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Archive Staff & Patient Safety 2018

Comprehensive Pressure Injury Prevention

Use this risk assessment tool to protect patients' skin from pre-op to PACU.

Cassendra Munro

Cassendra Munro, MSN, RN, CNOR


UNIVERSAL CARE All surgical patients are at some risk of developing pressure injuries.

Skin assessments alone won't help you identify patients who are most likely to suffer pressure injuries. That's why my Munro Pressure Ulcer Risk Assessment Scale addresses the many factors that can cause skin breakdown along the perioperative pathway. It standardizes how staff evaluate patients, sparks conversations about pressure injury prevention and ensures patients are checked multiple times throughout their stay. The scale assigns a score — 1 (low), 2 (moderate) or 3 (high) — for numerous risk factors in pre-op, the OR and PACU. Tallying risk factor scores in each section helps you determine the level of skin protection a patient requires.

1. In pre-op: Use the chart below to assess the patient's mobility, body mass index, NPO status, weight loss, age and comorbidities.

Pamela Bevelhymer, RN, BSN, CNOR
Pamela Bevelhymer, RN, BSN, CNOR
CONSTANT ATTENTION Perform thorough assessments at every stage of surgery to identify and address each patient's risk factors for pressure injury.

So, for example, if the patient hadn't lost any weight in the 6 months before surgery, give him a score of 1 in that section. But if he has a high BMI, low mobility and several comorbidities, he might earn 2s or 3s in those categories, which puts him in the "high risk" range for the preoperative phase. Share that information with the OR team, who can then follow best practices for preventing pressure injuries such as applying a multilayered dressing to the sacrum or using regional anesthesia, so the patient can ambulate sooner in PACU.

2. In the OR: Use this chart to assess the physical status, type of anesthesia, body temperature, hypotension, moisture, surface/motion and surgical position.

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