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After the ABCs, skin?

Updated: Mar 14, 2023

Jennifer Nopoulos MSNEd, RN, CPAN

3/12/2023

It is well known to hospital peri-operative nurses the importance of preventing health care associated pressure injuries (HAPI). What may be surprising or omitted from peri-anesthesia nursing orientation is the importance of prevention during peri-operative care, and who is responsible for instituting necessary interventions. Upon transfer to inpatient units, RNs participate in “two RN skin checks” to assess for any signs of pressure injury, the two RNs being a frequent policy requirement to make sure this assessment is not omitted, which promotes best care and ensures accountability (Boyes, 2018). Quality assurance monitoring is still detecting post operative signs of pressure injuries, so all peri-anesthesia nurses should be providing consistent quality assessment, application of interventions, and clear communication throughout peri-operative care.

The literature records a wide range of peri-operative pressure injuries, from 4-45% (Kimsey, 2019). Those most at risk include older age (greater than 60), obesity, nicotine use, diabetes, and medical co-morbidities (Kimsey, 2019). Surgical factors are identified by many authors and include surgeries lasting more than four hours, type of anesthesia, blood loss, surgical position, support surface and limb positioning, and intra-operative drops in blood pressure (Kimsey, 2019 & Stanton, 2022). Skin risk assessments such as the Braden score or Waterlow scale can also identify higher risk patients (Monfre et al., 2021 & Martinez-Garduno et.al. 2019). Patients with traumatic injuries or likely facing post operative mechanical ventilation and prolonged bed rest are also at risk (Sarani & Martin, 2022). Pre-admission nurses (PATS) and pre-operative staff are the first to recognize these risks and should have a means of communicating their findings. If the trauma or ER patient bypasses pre-operative assessment and interventions, this responsibility falls to the OR and PACU staff.

In addition to assessment, pre-operative or surgical staff can apply either silicone bordered foam (Mepilex®), hydrocolloid or soft cellulose fluff core dressings, depending on facility policy and availability. These prevent damage to skin over bony prominences by reducing friction and shear (Stanton, 2022) and are proven to significantly reduce new pressure sores (Berlowitz, 2022). Patient education is recommended so patients understand the need for regular position changes.

Ideally, skin checks should be done by both OR staff and receiving PACU RNs, but other patient priorities take precedence in the immediate PACU minutes. The feasible intervention would be good communication, including assessed risks, position during surgery, and the location of any protective dressings (Wang et al., 2018). As soon as the PACU patient is stable, offloading from the surgical position and skin assessments are necessary, along with acquiring a wound care expert’s opinion for concerns (Kimsey, 2019). Documentation, SBAR communication, and observation with the accepting in-patient RN completes the peri-anesthesia nurse’s responsibility.

Adding skin assessment, documentation, and interventions to prevent pressure injury may be a new priority to peri-anesthesia nurses, but longer cases, patients with more comorbidities, and higher risk patients on our surgery schedules require these evidenced based nursing actions to start with us. Ensuring evidence-based policies and inclusion in orientation and continuing education for peri-anesthesia staff will ensure best practice.


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Berlowitz, D. (2022, Jan 10). Prevention of pressure-induced skin and soft tissue injury. UpToDate.

https://www-uptodate-com.ezproxy4.library.arizona.edu/contents/prevention-of-pressure-induced-skin-and- soft-tissue-injury?search=Prevention%20of%20pressure- induced%20skin%20and%20soft%20tissue%20injury.%20UpToDate.%20&source=search_result&selectedTitle=1 ~150&usage_type=default&display_rank=1

Boyes, C. (2018) 2 RN skin assessment for the prevention of hospital acquired pressure injuries. Poster presentation Retrieved from https://wocn.confex.com/wocn/2018am/webprogram/Paper11018.html

Kimsey, D.B. (2019, Sept 27). A change in focus: Shifting from treatment to prevention of perioperative pressure injuries. AORN. Doi.org/10.1002/aorn.12806

Martinez-Garduno CM, Rodgers J, Phillips R, Gunaratne AW, Drury P & McInnes E. (2019). The surgical patients’ pressure injury incidence (SPPII) study: A cohort study of surgical patients and processes of care. WP&R Journal; 27(2):120-128. https://doi.org/10.33235/wpr.27.2.86-9

Monfre, J. & Batchelor F., & Skar A. (Dec 27, 2021). Improving skin assessment documentation in the electronic health record to prevent perioperative pressure injuries. AORN. Doi.org/10.1002/aorn.13573

Sarani, B. & Martin N. (2022, Oct 25). Overview of inpatient management of the adult trauma patient. UpToDate.

https://www-uptodate-com.ezproxy4.library.arizona.edu/contents/overview-of-inpatient-management-of-the- adult-trauma- patient?search=Overview%20of%20inpatient%20management%20of%20the%20adult%20trauma%20patient&so urce=search_result&selectedTitle=1~150&usage_type=default&display_rank=1

Stanton, C. (2022, April 27). Guideline for prevention of perioperative pressure injury. AORN. Doi.org/10.1002/aorn.13681

Wang I, Walker R & Gillespie BM (2018, March). How well do perioperative practitioners implement pressure injury prevention guidelines? An observational study. Wound Practice and Research, 26 (1).

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Love it!!! Thank you Jennifer, good information to include in our assessments in the PACU!

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