Incidence and Risk Factors of Operating Room–Acquired Pressure Injury: A Cross-Sectional Study

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Hospital-acquired pressure injuries (PI) are a health problem in Turkey and worldwide.^1-4 The National Pressure Injury Advisory Panel (NPIAP) has defined PI as "localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device."⁵ Pressure injury acquired in the operating room, or operating room–acquired PI, is defined by the Association of periOperative Registered Nurses (AORN) as PI that develops within the first 48 to 72 hours after surgery.⁶

Pressure injury negatively affects patients' quality of life, prolongs hospital stay, and causes complications such as infection and sepsis.⁷ In addition, increasing treatment costs also impose a serious burden on the health care system.⁸ The incidence of operating room–acquired PI is reportedly highest in the Netherlands (27%) and lowest in Finland (4.6%).⁹ In Turkey, the incidence of PI was 40.4% in a study of 151 surgical patients.¹⁰ In a study of 250 patients, stage 1 PI developed within 24 hours postoperatively in 12.8%.¹¹

Numerous risk factors for surgical PI have been identified.^1,12,13 Risk factors specific to the preoperative period include advanced age, obesity, a high risk score, low hemoglobin level (<12 g/dL), low albumin level (<3 g/dL), nutritional deficiency, drug use (steroid and/or vasoactive drugs), chronic disease history, neural loss of function, immobilization, moisture balance of the skin, and smoking.^5,14,15 Risk factors specific to the intraoperative period include the type of anesthesia, duration of the operation, operating position and instruments used, the operating table, wet and moist skin, solutions used for skin preparation, hypotension, extracorporeal circulation, hypothermia, hyperthermia, use of a heating blanket, immobilization, and a covering between the support surface and the patient.^16-18 Risk factors specific to the postoperative period include insufficiency of oral nutrition, vasopressor drug use, immobilization, and the type of bed used after surgery.^17,18

Due to all of these factors, patients undergoing operations are prone to the development of PI during the surgical procedure. Operating room nurses should evaluate the presence and risks of PI in the patient before surgery and when the patient is admitted to the operating room. In addition, necessary preventive measures should be taken, taking into account possible intraoperative risks. After the surgery, the clinic nurse should be informed about the patient's PI risks. Clinical and operating room nurses should cooperate in the effort to prevent PI. The primary goal is to preserve tissue integrity. It is believed that determination of the incidence and risk factors of operating room–acquired PI will make a significant contribution to the development of preventive approaches.

The goal of the present study was to determine the incidence and risk factors of operating room–acquired PI.

Study design.The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist for cross-sectional studies was used to report the findings of this descriptive, cross-sectional study.

Sample and procedure. The study population consisted of patients who underwent operations in Bilecik Training and Research Hospital in Bilecik, Turkey, between May 20, 2021, and December 20, 2021. The hospital had 300 beds and 11 operating rooms. There were 28 nurses across all of the operating rooms, and a mean of 22 surgeries were performed monthly. The inclusion criteria for patients were as follows: 18 years of age or older, undergoing elective surgery, absence of PI on admission to the operating room, and voluntary participation in the study. Patients who lacked consciousness, lacked place and time orientation, and had undergone emergency surgical interventions were excluded. A total of 309 patients were included in the study.

The G*Power software (version 3.1)^19,20 was used to calculate the sample size. Post hoc power analysis of the study data was performed. At the end of the study, the power was 0.98, with an effect size of 0.39, an alpha level of .05 for statistical significance, and a sample size of 309.

Patient data were collected using the Patient Description Form prepared by the researchers (AS, KK) based on the relevant literature,^10,21,22 the Turkish adaptation of the 3S Intraoperative Risk Assessment Scale (3S IRAS), and the Braden Scale for predicting PI risk. Other information collected included patient demographics (eg, sex, age, body mass index), as well as details about the clinic, the date of hospitalization, the date of surgery, the diagnosis that constituted the patient's surgical indication, the operation performed, the type of anesthesia, American Society of Anesthesiologists (ASA) score, skin turgor and moisture, skin antisepsis solution, use of vasopressors, intraoperative patient positioning, the areas under pressure during the operation, use of medical devices, support surfaces used while positioning the patient, use of heating devices, level of dependence on others, chronic diseases, medications used regularly, time elapsed after surgery, use of corticosteroids, and the presence of PI on admission to the hospital.

The 3S IRAS, which was developed by developed by Gao et al,²² is designed to determine the factors that affect PI formation in patients undergoing surgery. The Turkish validity and reliability study of the scale was conducted by Soyer and Özbayır.²³ The scale includes the following 9 items: the condition of the skin on the whole body, preoperative activity status, height-to-weight ratio, status of the skin under stress, amount of intraoperative bleeding, duration of the operation, intraoperative stress, intraoperative body temperature, and intraoperative body position. In the assessment, each item was given a score between 1 and 4 on a Likert-type scale (1 = low risk; 4 = high risk). A total score higher than 23 indicates that the patient is at risk of developing PI in the operating room.^22,23 Permission was received from Soyer and Özbayır to use the scale. The Cronbach α coefficient was found to be 0.74.

The Braden Scale was developed by Bergstrom et al in 1987 to aid in identifying patients at risk of developing PI.²⁴ It consists of the following 6 items: (1) sensory perception, (2) moisture, (3) activity, (4) mobility, (5) nutrition, (6) friction and shear. Sensory perception item is scored between 1 and 4 (1 = Completely limited; 4 = No impairment). Moisture item is scored between 1 and 4 (1 = Constantly moist; 4 = No impairment). Activity item is scored between 1 and 4 (1 = Bedfast; 4 = Walks frequently). Mobility item is scored between 1 and 4 (1 = Completely immobile; 4 = No limitation). Nutrition item is scored between 1 and 4 (1 = Very poor; 4 = Excellent). The friction and shear item is scored between 1 and 3 (1 = Problem; 3 = No apparent problem) on a Likert-type scale. The lowest possible score is 6 and the highest is 23.²⁴ A score of 12 or less indicates high risk, a score of 13 or 14 indicates moderate risk, and a score of 15 or 16 indicates low risk. Patients aged 75 years or older with a score of 15 to 18 are considered low risk for PI. The scale was first adapted into Turkish by Oğuz and Olgun.²⁵

The Patient Description Form, Braden Scale, and some items in the 3S IRAS that should be assessed preoperatively (ie, the condition of the skin on the whole body, preoperative activity status, height-to-weight ratio, status of the skin under stress) were assessed by the researcher (EA) in the preoperative preparation unit. During the operation, other items in the 3S IRAS (ie, the amount of intraoperative bleeding, duration of the operation, intraoperative stress, intraoperative body temperature, and intraoperative body position) were assessed. Patients were also assessed for the development of PI in the first 48 to 72 hours postoperatively. A single researcher evaluated PI risk assessment and development. This avoided measurement differences between different researchers. (Figure 1).

Statistical analysis. SPSS Statistics for Windows v23 (IBM Corp) was used for analysis of the research data. The conformity of the variables to normal distribution was examined using visual (histogram and probability graphs) and analytical methods (Kolmogorov-Smirnov test). Demographic and descriptive characteristics of the patients were presented as percentage (%) and frequency (n). The chi-square test, interquartile range, Kruskal-Wallis test, and Spearman correlation analysis were also used. For all the tests, the significance level was set at P < .05.

Ethics considerations. Before collecting the study data, ethics committee permission (decision dated July 8, 2021, [number 2021/12-03]) was obtained from the Non-Interventional Clinical Research Ethics Committee of the Kutahya University of Health Science, Kutahya, Turkey; institutional permission was obtained from Bilecik Training and Research Hospital, Bilecik, Turkey; and written informed consent was obtained from the patients. The information provided by the study participants was used for scientific purposes and kept confidential. The study was conducted in accordance with the ethical principles of the Declaration of Helsinki.

The mean (standard deviation [SD]) age of the participants was 57.81 (18.04) years; 51.8% of patients self-reported as male (n = 160), and 48.2% as female (n = 149). Moreover, 44.0% of the patients were treated in the orthopedic clinic (n = 136), 53.7% (n = 166) received general anesthesia, and 72.8% (n = 225) had an operation time of at least 91 minutes.

Postoperatively, 67.3% of patients developed PI between 49 and 72 hours (n = 208), and 32.7% (n = 101) developed PI between 24 and 48 hours (Table 1). According to the Braden Scale, 16.5% of patients were in the moderate- and high-risk groups (n = 51), whereas according to the IRAS, 2.6% of patients were at risk of PI (n = 8). Pressure injury developed in 5.8% of patients (n = 18), all of whom had stage 1 PI. Moreover, 54.4% of patients had medical devices (n = 168), and medical device–acquired PI was identified in 2.3% of these patients (n = 7).

The mean (SD) IRAS score was 15.46 (3.17) (range, 10.00–27.00), and the mean Braden Scale score was 17.15 (2.82) (range, 8–22). Among patients who developed PI, the mean IRAS score was 18.22 (3.20) and the mean Braden Scale score was 12.94 (3.20). There was a statistically significant difference in mean score between patients who developed PI and those who did not (P < .05). Furthermore, 72.2% (n = 13) of the 18 patients who developed PI were treated in the orthopedic clinic. There was a statistically significant difference in PI between clinics (χ² = 11.437, P = .043). Pressure injury developed in 94.4% (n = 17) of the patients with an operation time of at least 91 minutes; this result was statistically significant (χ² = 4.609, P = .023). There was no statistically significant difference between anesthesia type and development of PI (P > .05) (Tables 2 and 3).

A positive, statistically significant, weak relationship was found between 3S IRAS score and patient age (r_s = 0.386, P < .001), BMI (r_s = 0.348, P < .001), systolic blood pressure (BP) (r_s = –0.246, P < .001), and diastolic BP (r_s = –0.197, P = .001) (P < .05). A negative, statistically significant, weak relationship was found between 3S IRAS score and pulse (r_s = –0.167, P = .103), hemoglobin level (r_s = –0.260, P < .001), and hematocrit (r_s = –0.286, P < .001) (P < .05) (Table 4).

A negative, statistically significant, moderate relationship was found between Braden Scale score and patient age (r_s = –0.533, P < .001) (P < .05). Furthermore, a negative, statistically significant, weak relationship was found between Braden Scale score and BMI (r_s = –0.140, P = .014) and pulse (r_s = –0.238, P < .001.) (P < .05). A positive, statistically significant, moderate relationship was found between Braden Scale score and albumin value (r_s = 0.620, P = .001) (P < .05). In addition, a positive, statistically significant, weak relationship was found between Braden Scale score and hemoglobin level (r_s = 0.393, P < .001), hematocrit (r_s = 0.370, P < .001), systolic BP (r_s = 0.306, P < .001), and diastolic BP (r_s = 0.210, P < .001) (P < .05). A negative, statistically significant, moderate relationship was also found between 3S IRAS scores and Braden Scale scores (r_s = –0.569, P < .001) (P < .05) (Tables 2 and 4).

In the present study, PI risk was assessed between 24 and 72 hours postoperatively. As noted previously, AORN has reported that operating room–acquired PI occurs within the first 48 to 72 hours after surgical intervention.⁶ In the present study, PI occurred in 67.3% of patients between 49 and 72 hours postoperatively (n = 208). Patients assessed earlier than 48 hours postoperatively were those who had to be discharged early (32.7%). The majority of patients had low risk of PI according to the mean score of both scales. The rate of patients at moderate to high risk of PI was 16.5% according to the Braden Scale scores and 2.6% according to the IRAS scores. Stage 1 PI occurred in 5.8% of patients (n = 18). Kayser et al²⁶ reported a postoperative PI incidence of 9.3%. A literature review indicated a PI prevalence range of 4.6% to 27.2% in Europe,⁹ whereas a study in the United States reported a prevalence rate of 6%.²⁶ In the study by Joseph et al,²⁷ in which 18 of 292 patients had PI, 10 patients had stage 1 PI, 7 had stage 2, and 1 had stage 3 PI. In Turkey, the incidence of operating room–acquired PI ranges from 1.7% to 40.4%.^10,28 In another study conducted in Turkey, although the preoperative risk of PI was low, stage 1 PI developed in 12.8% of the patients within 24 hours postoperatively.¹¹ In the present study, 54.4% of the patients had medical devices (n = 168), and medical device–acquired PI developed in 2.3% of these patients. In an analysis of 102 865 patients in the United States and Canada, the rate of medical device–acquired PI was 0.60%.²⁶ The literature emphasizes that the presence of devices such as prostheses, orthopedic implants, catheters, tourniquets, drains, and positioning devices used preoperatively and/or intraoperatively should be assessed, that frequent monitoring should be performed, and that the skin should be observed.^5,6,29

In the present study, the majority of the patients who developed PI (72.2%) underwent orthopedic surgery; this result was statistically significant. Patients who underwent neurosurgical intervention were the next most likely to develop PI (22.2%). Other studies have reported that patients who underwent cardiac, orthopedic, and spinal surgery were at increased risk of PI.^30,31 In addition, operating room–acquired PI reportedly increased mortality by 21% in patients aged 75 years or older with hip fractures.³⁰ In the study, it was believed that the high rate of PI development in patients who underwent orthopedic surgery may have been due to the long surgical time, the use of tourniquets, and the high body mass of patients with obesity. The majority of these patients had obesity, underwent prosthesis surgery, and had a surgical duration of at least 90 minutes.

One study reported that patient position and surgery duration may contribute to the development of postoperative PI.²⁷ In one study, the prevalence rate of PI was at least 8.5% in patients whose surgery lasted more than 3 hours.¹⁸ In that study, a significant relationship was found between the duration of surgical intervention and the development of PI, with 94.4% of those who developed PI having an operation time of at least 91 minutes.¹⁸ Edsberg et al³¹ found in their study that the time spent on the operating table was a determining factor in PI formation. It is usually not possible to change the positions given according to the duration of surgery and type of operation. As the operation duration increases, the exposure of soft tissues overlying bone tissue to pressure increases with the effect of gravity. Therefore, tissue perfusion is impaired.^16,17 The high risk of PI in cardiac and orthopedic surgeries is due to the fact that they are performed with the patient in the supine position and that they last longer than other surgeries.^17,32 For this reason, the use of support surfaces that can redistribute pressure evenly on the operating table is recommended to reduce the pressure duration and shear force.⁶ It is believed that this may be the only possible way to maintain pressure points specific to the surgical patient positions. In addition, a significant relationship was found in the present study between patient age and BMI and their scale scores.

Age and obesity are also important in the development of PI.^5,18,33,34 The literature indicates that patients with obesity and patients with cachexia are at risk of PI and that precautions should be taken in such cases.^14,15 The relationship between PI and advanced age is due to physiological changes that occur with aging, including decreased subcutaneous tissue and elastin fibers, capillary blood flow, sensation of heat and pressure, and size, number, and secretion of the sweat and sebaceous glands. All of these physiologic changes are believed to accelerate the development of PI in patients aged 65 years or older. In addition, changes in the nervous system lead to neuropathy. It is reported that the anatomical region where sensory loss occurs is more affected by friction forces than the regions without sensory loss.^19,35

It has been reported that systolic BP lower than 111.5 mm Hg and diastolic BP lower than 60 mm Hg increase the risk of PI.^5,36 In the present study, the risk of developing PI increased as the systolic/diastolic BP values of the patients decreased. This relationship between hemodynamic indicators (pulse, BP, and blood values) and the risk of developing PI is due to decreased tissue perfusion, and all of the parameters that negatively affect tissue perfusion predispose the patient to PI.^14,37 A low albumin level (<3 g/dL without hepatic and renal dysfunction) is among the findings that are indicative of possible chronic nutritional deficiency, and it is believed to be an important factor in PI formation.^36,38

In the present study, no relationship was found between patient sex and the risk of operating room–acquired PI. In a meta-analysis, although the rate of developing PI was higher in male patients than in female patients, no clear conclusion was reported about sex.¹⁹ In the present study, no relationship was found between type of anesthesia, ASA score, use of a vasopressor and corticosteroids, surgical position, and the risk of developing operating room–acquired PI. However, the literature indicates that the type of anesthesia, use of vasopressor drugs, type of operation, and surgical position (when pressure-reduction intervention is not applied on the operating table) increase the risk of operating room–acquired PI.^5,35,38 It also has been reported that the pressure of the operating table on the patient due to the intraoperative patient position affects PI development; anatomic areas with bone spurs are most affected by pressure.^39-40

The present study had limitations. Because approximately one-third of the patients in the study had to be discharged early, it was possible to evaluate for the development of PI only between 49 and 72 hours postoperatively. The Braden Scale is not sufficient to detect the risk of operating room–related PI. However, because it is the most commonly used risk-assessment tool in hospitals, it was the preferred scale for determining the risk of PI in the preoperative period.

Operating room–acquired PI developed in 5.8% of the patients in the present study. Patient age, hemodynamic parameters, and albumin levels, as well as operation duration, had an effect on the development of operating room–acquired PI. All of the PIs identified were stage 1. Therefore, it is important that nurses not overlook physical signs characteristic of stage 1 PI. The risk of operating room–acquired PI was higher in patients who underwent orthopedic and neurosurgical interventions, and medical devices were associated with increased rate of PI. In line with these results, the authors of the present study emphasize the importance for nurses to determine existing and potential preoperative, intraoperative, and postoperative risks that impair skin integrity and affect tissue oxygenation.

A significant relationship was also found between the scale scores, and an increase in IRAS scores and a decrease in Braden Scale scores indicated an increased risk of developing PI. However, although the Braden Scale is used reliably in hospitalized patients, it is recommended than an operating room–specific scale be used in patients undergoing surgical intervention, because the Braden Scale does not assess patients' intraoperative status.

The results of the present study support the need for nurses to identify current and potential risks that impair skin integrity and affect tissue oxygenation. Because additional factors affect tissue oxygenation intraoperatively, it is recommended that an operating room–specific scale be used for these patients.

1. Becker D, Tozo TC, Batista SS, et al. Pressure ulcers in ICU patients: incidence and clinical and epidemiological features: a multicenter study in southern Brazil. Intensive Crit Care Nurs. 2017;42(10):55-61. doi:10.1016/j.iccn.2017.03.009

2. El-Marsi J, Zein-El-Dine S, Zein B, Doumit R, Kurdahi Badr L. Predictors of pressure injuries in a critical care unit in Lebanon: prevalence, characteristics, and associated factors. J Wound Ostomy Continence Nurs. 2018;45(2):131-136. doi:10.1097/WON.0000000000000415

3. Kaşıkçı M, Aksoy M, Ay E. Investigation of the prevalence of pressure ulcers and patient-related risk factors in hospitals in the province of Erzurum: a cross-sectional study. J Tissue Viability. 2018;27(3):135-140. doi:10.1016/j.jtv.2018.05.001

4. Sengul T, Karadag A. Determination of nurses' level of knowledge on the prevention of pressure ulcers: the case of Turkey. J Tissue Viability. 2020;29(4): 337–341. doi:10.1016/j.jtv.2020.06.005

5. European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance. Basınç Ülserlerinin/Yaralarının Önlenmesi ve Tedavisi: Hızlı Başvuru Kılavuzu 2019. (Türkçe versiyon). Emily Haesler (Ed.). EPUAP/NPIAP/PPPIA: 2019. Retrieved from: file:///C:/Users/Lenovo/Downloads/QRG-2019-Turkish.pdf. Accessed April 11, 2024.

6. Creehan S, Black J. Defining practices to avoid hospital-acquired pressure injuries in the operating room. J Wound Ostomy Continence Nurs. 2022;49(1):89-96. doi:10.1097/WON.0000000000000835

7. Chello C, Lusini M, Schilirò D, Greco SM, Barbato R, Nenna A. Pressure ulcers in cardiac surgery: few clinical studies, difficult risk assessment, and profound clinical implications. Int Wound J. 2019;16(1):9-12. doi:10.1111/iwj.12994

8. Agrawal K, Chauhan N. Pressure ulcers: back to the basics. Indian J Plast Surg. 2012;45(2):244-254. doi:10.4103/0970-0358.101287

9. Moore Z, Avsar P, Conaty L, Moore DH, Patton D, O'Connor T. The prevalence of pressure ulcers in Europe, what does the European data tell us: a systematic review. J Wound Care. 2019;28(11):710-719. doi:10.12968/jowc.2019.28.11.710

10. Celik B, Karayurt Ö, Ogce F. The effect of selected risk factors on perioperative pressure injury development. AORN J. 2019;110(1):29-38. doi:10.1002/aorn.12725

11. Karahan E, Ayri AU, Çelik S. Evaluation of pressure ulcer risk and development in operating rooms. J Tissue Viability. 2022;31(4):707-713. doi:10.1016/j.jtv.2022.09.

12. Galivanche AR, Kebaish KJ, Adrados M, et al. Postoperative pressure ulcers after geriatric hip fracture surgery are predicted by defined preoperative comorbidities and postoperative complications. J Am Acad Orthop Surg. 2020;28(8):342-351. doi:10.5435/JAAOS-D-19-00104

13. Registered Nurses' Association of Ontario (RNAO). Assessment and management of pressure injuries for the interprofessional team. 3rd ed. Toronto, 2016. Accessed January 21 2023. https://rnao.ca/bpg/guidelines/pressure-injuries

14. Khong BPC, Goh BC, Phang LY, David T. Operating room nurses' self-reported knowledge and attitude on perioperative pressure injury. Int Wound J. 2020;17(2):455-465. doi:10.1111/iwj.13295

15. Hayes RM, Spear ME, Lee SI, et al. Relationship between time in the operating room and incident pressure ulcers: a matched case-control study. Am J Med Qual. 2015;30(6):591-597. doi:10.1177/1062860614545125

16. Ter N, Yavuz Giersbergen M, Aslan Başlı A. Basınç Yaralarının Önlenmesi (Prevention of Pressure Ulcers). Yavuz Van Gıersbergen M, Kaymakçı Ş, (Eds). Ameliyathane Hemşireliği (Operating Room Nursing). İzmir: Meta Basım (Meta Press). İzmir. 2022. p.587-593.

17. Engels D, Austin M, McNichol L, Fencl J, Gupta S, Kazi H. Pressure ulcers: factors contributing to their development in the OR. AORN J. 2016;103(3):271-281. doi:10.1016/j.aorn.2016.01.008

18. Li Z, Lin F, Thalib L, Chaboyer W. Global prevalence and incidence of pressure injuries in hospitalised adult patients: a systematic review and meta-analysis. Int J Nurs Stud. 2020;105:103546. doi:10.1016/j.ijnurstu.2020.103546

19. Faul F, Erdfelder E, Lang AG, Buchner A. G*Power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behav Res Methods. 2007;39(2):175-191. doi:10.3758/bf03193146

20. G*Power Statistical Power Analyses for Mac and Windows. https://www.psychologie.hhu.de/arbeitsgruppen/allgemeine-psychologie-und-arbeitspsychologie/gpower Accessed on April 9, 2024.

21. Eberhardt TD, de Lima SBS, de Avila Soares RS, et al. Prevention of pressure injury in the operating room: heels operating room pressure injury trial. Int Wound J. 2021;18(3):359-366. doi:10.1111/iwj.13538

22. Gao XL, Hu JJ, Ma Q, et al. Design and research on reliability-validity for 3S intraoperative risk assessment scale of pressure sore. J Huazhong Univ Sci Technolog Med Sci. 2015;35(2):291-294. doi:10.1007/s11596-015-1426-1

23. Soyer Ö, Özbayır T. 3S Ameliyathane Basınç Yarası Risk Tanılama Ölçeği'nin Türkçe'ye uyarlanması (Turkish adaptation of the operating room pressure wound risk diagnostic scale). Uluslararası Hakemli Hemşirelik Araştırmaları Dergisi (International Refereed Journal of Nursing Researches). 2018;13. doi:10.17371/UHD.2018.2.9

24. Bergstrom N, Braden BJ, Laguzza A, Holman V. The Braden scale for predicting pressure sore risk. Nurs Res. 1987;36(4):205-210.

25. Oğuz S, Olgun N. Braden ölçeği ile hastaların risklerinin belirlenmesi ve planlı hemşirelik bakımının bası yaralarının önlenmesindeki etkisinin saptanması (Predicting the pressure söre risk with Braden scale and determining the effectiveness of predetermined nursing preventing of pressure sore). Hemşirelik Forum Dergisi (Nursing Forum). 1998;1(3):131-135.

26. Kayser SA, VanGilder CA, Ayello EA, Lachenbruch C. Prevalence and analysis of medical device-related pressure injuries: results from the International Pressure Ulcer Prevalence survey. Adv Skin Wound Care. 2018;31(6):276-285. doi:10.1097/01.ASW.0000532475.11971.aa

27. Joseph J, McLaughlin D, Darian V, Hayes L, Siddiqui A. Alternating pressure overlay for prevention of intraoperative pressure injury. J Wound Ostomy Continence Nurs. 2019;46(1):13-17. doi:10.1097/WON.0000000000000497

28. Gül A, Sengul T, Yavuz HÖ. Assessment of the risk of pressure ulcer during the perioperative period: adaptation of the Munro scale to Turkish. J Tissue Viability. 2021;30(4):559-565. doi:10.1016/j.jtv.2021.06.009

29. Triantafyllou C, Chorianopoulou E, Kourkouni E, Zaoutis TE, Kourlaba G. Prevalence, incidence, length of stay and cost of healthcare-acquired pressure ulcers in pediatric populations: a systematic review and meta-analysis. Int J Nurs Stud. 2021;115:103843. doi:10.1016/j.ijnurstu.2020.103843

30. Porter SB, Pla R, Chow JH, et al. Preoperative pressure ulcers, mortality, and complications in older hip fracture surgery patients. J Am Acad Orthop Surg Glob Res Rev. 2022;6(11):e22.00117. doi:10.5435/JAAOSGlobal-D-22-00117

31. Edsberg LE, Black JM, Goldberg M, McNichol L, Moore L, Sieggreen M. Revised national pressure ulcer advisory panel pressure injury staging system: revised pressure injury staging system. J Wound Ostomy Continence Nurs. 2016;43(6):585-597. doi:10.1097/WON.0000000000000281

32. Pittman J, Horvath D, Beeson T, et al. Pressure injury prevention for complex cardiovascular patients in the operating room and intensive care unit: a quality improvement project. J Wound Ostomy Continence Nurs. 2021;48(6):510-515. doi:10.1097/WON.0000000000000815

33. Spruce L. Back to basics: preventing perioperative pressure injuries. AORN J. 2017;105(1):92-99. doi:10.1016/j.aorn.2016.10.018

34. de Oliveira KF, Nascimento KG, Nicolussi AC, Chavaglia SRR, de Araújo CA, Barbosa MH. Support surfaces in the prevention of pressure ulcers in surgical patients: an integrative review. Int J Nurs Pract. 2017;23(4):10.1111/ijn.12553. doi:10.1111/ijn.12553

35. Rasero L, Simonetti M, Falciani F, Fabbri C, Collini F, Dal Molin A. Pressure ulcers in older adults: a prevalence study. Adv Skin Wound Care. 2015;28(10):461-464. doi:10.1097/01.ASW.0000470371.77571.5d

36. Avşar P, Karadağ A. Waterlow Basınç Ülseri Risk Değerlendirme Ölçeği'nin Türkçeye uyarlanması, geçerlik-güvenirlik çalışması (Turkish adaptation and validity reliability study of the Waterlow Pressure Ulcer Risk Assessment Scale). Hacettepe Üniversitesi Hemşirelik Fakültesi Dergisi (Journal of Hacettepe University Faculty of Nursing). 2016;3(3):1-15.

37. Park SK, Park HA, Hwang H. Development and comparison of predictive models for pressure injuries in surgical patients: a retrospective case-control study. J Wound Ostomy Continence Nurs. 2019;46(4):291-297. doi:10.1097/WON.0000000000000544

38. Lumbley JL, Ali SA, Tchokouani LS. Retrospective review of predisposing factors for intraoperative pressure ulcer development. J Clin Anesth. 2014;26(5):368-374. doi:10.1016/j.jclinane.2014.01.012

39. Angmorterh SK, England A, Webb J, et al. An investigation of pressure ulcer risk, comfort, and pain in medical imaging. J Med Imaging Radiat Sci. 2019;50(1):43-52. doi:10.1016/j.jmir.2018.07.003

40. Karacabay K. Pozisyon Verme (Positioning). In: Ameliyathane Hemşireliği (Operating Room Nursing). Yavuz van Giersbergen M. and Kaymakçı Ş. (Eds). Meta Basım (Meta Press). İzmir.2022:120-129.