desire to discriminate. The concern with implicit bias is that this can impact our actions and decisions with our workplace leadership, colleagues, and even our patients. While it is our universal goal to treat everyone equally, our implicit biases can influence our interactions, assessments, communication, prioritization, and decision-making concerning patients, which can ultimately adversely impact health outcomes. It is important to keep this in mind in order to intentionally work to self-identify our own risk areas where our implicit biases might influence our behaviors. Together, we can cease perpetuating stereotypes and remind each other to remain mindful to help avoid reacting according to biases that are contrary to our conscious beliefs and values.


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