Preventing Pressure Ulcers in Postoperative Patients

Introduction

Pressure ulcers are a major burden of illness in postoperative patients, reducing quality of life and imposing significant costs on the health system. In the United Kingdom, it is estimated that between £600,000 and £3,000,000 is spent each year on the prevention and treatment of pressure ulcers in a 600-bed hospital, with the cost per patient ranging from £10,000 to £40,000 (Royal College of Nursing, 2001). Pressure ulcers are localized damage to the skin and underlying tissue caused by pressure, friction, and shear. They can be prevented through straightforward quality-of-care improvement strategies and by ensuring that staff are well trained to recognize and manage them.

Risk factors associated with pressure ulcers include lack of movement, poor nutritional intake, hypothermia, and dry skin. Postoperative patients are at increased risk because they often experience prolonged periods of immobility and inadequate nutritional intake. Consequently, they suffer pain, discomfort, and a diminished quality of life. Pressure ulcers are preventable using strategies such as patient repositioning to relieve accumulated pressure, the use of mattress overlays to redistribute pressure on the skin, adequate nutritional intake, and skin care to prevent dryness.

Literature Review

Among hospitalized adult surgical patients, pressure ulcers cause pain, discomfort, reduced productivity, and poor health outcomes. They also lead to social isolation, helplessness, and loss of hope, all of which adversely affect patients' quality of life. Patients with pressure ulcers are often prone to sepsis and infections depending on the extent of the damage. In the United States, the International Pressure Ulcer Prevalence Survey found a 5% prevalence of hospital-acquired pressure ulcers; prevalence in patients receiving critical care ranged from 8% to 10%, and in intensive care unit patients it stood at 3.3% (VanGilder, Amlung, Harrison, & Meyer, 2009). An understanding of the risk factors and causes of pressure ulcers is essential for evaluating preventive measures.

A systematic review of prevention strategies for pressure ulcers grouped interventions into three categories (Reddy, Gill, & Rochon, 2006). The first category targeted impaired mobility. In acute care settings, support surfaces such as gel, air, and foam overlays placed on mattresses were found to be effective in reducing pressure ulcers. Repositioning patients by turning them every two hours was also identified as an important strategy, and some evidence supported the effectiveness of repositioning in postoperative patients specifically, though only two studies were identified (Reddy et al., 2006).

The second category targeted impaired nutrition. Little evidence was found to support a direct relationship between nutritional supplementation and pressure ulcer prevention; only one study of 672 patients provided evidence that nutritional supplementation was advantageous. The third category targeted impaired skin health. Three trials involving 439 acute-care patients found topical agents to be effective in preventing pressure ulcers (Reddy et al., 2006).

The trials included in the systematic review provided limited evidence of effectiveness overall because a meta-analysis could not be conducted due to data heterogeneity. Nevertheless, the authors recommend mattress overlays and skin care to prevent pressure ulcers, as well as nutritional supplements — despite limited evidence — because of the broader benefits of adequate nutrition (Reddy et al., 2006).

The recommendation for mattress overlays is also supported by Jackson et al. (2011). That study used air-fluidized therapy beds and found them effective in lowering pressure between the bed surface and the patient, reducing hospital-acquired pressure ulcer incidence from 40% to 15%. A cost-effectiveness analysis showed that treating pressure ulcers would have cost over $155,000, compared with $18,000 for renting the air-fluidized therapy beds — a finding that strongly supports their use for prevention (Jackson et al., 2011).

In a prospective comparative study examining the effect of immobility on pressure ulcer development, Lindgren, Unosson, Fredrikson, and Ek (2004) found that patients undergoing surgery or in the postoperative period had a higher risk of developing pressure ulcers. This elevated risk was attributed to prolonged immobility, poor food intake, friction from movement, and lack of physical activity. Although the study did not evaluate specific preventive measures, the authors recommend repositioning patients to stimulate mobility and thereby reduce pressure ulcer risk.

Quigley and Curley (1996) recommend using risk assessment tools to identify patients at early risk of developing pressure ulcers. They suggest the Braden Scale or Braden Q, which uses seven subscales — mobility, activity, sensory perception, moisture, friction, nutrition, and tissue perfusion and oxygenation — to detect early signs. The authors provide a detailed skin care algorithm that maps specific prevention strategies to identified risk factors. Those strategies include mattress overlays, optimized nutritional intake, patient turning, and air-fluidized therapy beds.

The Royal College of Nursing in the United Kingdom has also developed a clinical guideline with an algorithm for pressure ulcer prevention. The guideline recommends regular skin inspections for patients with identified risk factors and, depending on findings, strategies such as pressure redistribution through repositioning or mattress overlays, nutritional advice, and ongoing progress monitoring toward quality improvement (Royal College of Nursing, 2001).

Statement of Purpose and Study Design

Only a limited number of studies have focused specifically on the effectiveness of pressure ulcer prevention methods in postoperative patients. Given the substantial burden associated with pressure ulcers, it is important to evaluate preventive measures for their effectiveness in improving patient outcomes and quality of life, as well as for the cost savings they may generate for the health care system. This project aims to reduce the incidence and prevalence of pressure ulcers in postoperative patients and to pass the associated cost savings on to both patients and the institution.

Participants: The participants are postoperative patients, a group commonly receiving acute care who experience immobility throughout much of their postoperative period and therefore have a high probability of developing pressure ulcers.

Materials and procedures: Based on the literature, the most effective prevention strategies are the use of pressure-redistributing overlays, optimized nutritional intake, repositioning, and structured skin care. A validated skin care algorithm will be adopted to assess each patient's risk of developing pressure ulcers and to guide the appropriate response. The algorithm ensures that patients receive individualized care based on their specific risk factors while allowing nursing staff to deliver high-quality care efficiently.

Population and sample: A sample of postoperative patients at risk of developing pressure ulcers will be selected to pilot the preventive strategy. Convenience sampling will be used, given that the initial implementation is small scale.