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Pressure Ulcers in the Perioperative Setting

1.50 Contact Hours
A score of 80% correct answers on a test is required to successfully complete any course and attain a certificate of completion.
Author:    Berthina Coleman (MD, BSN,RN)


Prepare nurses in the perioperative setting to identify patients at risk and implement strategies to prevent pressure ulcers.


  1. Discuss the incidence and prevalence of pressure ulcers
  2. Identify patients at the highest risk of developing ulcers
  3. Apply an effective ulcer documentation system
  4. Apply recent research-proven interventions to prevent pressure ulcers
  5. Discuss the implications of the “never events” list from CMS


Why should we care?

A pressure ulcer is defined as a local injury to skin and/or underlying tissues which often occurs over bony prominences (Bluestein, 2008). Pressure ulcers are caused by unrelieved pressure or pressure with shear or friction. Other names for pressure ulcers include; bedsores, pressure sores and decubitus ulcers. Decubitus ulcers loosely translated from Latin means ulcers one get from lying down. Typically pressure ulcers are related to immobility or poorly fitted medical equipment such as braces or casts. Several factors have been identified as potential causative factors for the hospital-acquired pressure ulcers in surgical patients. These factors include sex, age, body mass index, 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 (Baumgarten, 2012)),total time of diastolic blood pressure < 50mmHg and the use of positioning devices.

Too often when we think about pressure ulcers, we conjure up an image of frail elderly patients in the nursing home who are unable to turn themselves. However, hospital-acquired ulcers are a reality, a costly one at that. According to the agency for healthcare research and quality, approximately 2.5 million patients are affected by pressure ulcers each year. It estimates the cost of pressure ulcers between $6.1-11.6 billion in the United States with the cost per patient per pressure ulcer ranging from $20,900 to 151,700. About 60,000 patients are estimated to die each year from a direct result of pressure ulcers, and finally, pressure ulcers are noted to be the second most common claim for lawsuits after wrongful death and before falls and emotional distress. 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 and CMS will not pay for any stage 3, stage 4, or unstageable pressure ulcers acquired after the patient has been admitted into a healthcare facility. Therefore, the cost of these pressure ulcers is passed onto the hospital or the health care facility.

There are numerous studies on pressure ulcers which 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 the life expectancy continues to increase and the percentage of seniors increases.  However, there is an agreement that not all pressure ulcers are avoidable and there a category of ulcers which are classified as “unavoidable” pressure ulcers.

More specifically, the risk of developing pressure ulcers in the perioperative and recovery setting where patients are temporarily sedentary has been well documented. Other patients at risk 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, and thus, the external appearance may underestimate the extent of the pressure-related injury. Up to 70% of pressure ulcers occur in adults over the age of 65. Pressure ulcers in younger patients often occur in patients with severe debilitating illness or with neurological impairment (Bluestein, 2008).

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

Classification of Pressure Ulcers:

According to the National Pressure Ulcer Advisory Panel-European Pressure Ulcer Advisory Panel 2014 international classification system for pressure ulcers the diagnosis of pressure ulcers is made by the physical appearance of the ulcer as designated below (NPUAP/EPUAP/PPPIA, 2014):

  • Category/Stage I - non-blanchable erythema of intact skin. It may be painful and of a different color, firmness and temperature than adjacent skin. Usually located over bony prominences.
  • Category/Stage II - partial thickness loss of dermis, appearing as an open ulcer with red-pink wound bed without slough or bruising. It also includes a serum-filled blister which may be intact, open or ruptured. It does not include skin tears, tape burns, perineal dermatitis, maceration or excoriation.
  • Category/Stage III - full-thickness tissue loss, subcutaneous fat may be visible but bone, tendon, or muscle not exposed.
  • Category/Stage IV - full-thickness tissue loss with exposed bone, tendon, or muscle visible or directly palpable. Slough or eschar could be noted at the base of the wound and must be removed to determine the full extent of the wound.
  • Unstageable - full thickness tissue loss with depth unknown because the base of the ulcer is covered by slough and/or eschar in the wound bed which must be removed to determine the full extent of the wound.
  • Suspected deep tissue injury, depth unknown - purple or maroon localized area of discolored intact skin or blood-filled blister

What do we know now?

According to a cross-sectional study with 4,679 adults, the prevalence of pressure ulcers in long-term care facilities was estimated at 8.5% in the United States (J Am Geriatr Soc 2002 Apr;50(4):728). The prevalence in hospitals was estimated to range from 4.7% to 32.1% (J Wound care 2001 Jan;10(1):530). In certain populations such as the cardiac surgery population, it has been reported to as high as 29.5% (Feuchtinger, 2006). Patients undergoing prolonged surgical procedures such as cardiac, transplant and oncological procedures are at risk for developing pressure ulcers (Stotts, 1999). Several studies have shown that the use of pressure-reducing devices in the operating room will decrease the occurrence of pressure ulcers (Hoshowsky & Schramm, 1994; Nixon 1998). There are several pressure-reducing systems currently available in the perioperative setting including; air systems, gel pads, foam overlays and combined foam and gel overlays.

The cause of pressure ulcers is multifactorial including immobility, pressure from a hard surface, friction from being unable to move well in bed, shear from involuntary movements, poor nutrition, comorbidities (depression, dementia, diabetes mellitus, peripheral arterial disease just to name a few). Specifically, in the perioperative setting risk factors include; hypotensive episodes during surgery, low core body temperature during surgery and reduced postoperative mobility (NPUAP/EPUAP/PPPIA, 2014). 

It has been shown that wound dressings could be used as an effective adjunct to standard preventive measures against pressure ulcers (Brindle, 2009). Also, research by Gawlitta has shown that distorting stress delivered to a tissue is much more damaging than ischemia and the resulting cellular injury.

Although dressings could be used as an adjunct to ulcer prevention strategies they cannot replace them (Call, 2015). Specifically, Mepilex and Allevyn dressings were shown to reduce the forces of friction on tissues. In addition, 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 the reducing or redistributing stress on tissues. 

The road ahead: A look at recent interventions to address pressure ulcers in health care facilities

A 2015 Cochrane review examining different surfaces for pressure ulcer prevention was conducted. Several randomized controlled trials and semi-randomized controlled studies were reviewed. This review included studies which had a measurable objective data collected whereas those which had subjective data were eliminated from the systematic review. Patients included in the study were those who either had pressure ulcers or were identified as having risk factors for the development of pressure ulcers. In total, about 59 trials were included in this review and patients from 31 of those trials had pre-existing ulcers. There were eight randomized controlled trials which compared standard mattresses to specialty mattresses used to prevent pressure ulcers (Andersen 1982; Collier 1996; Goldstone 1982; Gray 1994; Gunningberg 2000; Hofman 1994; Russell 2003; Santy 1994). When compared with standard hospital mattresses, the incidence and degree of severity of pressure ulcers in patients considered high risk were signicantly reduced when patients were placed on either the cubed foam mattress (Comfortex DeCube) (RR 0.34; 95% CI 0.14 to 0.85) (Hofman 1994); the bead-filled mattress (Beaufort beadbed)(RR0.32; 95%CI0.14to0.76) (Goldstone 1982); the Softfoam mattress (RR 0.2; 95% CI 0.09 to 0.45) (Gray 1994); or the water-filled mattress (RR 0.35; 95% CI 0.15 to 0.79) ( Andersen 1982).                                                                                                      

In operating rooms, it is not clear what the most effective means of preventing ulcers is. A 2006 study by Nixon et al. showed gel-filled overlays to be significantly better than standard operating tables. However, a gel filled overlay on the operating table was less effective than an alternating pressure overlay (such as the Micropulse system) both intra and postoperatively (Aronovitch 1999; Russell 2000). However, due to inconsistency in interventions postoperatively in both arms of the study, even though there is clearly a reduction in pressure ulcer incidence associated with the alternating pressure system, it is not clear whether this is merely a result of better postoperative pressure relief rather than intraoperative interventions.

Previously the evidence for different alternating pressure devices was unclear due to the poor quality and small size of existing trials. This review includes a large, robust trial which suggests that AP mattresses are clinically as effective as overlays, but likely to be more cost-effective, and more acceptable to patients (Nixon, 2006).

In a recent cost-effectiveness analysis of intraoperative prevention of pressure ulcers in patients undergoing surgery (Pham, 2011), patients undergoing procedures lasting 90 mins or greater were included in this cohort study which showed that intraoperative prevention strategy decreased the estimated intraoperative incidence of pressure ulcers by 0.51% (number needing treatment 196 patients). The average cost of using the operating table overlay as an intraoperative prevention strategy was estimated at $1.66 per patient. Also, the study showed a decrease in both hospital and home care costs for treating fewer pressure ulcers originating in the perioperative setting.

A retrospective observational study conducted in a quaternary care institution in the Midwest involving 2,695 surgical patients showed that the only significant association in causing perioperative pressure ulcers is the use of intraoperative blood products. Of note, it did not show any significant association between pressure ulcers and case length, hypotension, vasopressor use (O’brien, 2014). However, data on preoperative hemoglobin and hematocrit and intraoperative blood loss estimates were unavailable for a large proportion of patients in the sample thereby limiting the results.

A University of Miami Miller school of Medicine study published in 2013 showed that several nursing practices both intraoperatively and outside of the operating room can prevent the development of pressure ulcers. This was a retrospective study which was conducted over a two-year period, and the prevalence of pressure ulcers was evaluated before and after the implementation of their pressure ulcer prevention program. This hospital is a major acute care academic hospital with about 560 beds. A total number of 305 patients were surveyed.

Through the use of innovative and focused multidisciplinary interventions, they were able to achieve a rate of zero incidences of hospital-acquired pressure ulcers in the operating room. Some of their strategies included; considering every surgical patient at risk for developing pressure ulcers, thorough skin assessments at the beginning as well as the end of every surgical procedure, pressure redistribution devices used on every surgical patient. Gel overlays are known to be effective in reducing pressure but are known to be less effective than air mattresses. Also, documentation of loss of skin integrity or breakdown, rashes or incontinence proved to be helpful in follow-up and continued monitoring of patients at risk. Another intervention included increasing the number of wound care nurses doing education on the risk of ulcers and the follow-up of known ulcers. Finally, documentation of the ulcers with a picture and registering that information in a systems-wide database was beneficial (Lupe, 2013). One of the major challenges with the implementation of this program was difficulty with the staff engagement which was addressed by creating incentive programs and remaining flexible in terms of time available to complete training modules.

Other factors such as increasing the number of wound care nurses in charge of follow-up of patients with ulcers and patients potentially at risk. Often, patients with stage I ulcers 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 full blown stage II or III ulcer. Also, standardizing perioperative report will serve as a reminder to nurses to mention a skin assessment as part of the routine report to the receiving floor. After a long case, nurses may neglect to mention stage I/ II ulcers on a cardiac surgery patient who coded four times during the procedure. Often the receiving nurse may incorrectly view that information as superfluous 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. The University of Miami medical center identified certain nursing practices such as inappropriate layering of bed linen which were noted to contribute to the development of hospital-acquired pressure ulcers. Staffing ratios can directly affect the quality of care that patients get and thus increasing the risk of getting pressure ulcers.

The basis of any intervention must include a complete skin assessment which should include skin temperature, color, turgor, moisture status, and integrity (Lyder, 2013). The primary goal of any proper skin care program is keeping the skin clean and dry while avoiding excess dryness and scaling. 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 skin.

According to an article by Thomas DR, patients at risk of developing pressure ulcers should have a protein intake of approximately 1.2 to 1.5 gm/kg body weight daily unless there is a medical contraindication. The National Pressure Ulcer Advisory Panel recommends providing 30-35 kcal/kg per day in adult patients with pressure ulcer at risk of malnutrition. And they recommend 35-40 kcal/kg/day if underweight or losing weight.

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 skin care champion
  • Minimizing barriers to obtaining necessary supplies such as special mattresses overlays
  • Obtaining additional expertise through consultations and the use of audit and feedback.

The On-Time Pressure Ulcer Prevention Program proposed by the AHRQ, a clinical decision support addressing a variety of risk factors including nutritional status, weight, and moisture has been shown to result in a lower incidence of pressure ulcers. The NPUAP recommends a consultation for surgical repair of stage III or IV pressure ulcers which do not close with usual treatment or if more rapid closure is required (NPUAP/EPUAP/PPPIA). Also, improving arterial blood flow has been shown to be beneficial in preventing pressure ulcers or helping pressure ulcers heal. Measuring the ankle-brachial index (ABI) is useful in ruling out peripheral arterial disease. 


In conclusion, from a nursing perspective, several actions could be implemented in preventing hospital-acquired pressure ulcers in the perioperative setting. However, any system-wide effort would have to be multidisciplinary with a focus on education and continuous efforts to reeducate staff on the implementation of successful interventions. 


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This course is applicable for the following professions:

Advanced Registered Nurse Practitioner (ARNP), Clinical Nurse Specialist (CNS), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Registered Nurse (RN)


CPD: Practice Effectively, Medical Surgical, Perioperative

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