The Role of Shear Stress and Shear Strain in Pressure Injury Development.

ABSTRACT: Although other patient safety indicators have seen a decline, pressure injury (PI) incidence has continued to rise. In this article, the authors discuss the role of shear stress and shear strain in PI development and describe how accurate assessment and management can reduce PI risk. They provide explanations of shear stress, shear strain, friction, and tissue deformation to support a better clinical understanding of how damaging these forces are for soft tissue. Clinicians must carefully assess each patient's risk factors regarding shear forces within the contexts of activity and mobility. The authors also provide a toolbox of mitigation strategies, including support surface selection, selection of materials that contact the individual, management of immobility using positioning techniques, and the use of safe patient handling techniques. With a clear understanding of how shear forces affect PI risk and mitigation strategies, clinicians will more accurately assess PI risk and improve PI prevention care plans, ultimately reducing PI incidence to become more aligned with other patient safety indicators.

Current Perspectives on Pressure Injuries in Persons with Dark Skin Tones from the National Pressure Injury Advisory Panel.

BACKGROUND: Pressure injury (PI) development is multifactorial. In patients with dark skin tones, identifying impending PIs by visual skin assessment can be especially challenging. The need for improved skin assessment techniques, especially for persons with dark skin tones, continues to increase. Similarly, greater awareness of the need for inclusivity with regard to representation of diverse skin colors/tones in education materials is apparent. OBJECTIVE: To provide current perspectives from the literature surrounding skin assessment and PI development in patients with dark skin tones. METHODS: The following elements will be discussed through the lens of skin tone: (1) historical perspectives of PI staging from the National Pressure Injury Advisory Panel, (2) epidemiology of PI, (3) anatomy and physiology of the skin, (3) skin tone assessment and measurement, (4) augmented visual assessment modalities, (5) PI prevention, (6) PI healing, (7) social determinants of health, and (8) gaps in clinician education. CONCLUSIONS: This article highlights the gap in our clinical knowledge regarding PIs in patients with dark skin tones. Racial disparities with regard to PI development and healing are especially clear among patients with dark skin tones. Skin tone color assessment must be standardized and quantifiable in clinical education, practice, and research. This work is urgently needed, and support from private and governmental agencies is essential.

Perioperative pressure injury prevention: National Pressure Injury Advisory Panel root cause analysis toolkit 3.0.

OBJECTIVES: Operating room-related pressure injuries (ORPI) are particularly challenging to examine for several reasons. Time in the OR is often a distinct event within the hospitalisation, and discovery of an ORPI may occur between several hours and up to 5 days postoperatively. The National Pressure Injury Advisory Panel (NPIAP) first developed a root cause analysis (RCA) toolkit in 2017 as a systematic strategy for investigating the root causes of facility-acquired pressure injury (PI). The purpose of this 2021 RCA toolkit update was to address an expanded investigation of medical device-related PIs (MDRPIs), both inside and outside the OR, as well as the specific PI prevention issues of the perioperative area. METHODS: Clinicians have been using the 2017 toolkit as a basis for ongoing quality improvement tracking, since it provides more accurate information than data extractions from patient health records. A small working group consisting of NPIAP board and panel members developed investigative questions to identify the ORPI root causes and compliance with best practices for the entire perioperative experience. RESULTS: Action items are linked to evidence-based recommendations from the NPIAP/European Pressure Ulcer Advisory Panel/Pan Pacific Pressure Injury Alliance 2019 International Guideline and the Association of PeriOperative Registered Nurses (AORN) Guidelines for Perioperative Practice. A multidisciplinary clinician guide was also developed to identify practice gaps and to compile the information into an action plan for staff education and/or process improvement. CONCLUSION: The updated NPIAP RCA toolkit provides mechanisms for investigating, compiling and trending data as a basis for data-driven quality improvement. Using the enhanced investigative tools, the root causes of both MDRPIs and ORPIs can be better understood to target efforts to reduce their occurrence.

Validity and Reliability Evidence of the Munro Scale for Perioperative Patients, Part I: Correlation, Multiple Regression, and Reliability.

Background and Purpose: Patients undergoing surgery are at risk of pressure injury development and should be assessed to ensure measures are taken for prevention. The study's purpose was to examine the causal relationships and reliability of the Munro Pressure Injury Risk Assessment Scale for Perioperative Patients (Munro Scale). The Munro Scale is the first dynamic risk scale available for this patient population in the acute clinical setting. Methods: This study was a retrospective review to explore the relationships of the variables in the Munro Scale, identify the strongest predictors, and measure the reliability of previously collected data from two northeastern community hospitals. A total of 630 risk assessments were analyzed to obtain regression, correlation, and reliability evidence for the Munro Scale. Results: The correlation analysis among the 15 risk variables and combined comorbidities revealed commonalities among the variables and significant relationships to the final postoperative injury score. The model as a whole is significant to predict the final level of risk. Coefficient alpha revealed a lower than anticipated reliability when compared to the Chinese, Turkish, and Brazilian versions of the Munro Scale. Conclusions: There are significant relationships among the variables, and the scale is acceptable for use in the acute perioperative practice setting. This study has both clinical and statistical significance.

Validity and Reliability Evidence of the Munro Scale for Perioperative Patients Part II: Construct Validity.

Background and Purpose: The Munro Pressure Injury Risk Assessment Scale for Perioperative Patients (Munro Scale) is the first three-phase risk instrument designed specifically for perioperative patients. The purpose of this study was to establish validity and reliability evidence for the Munro Scale. This study also had a goal to reduce the data into more manageable constructs with fewer items. Methods: Exploratory and confirmatory factor analyses were used to test the hypothesized model for risk assessment using the Munro Scale to identify latent variables. A retrospective review of charts from 630 risk assessments was analyzed from two community acute care hospital settings. Results: The model explained 95% of the variance in the cumulative final risk level, R2 = .95, F(20, 588) = 501.88, p < .001. Six latent variables emerged in the model with a cumulative contribution rate of 56% of the variance. Similar results were obtained in studies with Chinese and Turkish translations of the Munro Scale. Conclusions: The validity and reliability evidence obtained in this study supports the implementation of the Munro Scale for clinical practice in the perioperative setting.

Translation, cross-cultural adaptation, and validation of the Munro Scale in Italian.

BACKGROUND: The Munro Pressure Ulcer Risk Assessment Scale for Perioperative Patients - Adult (Munro scale) is a pressure ulcer/injury risk assessment scale for adult surgical patients. It consists of 3 sections relating to the preoperative, intraoperative, and postoperative periods. It is not available in Italian. PURPOSE: The aim of this study was to translate the Munro scale into Italian and assess its cross-cultural content and face validity. METHODS: The translation and cross-cultural adaptation process adhered to World Health Organization guidelines including forward translation, expert review, and back translation. Health care professionals with a minimum of 5 years of experience working in the operating rooms of different hospitals in northern Italy were invited to participate in a content and face validation of the translated instrument. Content validity was evaluated by rating the relevance of each scale item using a 4-point Likert scale, ranging from 1 (not relevant) to 4 (very relevant). Face validity (comprehensibility and clarity) was also measured using a 4-point rating scale. RESULTS: Expert agreement of the translated instrument reached a Fleiss' kappa of 0.95. The content validity index was 0.91, and all items had a score ≥ 3 for clarity and comprehensibility. CONCLUSION: The Italian version of the Munro scale can be used safely to assess patient risk of injuries during the perioperative period in Italy. The translation and validation study results confirmed that the Italian version was consistent with the original version. Further testing, including prospective validation, is needed.

The perioperative nurse's role in table-enhanced anterior total hip arthroplasty.

The anterior approach to total hip arthroplasty (THA),when performed with the patient in the supine position,is enhanced by the use of a radiolucent, orthopedic table.This technique has numerous advantages: enhanced intraoperative fluoroscopy because of the patient's supine position on a radiolucent table, improved femoral exposure,and reduced soft tissue trauma. Criteria for patients election is not limited as it may be for other arthroplasty techniques.The role of the perioperative nurse during an anterior THA is to ensure optimal function of the orthopedic table and provide safe patient care. A clear understanding of the surgical techniques used and the functions of the table are imperative.

The development of a pressure ulcer risk-assessment scale for perioperative patients.

The high incidence of pressure ulcer development in patients in the perioperative setting indicates the need for improved risk assessment and the use of preventive measures. A clinical nurse specialist used Dever's Epidemiological Model as the theoretical framework to develop a perioperative pressure ulcer risk-assessment scale. The risk factors for the scale were based on findings from a review of the literature. The scale, along with a demographic questionnaire and an evaluation form, was distributed to 12 nurses and three anesthesiologists to obtain expert opinion to further the design of the scale. Twelve participants returned the forms. Only four of the participants had previous experience with a pressure ulcer risk-assessment scale. The results indicated that diabetes should be included as a risk factor category and that preexisting skin ulcerations, breakdowns, and conditions should be addressed within the scale. The participants unanimously agreed that moisture is an important factor to assess. Validation of each risk factor is essential to improve the reliability of the scale before its implementation.