Identification of Variables Predictive of Pressure Ulcer Development
Identification of Variables Predictive of Pressure Ulcer Development
This study examined variables predictive of pressure ulcers among patients undergoing urologic surgical procedures. Anesthesia duration and total time of the diastolic blood pressure was less than 50 Hgmm were statistically significant predictors. Dynamic pressure-relieving devices are recommended to reduce incidences of pressure ulcer incidence.
Patients undergoing surgical procedures are at risk for pressure ulcer formation during any phase of the peri-operative period for a variety of reasons. Patients who receive general anesthesia experience prolonged pressure on dependent body parts causing compression of a patient's skin and muscle between bones and the operating room (OR) bed. This unrelenting pressure has the potential for damaging skin integrity (Armstrong & Bortz, 2001). There are also other variables unique to the OR setting that also increase patients' risk for pressure ulcer formation. Aronovitch (1999) determined 23% of all hospital-acquired pressure ulcers occurred in the OR. Subsequent research has determined the rate of new pressure ulcer formation in acute care settings is between 0.4% to 38% (mean = 7%) (Stotts & Wu, 2007). Costs to treat pressure ulcers range from $2,000 to $30,000 but can be as high as $70,000 for a complex, full-thickness ulcer (Young, Evans, & Davis, 2003).
Pressure ulcer prevention is a priority for all health care organizations, and the Centers for Medicare and Medicaid Services (CMS) has identified Stages III and IV pressure ulcers as "never events" (CMS, 2008). This means that CMS will not reimburse care costs for serious pressure ulcers because they are considered a preventable situation. Science-based guidelines have been outlined by the Institute for Healthcare Improvement (IHI) in its 5 Million Lives Campaign (Duncan, 2007).
Pressure ulcer development in surgical patients often begins preoperatively and is associated with intrinsic factors, such as advanced age, obesity (body mass index [BMI] over 30), co-morbid conditions, mobility status, poor nutrition and hydration, steroid use, and hypotension (Bryant, 2002; Papantonio, Wallop, & Kolodner, 1994; Scott, Mayhew & Harris, 1992). There are inherent risks for pressure ulcer formation associated with surgery. Among these is the type of positioning device used in the surgical procedure. A positioning device is typically firm and holds a patient in place by placing pressure on bony prominences for the duration of surgery (Armstrong & Bortz, 2001). The administration of anesthesia alters blood pressure and tissue perfusion, and an alteration in hemodynamic status can result in hypoxic tissue formation. The decrease in blood pressure resulting from the use of general anesthetic agents may also contribute to the formation of pressure ulcers. Lewicki, Mion, Splane, Samstag, and Secic (1997) state this is particularly true when diastolic pressure is less than 60 mmHg. When skin-prep solutions pool, they may cause skin maceration and change the skin pH, making the skin more susceptible to pressure and friction (Armstrong & Bortz, 2001). Further, when health care providers place multiple layers of blankets and sheets under a patient, they can negate the pressure, reducing effect of a mattress overlay (Grous, Reilly, & Gift, 1997). Finally, any surgical procedure lasting more than 2.5 hours places the patient at significant risk for the development of pressure ulcers (Schoonhoven, Defloor, van der Tweel, Buskens, & Grypdonck, 2002).
Most research evidence regarding predictors of pressure ulcer formation has originated from long-term care, intensive care (ICU), and select acute care settings. The Braden Scale has been tested repeatedly for reliability (r = 0.83 to r = 0.99) and validity, and is widely recognized as a leading instrument for early identification of patients at risk for pressure ulcer formation (Bergstrom, Braden, Laguza, & Holman, 1987). The Braden Scale is a psychometrically sound instrument that has performed well in non-surgical patient populations. The predictive validity of the tool has been tested among patients in general nursing, critical care step-down, and adult ICU units (Feuchtinger, Halfens, & Dassen, 2007; Jiricka, Ryan, Cargvalho, & Bukvich, 1995). Recently, a new risk assessment scale has been developed for solely predicting pressure ulcers in ICU environments (Suriadi, Sugama, Thigpen, & Subuh, 2008). There is no single instrument that has been predictive of pressure ulcers that occur intraoperatively. Studies examining factors most likely associated with intra-operatively acquired pressure ulcers have not yielded a reliable and valid risk assessment tool specific to the surgical population (Edwards, Pandit, & Popat, 2006).
To date, investigation of pressure ulcer occurrence in the OR has involved primarily orthopedic, cardiovascular, and neurosurgical procedures (Edwards et al., 2006; Feuchtinger et al., 2007). Urologic surgery is a specialty area that has not been widely studied. Patients undergoing urologic surgical procedures face specific risks for pressure ulcer formation related to the manner in which they are positioned for surgery (such as lateral and lithotomy positions) and the duration of the procedures. Historical data from the study site indicate that the average OR time for a patient undergoing a urologic procedure is four hours. Research by Hoshowky and Schramm (1994) has shown the chance of developing pressure ulcers doubles in surgical procedures lasting over four hours. These individuals, despite any co-morbidities, are at risk for pressure ulcer formation.
Abstract and Introduction
Abstract
This study examined variables predictive of pressure ulcers among patients undergoing urologic surgical procedures. Anesthesia duration and total time of the diastolic blood pressure was less than 50 Hgmm were statistically significant predictors. Dynamic pressure-relieving devices are recommended to reduce incidences of pressure ulcer incidence.
Introduction
Patients undergoing surgical procedures are at risk for pressure ulcer formation during any phase of the peri-operative period for a variety of reasons. Patients who receive general anesthesia experience prolonged pressure on dependent body parts causing compression of a patient's skin and muscle between bones and the operating room (OR) bed. This unrelenting pressure has the potential for damaging skin integrity (Armstrong & Bortz, 2001). There are also other variables unique to the OR setting that also increase patients' risk for pressure ulcer formation. Aronovitch (1999) determined 23% of all hospital-acquired pressure ulcers occurred in the OR. Subsequent research has determined the rate of new pressure ulcer formation in acute care settings is between 0.4% to 38% (mean = 7%) (Stotts & Wu, 2007). Costs to treat pressure ulcers range from $2,000 to $30,000 but can be as high as $70,000 for a complex, full-thickness ulcer (Young, Evans, & Davis, 2003).
Pressure ulcer prevention is a priority for all health care organizations, and the Centers for Medicare and Medicaid Services (CMS) has identified Stages III and IV pressure ulcers as "never events" (CMS, 2008). This means that CMS will not reimburse care costs for serious pressure ulcers because they are considered a preventable situation. Science-based guidelines have been outlined by the Institute for Healthcare Improvement (IHI) in its 5 Million Lives Campaign (Duncan, 2007).
Pressure ulcer development in surgical patients often begins preoperatively and is associated with intrinsic factors, such as advanced age, obesity (body mass index [BMI] over 30), co-morbid conditions, mobility status, poor nutrition and hydration, steroid use, and hypotension (Bryant, 2002; Papantonio, Wallop, & Kolodner, 1994; Scott, Mayhew & Harris, 1992). There are inherent risks for pressure ulcer formation associated with surgery. Among these is the type of positioning device used in the surgical procedure. A positioning device is typically firm and holds a patient in place by placing pressure on bony prominences for the duration of surgery (Armstrong & Bortz, 2001). The administration of anesthesia alters blood pressure and tissue perfusion, and an alteration in hemodynamic status can result in hypoxic tissue formation. The decrease in blood pressure resulting from the use of general anesthetic agents may also contribute to the formation of pressure ulcers. Lewicki, Mion, Splane, Samstag, and Secic (1997) state this is particularly true when diastolic pressure is less than 60 mmHg. When skin-prep solutions pool, they may cause skin maceration and change the skin pH, making the skin more susceptible to pressure and friction (Armstrong & Bortz, 2001). Further, when health care providers place multiple layers of blankets and sheets under a patient, they can negate the pressure, reducing effect of a mattress overlay (Grous, Reilly, & Gift, 1997). Finally, any surgical procedure lasting more than 2.5 hours places the patient at significant risk for the development of pressure ulcers (Schoonhoven, Defloor, van der Tweel, Buskens, & Grypdonck, 2002).
Most research evidence regarding predictors of pressure ulcer formation has originated from long-term care, intensive care (ICU), and select acute care settings. The Braden Scale has been tested repeatedly for reliability (r = 0.83 to r = 0.99) and validity, and is widely recognized as a leading instrument for early identification of patients at risk for pressure ulcer formation (Bergstrom, Braden, Laguza, & Holman, 1987). The Braden Scale is a psychometrically sound instrument that has performed well in non-surgical patient populations. The predictive validity of the tool has been tested among patients in general nursing, critical care step-down, and adult ICU units (Feuchtinger, Halfens, & Dassen, 2007; Jiricka, Ryan, Cargvalho, & Bukvich, 1995). Recently, a new risk assessment scale has been developed for solely predicting pressure ulcers in ICU environments (Suriadi, Sugama, Thigpen, & Subuh, 2008). There is no single instrument that has been predictive of pressure ulcers that occur intraoperatively. Studies examining factors most likely associated with intra-operatively acquired pressure ulcers have not yielded a reliable and valid risk assessment tool specific to the surgical population (Edwards, Pandit, & Popat, 2006).
To date, investigation of pressure ulcer occurrence in the OR has involved primarily orthopedic, cardiovascular, and neurosurgical procedures (Edwards et al., 2006; Feuchtinger et al., 2007). Urologic surgery is a specialty area that has not been widely studied. Patients undergoing urologic surgical procedures face specific risks for pressure ulcer formation related to the manner in which they are positioned for surgery (such as lateral and lithotomy positions) and the duration of the procedures. Historical data from the study site indicate that the average OR time for a patient undergoing a urologic procedure is four hours. Research by Hoshowky and Schramm (1994) has shown the chance of developing pressure ulcers doubles in surgical procedures lasting over four hours. These individuals, despite any co-morbidities, are at risk for pressure ulcer formation.
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