Skin Alterations from Positioning

[NurseFrawg]

I have been tasked to do some sluething about skin alteration caused by positioning in the OR. I work in a small children's hospital that specializes in ortho and plastic surgery. I work in presurgery admitting, OR and PACU. We currently have a form that is NOT part of the chart used to track any skin issues, but the form isn't always filled out or lost or incorrect verbage is used.

We have seen some pretty significant skin breakdown on our kids, mostly over bony prominences after extended length spine surgeries. Most of us feel we are doing everything possible to avoid alterations, but we are seeing more obese children that do not fair well with being in one position for 9 plus hours.

I would like to know

1. Who and how do you chart this?
   
2. How do you follow up with patients?
   
3. Do you write an incident report for each case?
   
4. What have you done to avoid breakdowns?
   

Thanks for any help!

[cirqul8r]

I work in the OR, so here's my viewpoint:

Skin condition, pre and post op, are generally AORN required items to address in charting. Important enough that, at least in our version of EPIC, we can't sign off the chart unless it has been addressed. Any exceptions to clear intact skin must be addressed. This should be part of the chart, not a separate tracking form.

We use gel and foam padding when and where necessary. Be sure there are no wrinkles in the sheets. Lengthy procedures increase the risk of skin issues, and prone position is one of the worst. We are using the outer rings of a foam circle pillow to pad knees and sometimes even hip bones. Chart all positioning aids and padding and where you placed them.

Usually don't do an incident report, it needs to be part of the documentation.

Oh, also be sure skin is dry before positioning. Wet skin tears easier.

[Rose_Queen, BSN, MSN, RN]

1. Who and how do you chart this?
   

It's part of our standard documentation- a preop and postop skin assessment. Issues are to be documented in the skin assessment and an incident report is to be filled out.

1. How do you follow up with patients?
   

We personally don't. There's a committee or designated group that deals with this information.

1. Do you write an incident report for each case?
   

Any kind of a skin issue that doesn't resolve itself within a few minutes. Someone who maybe has some indentations from the foam egg crate that is resolved by the time the patient leaves the OR? No incident report. Someone who has a skin tear? Incident report.

1. What have you done to avoid breakdowns?
   

Appropriate padding, whether that's gel or foam. Adequate people to position patients to prevent shearing forces. Ensuring any sheets are wrinkle free. Specialty positioning devices designed specifically for certain types of surgery. Pressure reducing dressings on areas prone to breakdown (sacrum, trochanter, etc.).

[SandraFenway]

[quote=NurseFrawg;9077502

1. Who and how do you chart this?
   
2. How do you follow up with patients?
   
3. Do you write an incident report for each case?
   
4. What have you done to avoid breakdowns?

1. We chart preop and post op skin condition in the skin assessment portion of the operative charting. If there's a noteworthy change, I document who I spoke with in PACU, take pictures for the chart and file an incident report. I document that I showed the surgeon and anesthesiologist.

2. No, I don't follow.

3. If there is a significant issue, like what prompts me to take pictures, yes, definitely an incident report. Want to evaluate processes especially with positioning. We had a surgeon that was a fan of putting pt chest directly on a stack of bath blankets - until his pt had a serious shear incident that left her with open wounds. Writing it up encouraged immedilate change. Also, the write up alerts all services to watch over this patient - it's part of letting the facility rise to the occasion and make sure the patient come out whole.

4. No lift sheet under patient, pt directly on gel padded bolsters, large gel under lower body, padding hips, knees. Suspend forefeet with pillow under shins. There's more, but that's the gist. Directly on gel pads help distribute load, pts don't slip/shear on gel. Foam is very bad in regards to shear forces, I try not to use it for serious padding needs. Other nurses like duoderm dressings on bony areas. I'm less a fan, but you may want to try it.

Pardon, if I may: breakdown on bony prominences shouldn't be happening at all. Boobs and chest tend to be the difficult areas because it's simply super tricky to avoid. Sometimes it cannot be avoided, but the soft tissue does seem to recover OK.

But, if you're getting breakdown on the hip bones... That's preventable. Really evaluate what those practioners are doing in that room. Use gel pads, try duoderm ( put on pt in areas of concern).

[NurseFrawg]

Thank you all for your replies! So we are doing some stuff well. We do chart about skin pre and post in the chart. I think our manager wanted something else for us to fill out so that tracking of cases could be easier. Our PACU staff follows up on all of postop patients, issues or not.

We use a lot of foam padding, gel padding, and padded covers that go on the hip pads for the Jackson table. We tried duoderm without much success and in a few cases caused more issues that it prevented.

Maybe breakdown is a bit of an overstatement. Generally what we see is intact red to dark red blanchable intact skin. Very rarely we have blistering.

Many of our kids are not great surgical candidates unfortunately either very underweight or obese with many contractures and other deformities that we must position and pad around.

What I saw is that we under use our camera for documenting purposes and I will relay this information back.

Thanks again for your responses.