A pressure injury, also known as a pressure ulcer or bedsore, is a localized area of damage to the skin and underlying tissues, usually over a bony prominence, as a result of prolonged pressure or pressure in combination with shear and/or friction (Gefen, Brienza, Cuddigan, Haesler, & Kottner, 2022).
Pressure injuries typically develop when an individual remains in one position for an extended period, and the pressure restricts blood flow to the affected area, leading to tissue damage and, in severe cases, the formation of an open sore(Lim, Mordiffi, Chew, & Lopez, 2019).
Intraoperative pressure injuries can cause immediate discomfort and pain for patients during and after surgery which may lead to extended recovery times and potentially complicate the healing process.
Operating room nurses play a crucial role in patient care during surgical procedures, and they should not only put their primary focus on the surgical aspect of patient care but also ensure the patients' overall well-being, including the prevention of pressure injuries(Cebeci & Çelik, 2022)
3 of 14
Age significantly increases the risk of developing pressure injuries due to several physiological factors.
As skin ages, it becomes thinner and less elastic, losing moisture and structural integrity, which heightens vulnerability to damage.
Older adults often experience reduced circulation, impairing nutrient delivery and hindering healing processes.
Neurological changes can decrease skin sensitivity, preventing individuals from recognizing discomfort and shifting positions to relieve pressure.
Older adults are more likely to have chronic health conditions, such as diabetes and vascular disease that compromise skin health.
Mobility issues, whether from frailty or health problems, can lead to prolonged immobility, further increasing the risk of pressure injuries.
4 of 14
Lower BMI (e.g., Below average) indicates potential malnutrition which can lead to reduced cushioning over bony areas, increasing the risk of pressure injuries.
Higher BMI (e.g., Obese) increase pressure on certain areas, particularly if mobility is compromised hence increasing the risk of pressure injuries.
Dry skin lacks moisture and can lose resilience over time, making it more susceptible to injury same as edematous skin which can hinder blood flow, further increasing the risk of pressure injuries.
Cold, clammy and discoloured skin often indicates circulatory problems, which can elevate the likelihood of skin breakdown and compromised tissue perfusion.
Sore, broken skin may lead to further breakdown hence increased risk.
5 of 14
Incontinence can lead to skin maceration due to prolonged exposure to moisture, weakening the skin barrier and making it more vulnerable to breakdown.
Moisture increases friction and shear forces during movement, further contributing to tissue damage.
Fecal incontinence can also cause chemical irritation, leading to inflammation and heightened susceptibility to pressure injuries.
Incontinence may limit mobility to avoid accidents, resulting in prolonged pressure on specific areas of the body.
Psychological factors, such as embarrassment or anxiety about incontinence, can discourage movement and repositioning thus compounding the risk.
Protein is essential for skin repair and collagen synthesis, and when intake is insufficient often due to poor appetite, anorexia, or restricted diets the body struggles to maintain skin integrity and heal existing wounds.
6 of 14
Low calorie intake can lead to weight loss and muscle atrophy, reducing the natural padding over bony areas and increasing pressure on the skin and tissues beneath.
This lack of cushioning, combined with compromised skin repair mechanisms, heightens the risk of pressure injury formation.
Dehydration and electrolyte imbalances, which are more likely in patients with poor fluid intake or those dependent on TPN/NG tubes, result in reduced skin elasticity and greater skin fragility.
These conditions make the skin more vulnerable to damage from friction and prolonged pressure.
Without adequate hydration, the body’s ability to maintain healthy, resilient skin diminishes, contributing to injury susceptibility. Mobility limitations reduces blood circulation and increases the likelihood of pressure injuries due to a lack of natural weight shifts that help protect skin and tissue integrity.
7 of 14
Patients with terminal illness often experience limited mobility, reduced appetite, and weakened skin, all of which increase the risk of prolonged pressure on certain areas
In cardiac failure, the heart’s reduced capacity to pump blood effectively leads to poor circulation, depriving tissues of vital oxygen and nutrients for skin repair.
Reduced blood flow in areas under prolonged pressure accelerates tissue breakdown, increasing the risk of pressure injuries.
Peripheral vascular disease restricts blood flow, particularly to the extremities, making it difficult for tissues to obtain adequate oxygen and nutrients hence weakens the skin, reducing its ability to heal from minor injuries and making it more prone to pressure-related injuries.
Anemia lowers the amount of oxygen carried in the blood, reducing oxygen delivery to tissues which is essential for skin health and wound healing, so anemia makes oxygen-poor tissues more susceptible to damage from prolonged pressure, increasing the risk of pressure injuries.
8 of 14
Smoking impairs blood circulation, reduces skin elasticity, and lowers oxygen levels in the blood and this weakens the skin’s ability to withstand pressure and friction, hindering the healing process and increasing the risk of pressure injuries.
Neurological deficits reduce the ability to perceive pain or pressure and often limit mobility, which are both crucial for preventing pressure injuries.
Conditions like diabetes and multiple sclerosis impair circulation; particularly to the extremities and reduce sensation, leading to more fragile skin that is less resistant to pressure and friction.
Steroids and cytotoxic drugs reduce collagen production, which impairs skin healing and resilience, while anticoagulants increase bleeding risk within tissues making them more vulnerable to breakdown under pressure.
Long-term use of anti-inflammatory drugs can delay tissue healing and reduce skin strength, both of which increase the likelihood of developing pressure injuries.
9 of 14
Anaesthetic agents reduce sensory perception and blood flow, which exacerbates tissue ischaemia. They also decrease the patient’s ability to feel discomfort, limiting any natural adjustments that could relieve pressure points(Martinez-Garduno et al., 2019)
Immobility and absence of protective reflexes prevent the patient from repositioning, increasing the likelihood of prolonged pressure on certain areas.
Certain surgical positions, such as prone, lithotomy, or Trendelenburg, are associated with increased pressure on the sacrum, heels, and other bony prominences (Black et al., 2020). Each of these positions places specific areas of the body under higher pressure, increasing the risk of surgical pressure injury formation.
Raising knees >90 degrees and both lower and upper limbs opened >90 degrees applies extreme pressure to multiple areas, substantially restricting blood circulation and heightening the risk of pressure injuries, particularly when combined with anesthesia-induced immobility.
Lithotomy position poses a high risk for pressure injuries, as circulation can be restricted in the legs, and pressure is focused on several bony areas.
10 of 14
Scoring
Scoring allows healthcare providers to assess risk systematically and allocate resources appropriately to prevent pressure injuries.
Regular use of this tool helps ensure that at-risk patients receive timely and effective interventions to maintain skin integrity and overall health.
0-15 points- Low Risk - patient is at minimal risk for developing pressure injuries and standard preventative measures may suffice.
16-20 points- Moderate Risk- patient may be at some risk and additional monitoring and preventive interventions are recommended.
21-25 points- Medium Risk- patient shows a moderate level of risk hence targeted preventive measures should be implemented to minimize potential injury
11 of 14
Scoring
26-35 points-High Risk- patient is at significant risk for pressure injuries therefore comprehensive preventive strategies are necessary, including frequent repositioning and use of specialized support surfaces.
36+ points-Very High Risk- patient has a very high risk of developing pressure injuries and requires intensive monitoring and intervention, including possible consultation with a wound care specialist.
12 of 14
RECOMMENDATIONS
Organize training to help staff understand the new tool and its effective use.
Integrate the tool into existing assessment protocols for standard use.
Implement a tracking system for the tool's usage and patient outcomes over time.
Identify areas for improvement and further research.
Periodically review adherence to the tool as part of staff performance evaluations and quality assurance.
13 of 14
References
Cebeci, F., & Çelik, S. Ş. (2022). Knowledge and practices of operating room nurses in the prevention of pressure injuries. Journal of Tissue Viability, 31(1), 38-45.
Dealey, C., Posnett, J., & Walker, A. (2012). The cost of pressure ulcers in the United Kingdom. Journal of wound care, 21(6), 261-266.
Gefen, A., Brienza, D. M., Cuddigan, J., Haesler, E., & Kottner, J. (2022). Our contemporary understanding of the aetiology of pressure ulcers/pressure injuries. International wound journal, 19(3), 692-704.
Hussain, S. T., Lei, S., Akram, T., Haider, M. J., Hussain, S. H., & Ali, M. (2018). Kurt Lewin's change model: A critical review of the role of leadership and employee involvement in organizational change. Journal of Innovation & Knowledge, 3(3), 123-127.
Lim, E., Mordiffi, Z., Chew, H. S., & Lopez, V. (2019). Using the Braden subscales to assess risk of pressure injuries in adult patients: A retrospective case‐control study. International wound journal, 16(3), 665-673.
Lovegrove, J., Ven, S., Miles, S. J., & Fulbrook, P. (2023). Comparison of pressure injury risk assessment outcomes using a structured assessment tool versus clinical judgement: A systematic review. Journal of Clinical Nursing, 32(9-10), 1674-1690.
Padula, W. V., & Delarmente, B. A. (2019). The national cost of hospital‐acquired pressure injuries in the United States. International wound journal, 16(3), 634-640.
Sengul, T., Gul, A., Yilmaz, D., & Gokduman, T. (2022). Translation and validation of the ELPO for Turkish population: Risk assessment scale for the development of pressure injuries due to surgical positioning. Journal of Tissue Viability, 31(2), 358-364.