Evidence-Based, Pressure Ulcers, Protocol, Skin Integrity



  1. Strasser, Leslie A.


ABSTRACT: The perioperative environment presents complex challenges for protecting patient's skin during surgery. At a large academic medical center, an assessment of resources, current knowledge, and data of reported skin events provided baseline information and the necessity of a skin integrity protocol. With an increased number of skin events in multiple surgical specialties and various approaches being taken to protect skin, an intraoperative skin integrity protocol based on evidence-based research and professional association recommendations was developed. Development of the protocol included variables specific to the surgical patient and special considerations for various patients. An educational presentation was given to staff to improve knowledge of skin integrity and how to implement the protocol. Following implementation, data indicated that skin events decreased with the use of an intraoperative skin integrity protocol. Using this framework, other nursing specialties can use an evidence-based research approach to develop protocols that will improve patient care.


Article Content

Each year, the patients at our large academic medical center are experiencing more skin integrity events. Many of the institution's nursing resources and recommendations for protecting patient's skin are not applicable or able to be fully implemented during the intraoperative period because of the variables of the surgical environment. Perioperative nurses are left with limited resources and knowledge about how to adequately protect and maintain skin integrity given the multiple variables each patient brings. This has led to a practice of staff doing what they believe is best, not always being based on evidence-based practice or professional recommendations but personal beliefs and reasoning. The goals of the project were to establish an intraoperative skin integrity protocol to standardize positioning based on evidence-based research, improve quality of patient care, and decrease skin events. Following the model used, nurses can implement this framework into their own practice to improve patient care and develop protocols specific to their patient's needs.

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Along with the decrease in complications associated with skin events, organizations can save money by preventing injuries. Currently, the Centers for Medicare & Medicaid Services (2011) do not reimburse the cost of treatment for Stage III or Stage IV pressure ulcers. As many of you know, a large volume of patients only have government insurance, so abiding by their standards can have a huge financial impact within an institution. It is estimated that the cost per patient for a hospital-acquired pressure ulcer is $43,180 (Armstrong et al., 2008). Even if pressure ulcers were the only type of skin events decreased, this would save thousands of dollars a year for the hospital. What is important to remember is that pressure ulcers and other skin events, such as blisters, skin tears, or erythema, are 100% preventable, so it is imperative to have the tools and resources in place to prevent harm to patients.



The process for collecting data about skin events at our large academic medical center, which is comprised of two hospitals, is through a phone line. Patient demographics, type of skin event, and complications related to the event are included in the report. Each month, data are tabulated for each department and specialty, with a list of every event that was called into the event line. The data collected for the 2010 Skin Impairment Events of the first quarter at our academic center revealed an increase in events of 35% as compared with the data from the 2009 first quarter events. In addition to the entire quarter, each month of the 2010 quarter saw an increase in events as compared with each month of the first quarter of 2009. Data showed that February skin events increased by 19% and March skin events increased by 39%, when comparing the 2010 first quarter to the 2009 first quarter. Data comparing the month of January was not available. Skin tears were the most frequently reported event, accounting for 25% of all skin impairments. Erythema and blisters were also elevated reportable events. The most frequently reported position was prone with 37% of skin breakdown events occurring. Each month within the first quarter of 2010, orthopedic surgery had the most frequent number of reported events. Because of the surgical specialty having a high volume of procedures done in the prone position, this specialty is determined to be a high-risk area for patients acquiring skin breakdown.


Upon further study of the data, it was noted that most skin tears were attributed to the removal of the surgical drapes. Upon examining the cause of blisters, most patients were placed in the prone position and the blisters were noticed when flipping the patients' back over after the procedure was done. Common areas of the blisters while in the prone position were the chest, hips, and knees.


When in the supine position, many patients who had blisters or erythema were found to have them on the heels or coccyx. There was not one common skin event attributed to a specific procedure while in the supine position in any specialty or overall between the two hospitals. The other positions reported were lateral, lithotomy, and beach chair. These did not have any common or specific skin events related to the position.


After examining the data, it is intriguing as to why the incidence rates of skin impairments increased each month during the first quarter of 2010. One explanation was that the number of surgeries typically decreases in January and slowly starts to increase as spring and summer approaches. Perhaps the increased rates are due to more procedures being done and the events are relative to the number of surgeries performed. However, when looking at the yearly data from 2009, the events did not significantly increase in the summer months when the highest amounts of surgeries are performed within the year. It is possible that the complexity of the surgeries are increasing each year and adding more time to each procedure, which invites the opportunity for skin breakdown. The institution being studied did not allow the author to review specific patient data or data regarding the number of surgical cases so the hypothesized explanations cannot be proven or disproven. Although there are many theories as to why the numbers are increasing, the data clearly demonstrate a need for standardized positioning, padding, and protection of the skin, which is evidence-based and proven to be best practice during the intraoperative period.



The author completed face-to-face interviews with a Surgical Services Registered Nurse in each subspecialty. After meeting with a nurse from each surgical specialty, there were areas of practice that followed current guidelines and those that needed correction. During the interviews with each nurse, there was a discussion as to what concerns the specialty has with protecting skin integrity during the perioperative period and how to correct known problems. All of the concerns within the assessment of the various specialties helped form a base of knowledge of what we currently were doing right and how our care could improve.


The specialties that were included in this phase of the assessment were urology, EOPPO (ears, nose, throat, oral, pediatric, plastics, and ophthalmology), vascular/thoracic, general, orthopedics, neurology, cardiac, and gynecology surgery. The major current issue for urological patients is whether or not it is appropriate to tuck the arms when in the supine position. Staff are instructed to tuck the arms for certain procedures that require the arms at the sides of the patient to be able to access the surgical field. This involves taking a draw sheet and wrapping it over the patient's arms, which have been covered with gel pads, and tucking them underneath the mattress. The specialty would like to determine if tucking the arms should be for every patient or just when surgically necessary. Other concerns were pressure ulcers on the coccyx while in the lithotomy position and then being placed in Trendelenburg. The patients seem to slide when changing the position of the table, which causes certain pressure relieving devices to become dislodged and not remain in the appropriate position to be effective.


The common positioning problems that staff face in EOPPO is trying to get enough exposure of the surgical site for the surgeon while still providing support during long and complex surgeries (i.e., facial reconstructions and skin grafting). Being able to make sure the patient is properly positioned but still has support and relief from pressure is difficult when three surgeons are involved and all have different needs and requirements for their portion of the surgery. Common problems in vascular/thoracic included wrinkling of the draw sheet, the bean bag wrinkling and causing pressure, the axillary rolls not being used on the right side for protecting skin contact and the Ioban or Steri-Drapes causing skin tears.


For general surgery, because there is a rising population of obese patients and the facility is unequipped with the proper positioning aids needed, much of the strategies are improvised as best as possible. An example was given that a patient coming for a gastric bypass was too wide for one surgical table, so two operating room (OR) beds were brought in and locked together to provide a surface that was large enough for the patient. Because of the rising obese patient population, many incidents of pressure ulcers are due to a lack of proper load bearing support with the aids available and the patient's large body mass. Discussing these issues with a nurse from this specialty helped us both realize how much we need to develop a protocol and devise solutions to protect these patients in all surgical specialties.


When reflecting on the data from the skin events of the first quarter of 2010, orthopedics had the highest rate of skin events and most were due to the prone position. With such complex and new surgeries, many times the operation can be at least 10-12 hours long and the patients cannot be repositioned or moved. In neurology, the length of complicated spinal procedures tends to cause problems with an inability to move the patient and the pressure of being in the prone position for an extended time period. Some staff described the table as a hazard in itself because the support structures impact pressure even with additional padding.


The positioning seen in cardiac is mainly in the supine position because the incision type is mostly made through a sternotomy. This causes the patient to be lying flat for an average of 6 hours, and many have additional intrinsic risk factors for acquired skin events. A concern for nurses is providing support under the knees and ankles while having access to the legs for surgeons to harvest the saphenous vein for coronary artery grafting. Manipulating the leg can shift positioning devices and causes the heels to lie directly on the bed. Another concern noted was that it is difficult to secure the arms of larger patients and supportive devices, such as toboggans, are only useful to a degree. Furthermore, surgical staff have trouble seeing into the chest with wider patients, and they can cause compression while leaning over the arms to get a better view.


For staff working in gynecology, some staff raised the concern that patients with large thighs tend to rest up against the metal of the stirrups. Trying to pad between the skin and the metal stirrups can be difficult given the degree of exposure necessary and the size of the patient. Another problem is whether it is necessary to tuck the arms. An example of a complication of tucking a patient's arms could include compartment syndrome. This condition occurs when fascia in the arms or legs is unable to adjust to high pressure, and blood flow is obstructed to the area. The swelling that follows can lead to permanent nerve and muscle injury (PubMed Health, 2011). If the arms are being tucked too tightly and compartment syndrome occurs, there can be a need for an emergent fasciotomy.



A review of information available to employees regarding skin integrity was performed and revealed a lack of educational resources available to protect the skin of patients during the intraoperative period.


Within the Department of Surgical Services, the only guideline, protocol, or procedure related to skin integrity was a protocol on draping the patient. This document only focused on when the patient should be draped, who should be responsible for draping the patient, and how to maintain the sterility of the drapes. There was no mention of how to protect the patient's skin from the adhesive of the drapes or how removal of the drapes in a careless manner increases the risk of skin tears, blisters, and abrasions.


The intranet at our large academic medical center had more information related to this subject within the nursing division at the institution. A search of the Department of Nursing intranet revealed limited information for skin care of the anesthetized patient who is unable to be turned or repositioned every 2 hours. The information was aimed at nurses who work with patients in the inpatient/outpatient setting.


One document under Nursing Guidelines was the Nursing Diagnosis Guideline: Risk for Impaired Skin Integrity. It identified risk factors of impaired skin integrity and included assessment tools available for nurses to use for determining high-risk patients. The guideline covered skin surveillance, pressure ulcer prevention, skin care with topical treatments, pressure management, and nutrition therapy. Further examination of the guideline revealed that only the pressure ulcer prevention section contained information that could be applied to the intraoperative patient. This section recommended thorough documentation of any previous skin injuries, positioning with pressure relieving devices, using lift sheets to transfer patients higher in the bed/table, and inspecting bony prominences for signs of pressure ulcer formation. Although it was guided toward the patient in the inpatient/outpatient setting, there was information that could be applied to perioperative nursing care.


The other document found was the Procedural Guideline: Skin Tear Management. This provided information on how to correctly care for a skin tear after it has just been identified. Information on how to appropriately stage the wound was given as well as how to correctly document the injury. A flow chart of managing skin tears was provided based on the characteristics of the wound. The dressing that should be used was identified, as well as how different products are appropriate based on the severity of the skin tear. This chart is very useful as it provides clear direction on the recommended practice for treatment of skin breakdown.


For patients who are on the inpatient care units, intensive care units, and outpatient settings, the information available to nurses is thorough and addresses the common issues seen in maintaining good skin integrity. However, for perioperative nurses, there is a large gap in the amount of information and lack of recommended practices for intraoperative skin breakdown prevention and treatment. This review of available educational resources for surgical staff is another clear indicator of the need for a protocol for maintaining skin integrity of patients during surgery.



Once the need for a protocol was identified, the information to be included was collected. This was accomplished through conducting a literature review of at least 15 peer-reviewed articles related to current evidence-based practice of prevention and treatment of perioperative skin breakdown. In addition to the professional literature, information was obtained from a clinical nurse specialist who focuses on skin integrity and with a member of the Pressure Ulcer Workgroup within Surgical Services at a large academic medical center.


Variables Addressed Within the Protocol

Because the environment that the patient is in during the intraoperative period is very different than other portions of the admission, it was important to address the intrinsic and extrinsic factors affecting skin integrity. Intrinsic factors are those that the patient has him or herself and we have little or no control over. Extrinsic risk factors are the variables that we have control over and are outside of the patient.


The Braden Skin Scale is used to tabulate a score that can indicate the risk of pressure ulcer development (Rothrock, 2007). Although some studies have deemed a score of 16 or lower to indicate risk, the institution as a whole uses a score of 18 or less for identifying high-risk patients. This reinforces the importance of proper use of the scale when admitting patients and how this number can affect care provided.


One of the most indicative factors for acquiring a skin event is time. Although multiple studies have been conducted to see how much time must pass before risk is involved, some studies have shown that any procedure over 3 hours long can lead to risk (Armstrong & Bortz, 2001). Most cardiac, general, thoracic, orthopedic, and vascular cases last at least this long so patients are at a higher risk for skin events to occur. According to Sewchuk, Padula, and Osborne (2006), cardiac procedures have the highest rate of pressure ulcers due to the length of a typical surgery.


Diabetic patients are at a higher risk because of the problems involved with their vessels and any organ damage accrued by the disease. Patients with diabetes are three times more likely to develop a pressure ulcer than nondiabetic patients (Armstrong & Bortz, 2001). Recognizing how this disease will impact the skin of patients will help to better assess what protective devices they can benefit from.


Multiple studies have concluded that advanced age is an intrinsic risk factor. Any patients over 65 are deemed as being advanced in age, with older patients being even at higher risk than those who are 65 (Armstrong & Bortz, 2001). The change in patients' skin as the aging process occurs makes them more susceptible to acquiring injuries, so it is important that they have extra protection. Patients who are not properly nourished cannot properly heal or protect their bodies from injury. Having a low serum protein, such as albumin levels, has been shown to increase risk (Walton-Geer, 2009). Making sure that the laboratory values for nutritional status are within range is important to consider, as well as what steps can be taken to try and correct them if needed. Additional comorbidities that act as risk factors include cancer, cardiovascular and peripheral vascular diseases, neurological diseases, and respiratory diseases (Walton-Geer, 2009). Many patients have one or more comorbidity causing multiple intrinsic risk factors. These conditions alter the body and how it is able to respond to trauma and other injuries it sustains.


A patient's hemodynamics can impact how he or she is able to nourish skin with an adequate blood supply. Certain anesthetic agents, vasoconstrictive drugs, decreased hematocrit and hemoglobin, being on cardiopulmonary bypass, having an intra-aortic balloon pump, and being on extracorporeal membrane oxygenation are all risk factors (Sewchuk et al., 2006). These variables combined are all fairly common for occurring in cardiac surgery, so being prudent about adequate protection and positioning devices is important given the multiple risk factors acquired.


Body temperature is an important intrinsic factor to consider. Many patients are cooled down during surgery, and the use of warming devices helps them return to normothermia. If a patient is too hot, the sweat can cause moisture around the tissue and lead to maceration. However, when patients are too cold, vasoconstriction occurs, which increases the risk of skin breakdown because the skin gets less blood flow. Using warming devices or turning up the heat in the OR can counteract these problems to prevent rapid changes in body temperature. The purpose of the warming device is to help the patient return to normothermia, but the side effect of warming can cause the patient to sweat, which ultimately can lead to maceration. It is important to note that warming devices can be a help or a hindrance if not being used appropriately.


Many of our patients are immobile during surgery. Being taught to change a patient's position every 2 hours is not feasible in surgery. If patients are on life-sustaining machines and return to the OR for procedures, being aware of their mobility status before entering the OR will also indicate the risks associated with their skin. Although mobility is assessed in the Braden Skin Scale, it is not measured when the patient is under anesthesia and has no control or voluntary body movements. Also, patients who have neurological problems that cause paralysis are also at an increased risk for skin events. Because many variables are risk factors that are directly related to the surgical experience, surgery itself is becoming a risk factor (Armstrong & Bortz, 2001). Given this, we need to treat all patients as if they are at risk for developing issues with skin integrity.


As previously mentioned, heat can also act as an extrinsic factor because body temperature is directly correlated to changes in the vascular system, which can alter how the skin is able to adapt to changes. The phenomenon of shearing, "defined as the applied force that can cause an opposite, parallel sliding motion in the planes of an object," is another factor that impacts perioperative patient skin integrity (Walton-Geer, 2009, p. 540). This can occur if a patient is not secure on the table and it is being tilted during a procedure. Making sure that patients are not sliding when on the bed and that the patient is properly secured on the bed can avoid this phenomenon.


Friction is "a superficial, mechanical force directly against the epidermis, resulting in increased susceptibility to ulceration" (Walton-Geer, 2009, p. 540). One example of when this can occur is when using a slider board to transfer a patient from a cart to the OR table and a sheet is used to cover the board. The sheet is dragged and rubs against the skin, causing friction.


Moisture can cause damage by decreasing the elasticity of the skin when it becomes overhydrated. Maceration occurs with excess moisture whether it is directly from the patient or from prep solutions that have pooled on the skin. Making sure that solutions have dried before draping the patient, that none has pooled underneath him or her, and that the patient is not sweating during the case will protect that patient from any injuries.


Time, as an extrinsic factor, has been discussed in relation to the length of surgery (St. Arnaud, 2008). The way time impacts skin can include the time an amount of pressure is on tissue and how that tissue is responding. Capillary refill pressure is approximately 32 mm Hg, and when it is exceeded, tissue ischemia begins leading to tissue death (Rothrock, 2007). Therefore, a short length of time with high pressure can have just as much damage as a low amount of pressure over a long period of time (Walton-Geer, 2009).


An additional extrinsic variable is the type of mattress that the OR table is comprised of. Lying for hours on a type of mattress can make a lot of difference in how the patient is able to respond to tissue pressure. Studies have shown that standard foam mattresses cause more injuries than gel mattresses (AORN, 2009). Many of the mattresses at our institution are tempurpedic and are primarily comprised of gel. Some areas are currently using foam pads or egg-crate-type padding, but this is shown to be not effective as it bottoms out and provides no or little relief, especially with obese patients (Dybec, 2004). The research showed that air overlay mattresses are best at pressure redistribution, but this is not a realistic option because they cannot be thoroughly cleaned between the uses of patients (Armstrong & Bortz, 2001). Therefore, the best option is a gel mattress with the use of additional gel pads if necessary.


Special Populations Addressed Within the Protocol

Recently, we have seen an increase in the patient population of obese patients. These individuals pose unique challenges as not all of the equipment can suitably position and protect patients during a procedure. As with all patients, it is important to only use positioning devices that are designed to position patients and not designed for an alternative use. Sheets should never be used as a safety strap, so if one is not long enough, connect two together to secure the patient (Dybec, 2004). Extra gel pads can help provide extra pressure relief in addition to the mattress. If a toboggan is needed to hold the arms, wrap them in gel pads or place on foam crates but do not use bath blankets as it creates more pressure (AORN, 2009). Bed extensions should be attached if the patient is not supported on the sides of the table (Grahling, 2003). Because not all beds have extensions, using extra armboards on the lower part of the bed can add additional width to the table (Dybec, 2004). With a large patient, verify the amount of weight the bed is able to support and, if necessary, change the OR table if it is unable to support bariatric patients.


Pediatric patients have special needs because of their growth and development changes that adults do not present with. Not a lot of research has been done on the positioning and skin integrity challenges of pediatric patients in the intraoperative setting. Opposed to adults, the areas of skin breakdown are more common on the occiput, sacrum, ear lobes, and heels (Butler, 2006). Because the gel donut is too large for some children and infants, placing a gel overlay under the head can protect the occiput and ear lobes (Butler, 2006). As pillows are sometimes too large to be placed under the legs to elevate the heels, one can place an egg crate under the legs or a rolled gel pad instead (Butler, 2006). Do not use objects that are not specifically designed for surgical positioning, such as intravenous bags (Denholm, 2010). If the proper aids are not available, it is important to notify the correct personnel to order suitable and approved equipment.


All of the recommendation and statements within the protocol can be linked back to a credible article that promotes the practice and is evidence-based. By having a rationale behind each instruction, it was hoped that the protocol would be easier to implement and better received by staff. A copy of the protocol is seen in the Appendix.



On the basis of the assessment data that were collected, staff was lacking specific knowledge regarding skin integrity and best practices. For the implementation phase, the first strategy was to deliver an educational presentation regarding skin integrity and the proposed protocol to staff in a monthly update meeting. Given that there are surgical divisions at both hospitals within our medical center, the author gave the presentation to one hospital 1 week and the other hospital on the following week. The presentation audience members included nurse managers, nurse educators, registered nurses, certified surgical technologists, and surgical core technicians. Between the two sites, information was presented to a total of 424 staff members. For any staff that was not able to attend the educational offering, the presentation was taped and is on the internal Surgical Services Web site for staff to refer to.


The second step was to administer the survey to staff that were at the presentation. The purpose of the survey was to assess knowledge gained from the educational presentation and allow staff to give us comments and feedback on what additional education or support they would need to implement the protocol. The results from the survey assisted the presenter in determining if the presentation was effective and if additional education was necessary. Our facility uses electronic survey software, so the survey was formatted into the software and e-mailed to everyone who attended. When staff go to an educational meeting, their nametags are scanned into a system that tracks attendance. This sheet was used to send the survey to the appropriate personnel.


Some of the suggestions that staff had in the postpresentation surveys were to purchase more gel pads because other alternative equipment were deemed not useful. Completing a thorough inventory of supplies will determine what we still need and if any specialties are missing specific protection devices that they need to be compliant with the protocol. Once the protocol was approved, all the ORs and store rooms had their equipment removed that we should not be using so staff does not take it when other supplies are not readily available. Not only will staff be more likely to use the right equipment but it will also help with saving space and making room for appropriate items.


Lastly, the final strategy was to submit a copy of the protocol to the Surgical Services Administration for consideration as an approved protocol. The document was sent to a Procedures and Protocol Committee for consideration. Following approval, the protocol was included within the Policies, Procedures, and Guidelines in Surgical Services.



As the educational presentation and protocol was initiated in the late fall of 2010, the data from the first quarter of 2011 can be used to tabulate how changes were seen in a surgical quarter after implementation. The data collected for the 2011 Skin Impairment Events of the first quarter at a large academic medical center revealed an increase in the total number of events compared with the first quarter of 2010, but the number of events decreased each month of 2011 (Figure 1). However, this is largely because of an increase in events during the month of January 2011. When evaluating the data from December of 2010 to January of 2011, events increased by 29%. The data of January of 2010 reveals that this is an increase of 87% when measuring the reported events of January of 2011. Comparing the events of January and February of 2011, events decreased 36%. Skin impairment events continued to decrease from February to March of 2011 by 10%. Although the cumulative data displays an increase in skin impairment events, the continual decline of events each month demonstrates a positive change in patient outcomes.

Figure 1 - Click to enlarge in new windowFIGURE 1. Number of skin events in surgical services for the first surgical quarter.FIGURE 1. APPENDIX Number of skin events in surgical services for the first surgical quarter.

Skin tears continue to be the most frequently reportable event accounting for 29% of reported skin impairments. Erythema and blisters were also frequently accounted as was the same type of events reported in 2010. The most frequently reported position that acquired an event was the supine position, accounting for 43% of reported patient positions. This actually changed, as the first quarter of 2010 had a larger volume of skin events reported in the prone position. Evaluating the data did not reveal one specialty that had a larger number of patients in supine position related to certain events. Of all the surgical specialties, neurology had the largest volume of reported events. This may be because of the variables associated with the types of surgeries that the events happened with, such as long spinal stabilization and fixation procedures.


Examination of variables attributing to skin tears revealed them to be primarily because of the removal of drapes and the high volume of patients with fragile skin. Erythema was most noted when patients were in prone position. The trends in the data showed that no changes were noted for patients in the lateral, lithotomy, or beach chair position. Data trends did not show changes related to events of hematomas, pressure ulcers, abrasions, burns, and lacerations when compared to the first surgical quarter of 2010.


The data demonstrate that, although the overall comparison of the data shows an increase in events, the monthly decrease demonstrates a positive change. This special cause variation in the data for the month of January could have been influenced by the educational in-service regarding the protocol that was delivered in November. Nurses may have been more aware of their patient's skin condition and more diligent in using the event line to report skin breakdown. Another explanation for the surge could be that the complexity of the surgical cases that month was greater than normal, which invited more events to occur in very ill patients. Although there is not a definite way to determine the cause of the increase of events for this month, the continual drop in rates during the following months are supportive of a protocol that is making a difference in the skin protection of patients. Except for the month of January, the number of reported events for February and March were lower in 2011 than in 2010. This helps to further prove the success of the protocol and positive impact that is indicated in the data.


One limitation of the data is that in-depth statistical analysis was not performed. Because of institutional confidentiality and the methods used for data collection, information including the specific numbers of cases, patients, and patient characteristics were not used in the evaluation phase. Further analysis is necessary to determine the statistical significance of the changes seen.



Using the knowledge of how skin is affected during a surgical operation can be beneficial for nurses in a variety of settings. Becoming aware of the conditions a patient's skin will be exposed to during an operation can make nurses caring for these patients before and after surgery more informed. Certain skin conditions may worsen after an operation because of the intraoperative milieu, and knowledge of the variables and protection methods can enhance postoperative care.


On the basis of the increased complexity of surgical cases and the need for various positioning techniques, it is important to have a discussion with the surgical team as to what type of positioning techniques are vital to the procedure and which can be foregone to prevent complications. Being aware of the potential complications related to some positioning techniques is important during this discussion. Determining what is necessary versus what is most convenient can be a hot topic for some surgical teams but is in the best interest of the patient.


For any nursing intervention to be successful, it is vital to complete a thorough assessment of the patient. A skin assessment needs to include a Braden Skin Score or another approved skin scoring scale, intrinsic risk factors, and extrinsic risk factors that could affect the patient during the intraoperative period. Because the perioperative nurse has more control over the extrinsic risk factors, taking measures to minimize their impact is key in preventing skin breakdown.


With the abundance of a variety of positioning aids, only use those that are designed for their specific use and deemed effective. Avoid the use of bath blankets, sheets, and towels to pad or protect a patient because these only cause more pressure. When available, gel products are the best aids to use as they promote even pressure distribution and ensure skin protection. Special populations can present unique challenges for positioning and protecting skin but always use approved positioning devices for the safety of the patient.


The surgical team is comprised of various levels of expertise and knowledge. All members should be included and their input respected when positioning the patient. Communication is key in preventing injuries from occurring, and communication breakdown can lead to skin injuries.


The framework used to create this protocol can be adapted and used in a variety of settings to develop evidence-based protocols for different institutions. For purposes of this study, the perioperative environment related to patient's skin integrity was used, but the possibilities of changing the setting, patient, and clinical issue are endless. Using this model can empower nurses to make changes needed in their practice to improve the quality of patient care.



Although some variations have occurred since the initiation of the protocol, the changes seen have revealed that standardized patient positioning, padding, and protection of the skin has improved using evidence-based guidelines and practices. Perioperative nurses face a unique challenge of having to always remember there is a person underneath all the drapes who cannot tell us if he or she is uncomfortable or in pain. It is our job to protect patients and make sure no additional injuries occur while under our care. Within the findings of this project, it was found that developing and implementing an intraoperative skin integrity protocol based on evidence-based research and recommended practices can reduce the number of skin events within the perioperative environment.




AORN (2009). Recommended practices for positioning the patient in the perioperative practice setting. Denver, CO: Author. [Context Link]


Armstrong D. G., Ayello E. A., Capitulo K. L., Folwer E., Krasner D. L., Levine J. M., Sibbald R. G., Smith A. P. S. (2008). New opportunities to improve pressure ulcer prevention and treatment: Implications of the CMS inpatient hospital care present on admission (POA) indicators/hospital-acquired conditions (HAC) policy. A consensus paper from the International Expert Would Care Advisory Panel. Journal of Wound, Ostomy and Continence Nursing, 35 (5), 485-492. doi: 10.1097/01.WON.0000335960.68113.82. [Context Link]


Armstrong D., Bortz P. (2001, March). An integrative review of pressure relief in surgical patients. AORN Journal, 73 (3), 645-648, 650-653, 656-657 passim. [Context Link]


Butler C. T. (2006, September-October). Pediatric skin care: Guidelines for assessment, prevention, and treatment. Pediatric Nursing, 32 (5), 443-450. [Context Link]


Centers for Medicare & Medicaid Services. (2011). Hospital-acquired conditions. Retrieved from[Context Link]


Denholm B. (2010, July). Clinical issues: Using IV bags to position patients. AORN Journal, 92 (1), 106-107. [Context Link]


Dybec R. B. (2004, July-September). Intraoperative positioning and care of the obese patient. Plastic Surgical Nursing, 24 (3), 118-122. [Context Link]


Graling P., Elariny H. (2003, April). Perioperative care of the patient with morbid obesity. AORN Journal, 77 (4), 802-805, 808-819, quiz 820-821, 823-824.


PubMed Health. (2011). Compartment syndrome. Retrieved from[Context Link]


Rothrock J. C. (2007). Positioning the patient for surgery. In Heizenroth P. A. (Ed.), Alexander's care of the patient in surgery (13th ed.). St. Louis, MO: Mosby Elsevier. [Context Link]


Sewchuk D., Padula C., Osborne E. (2006, July). Prevention and early detection of pressure ulcers in patients undergoing cardiac surgery. AORN Journal, 84 (1), 75-96. [Context Link]


St-Arnaud D., Paquin M. (2008, June). Safe positioning for neurosurgical patients. AORN Journal, 87 (6), 1156-1168, quiz 1169-1172.


Walton-Geer P. S. (2009). Prevention of pressure ulcers in the surgical patient. AORN Journal, 89 (3), 538-548, quiz 549-551. [Context Link]


Intraoperative Skin Integrity Protocol

APPENDIX. Patient Safety: Skin Integrity

Content Applies To





Mayo Rochester Hospital Surgical Services



The purpose of this policy is to define the correct way to position patients and protect them from acquiring skin impairments as a direct result of surgical positioning. Special considerations are listed for the current needs of the patient population. Appropriate treatment of skin injuries with recommended products and dressings are to be performed when necessary.

Key Terms


Supine: lying flat on one's back or with the face pointed upwards


Prone: lying with the front or face downward


Lateral: situated at or laying on the side


Lithotomy: lying on one's back with their hips and knees flexed and thighs are apart


Beach Chair: in a sitting position, with the head of the bed elevated to at least 70[degrees] and the lower portion of the bed lowered


Obese: a patient with a body mass index of 30 or more


Pediatric: pertaining to infants, children and adolescents


Skin Impairment: any alteration of the skin that was due to a direct result of the operation or procedure being performed which can include a pressure ulcer, burn, blister, skin tear, abrasion or erythema


Gel Products: a positioning device made from polymer elastomer gels which are pliable, resemble the composition of skin and conform to the body part to distribute pressure


Positioning Device: products made for immobilizing, positioning, and providing pressure redistribution during a surgical operation which are proven effective and safe for patient use


Pressure Redistribution: the act lowering the interface capillary interface pressure, which is the amount of pressure needed to close the capillaries and impair tissue blood flow leading to cellular death and is 32mmHg in healthy adults, as compared to the pressure of a regular surface such as an operating table

Policy Statements


Protecting patient's skin and positioning correctly according to evidence-based research optimal perioperative patient outcome.


Patient emergencies may necessitate waiving temporarily one or more of the recommended positioning steps.


Unique patient characteristics may prevent some positioning techniques from being applied. All positioning and protection of patient's skin should be used with approved positioning devices and pressure redistribution aids.



All patients should be positioned with the recommended positioning devices and techniques applicable to the surgical position.


Positioning the patient is a team effort and the adequate number of personnel should be available to safely position the patient for surgery.


Documentation of the position(s) used during the operation and the positioning aids used should be documented in the electronic medical record.


All positioning devices should be thoroughly cleaned and disinfected before use on another patient.


Positioning aids which are broken, unable to be properly cleaned or not working properly should be brought to the nurse manager's attention.




* A gel-donut is placed under the head. If the donut causes too much extension, a gel pad can be placed under the head as an alternative.


* At least two pillows are placed under the knees ensuring the heels are hanging free and not in contact with the mattress.


[white circle] Under no circumstances should blankets or towels be used to elevate an extremity


* A safety strap is placed above the knees


* If the patient is pregnant of morbidly obese, place a gel wedge under the patient's right side to prevent supine hypotensive syndrome


* Place additional gel pads and overlays over the mattress or pressure point areas for additional pressure redistribution and skin protection


* If the patient will be tilted throughout the surgery, attach a padded footboard


* Place arms at sides on padded arm boards and secure with a safety strap or a towel three inch tape


[white circle] If it is surgically necessary to tuck the patient's arms, make sure the draw sheet covers the patient's elbow and hand. Wrap the arm with a gel pad, which can be covered with a pillowcase, and secure between the patient and the mattress. Pad all IV connection sites with gauze. Ensure hands are place in a neutral position at the sides. Verify with anesthesia personnel that all IV lines are working properly.




* Face is placed in a foam or gel headrest


* Two gel chest rolls are aligned to lie under the patient's chest, extending from the clavicle to iliac crest. The chest wall is still able to expand and abdomen is free from pressure


* Pillows are placed under the knees, shins and ankles making sure the toes are free to hang over the edge of the bed


* Arms are placed at sides on padded arm boards flexed at 90 degrees and secured with a safe strap or a towel with three inch tape. Alternatively, arms are placed in padded arm cradles and secured appropriately.


* A safety strap is placed over the back of the thighs


* Compression or pressure of the breasts is avoided with female patients


* Compression or pressure of the genitalia is avoided with male patients




* A pillow or gel headrest is placed under the patient's head. Care is taken to ensure the ear is not folded or compressed in an inappropriate manner.


* The upper arm is placed on a padded arm board and secured with a safety strap or secured with a towel and three inch tape


* The dependent arm is placed on a padded overarm board and secured with a strap or secured with a towel and three inch tape


* A gel roll is placed between the bed and the axilla on the depended site of the body


[white circle] Sandbags or IV bags should not be used to provide support


[white circle] Beanbags should not be used unless surgically necessary and ordered by the consultant. If used, cover the surface which the patient will have direct contact with gel overlays.


* Two pillows are placed between the thighs, legs, and ankles with the lower leg slightly flexed


* A safety strap is placed over the hips and lower legs




* A gel-donut is placed under the head. If the donut causes too much extension, a gel pad can be placed under the head as an alternative.


* A gel overlay is placed where the coccyx will be. If the patient's suffers from lower back pain, a gel wedge can be placed under the lumbar area.


* The legs are lifted simultaneously and placed in stirrups. When possible use the Yellow Fins as they provide a large area for support. Assess that the legs are not resting on any metal or posts from the stirrups.


* Keep the stirrups as low as possible


* Place the arms on padded arm boards and secure with a safety strap or towel and three inch tape


[white circle] If it is surgically necessary to tuck the patient's arms, make sure the draw sheet covers the patient's elbow and hand. Wrap the arm with a gel pad, which can be covered with a pillowcase, and secure between the patient and the mattress. Pad all IV connection sites with gauze. Ensure hands are place in a neutral position at the sides. Verify with anesthesia personnel that all IV lines are working properly.


Beach Chair


* Place a gel overlay where the hips will be and verify with patient that it is comfortable for them upon transfer to the operating table


* At least two pillows are placed under the knees ensuring the heels are hanging free and not in contact with the mattress.


[white circle] Under no circumstances should blankets or towels be used to elevate an extremity


* A safety strap is placed above the knees


* Arms are placed on lap resting on a pillow or secured on padded arm boards which are parallel to the floor


* A head frame is appropriately attached and any metal from the device is not causing compression on the rest of the body


Special Considerations for Obese Patients


* Only use approved positioning devices for patients


* If necessary, use an extra long safety strap


[white circle] Sheets should not be used as a safety strap


* Use gel pads and additional foam to pad arms in a toboggan and not blankets or sheets


* Always use bed extensions to support areas of the body that hang off the edges


[white circle] Use additional arm boards at the lower end of the bed for additional width and support of the lower extremities if bed extensions are not available for a particular table


* Verify that the bed is able to support the weight of the patient before the patient enters the operating room


Special Considerations for Pediatric Patients


* Use a gel overlay under the head as skin breakdown occurs more often on the occiput and ear lobes


* Suspend legs with a rolled gel pad under the knees so the heels are free the hang


* Do not use any objects that are not approved as positioning devices or skin protection aids



Skin Tears


* Category I (no tissue loss)


[white circle] Approximate edges with Steri Strips and cover with vaseline gauze


* Category II ( complete tissue loss)


[white circle] Irrigate the wound, apply vaseline gauze, wrap with a Kerlix roll


[black small square] If area of injury is unable to wrapped with a Kerlix roll, cover with 4x4 sterile gauze




* Do not pop blisters as ones intact are less likely to become infected and heal faster


* If blister is open irrigate the wound before placing a dressing


[white circle] Cover blister with vaseline gauze and wrap with a Kerlix roll or cover with 4x4 sterile gauze




* Apply a triple-antibiotic ointment and cover with a barrier spray


Special Considerations for Treating Skin Injuries


* Do not cover a wound with a Tegaderm or Primapore dressing as the adhesive can cause more damage and prevent faster healing


* If a medicated ointment is necessary, have the consultant place an order to continue treatment of the wound once the patient leaves the operating room


* If treatment of a wound is questionable, always defer to the consultant


* Any time a skin event occurs remember to call the event line 127-890


Documentation is Completed in the Electronic Medical Record


* Documentation of the position and positioning aids used is completed in the electronic medication under the appropriate section


* If a skin event occurs, documentation of the wound, treatment provided and a report of actions taken is documented in the post procedure notes



Copyright. Mayo Foundation and Medical Research. All Rights Reserved. 2011.