is high risk), nutritional condition, recent weight loss and BMI.
"Unlike the Braden Scale or the full Munro Scale, we're not looking
to generate a score to determine the patient's PI risk level," says Ms.
Kooiker. "We simply want to identify if the patient is at risk."
To save time, it's a focused assessment. Nurses don't examine the
whole body, but rather the parts that will be under stress during sur-
gery, she says.
"We take the necessary precautions, including applying foam dress-
ings," says Ms. Kooiker. "We'd rather go overboard on prevention for
any patient that's at risk, no matter how seemingly slight."
In the OR, the CMunro Scale prompts nurses to assess systolic
blood pressure, the surface the patient is on, core body temperature,
anesthesia type/ASA physical classification, positioning and presence
of moisture underneath the patient. They implement position-specific
protective measures:
• Supine. Float heels without hyperextending the knee; apply foam
dressing to heels and sacrum.
• Prone. Put protective helmet on patient; apply foam dressing/gel
pad to chest, knees, iliac crest and other bony prominences.
• Lateral. Place pillow between legs; apply foam dressing/gel pad
under knee, ankle, foot of dependent leg, axillary gel roll, other areas
of pressure; ensure dependent ear is well-padded and not folded.
They also coordinate with the rest of the OR team to offload pres-
sure points throughout the case, usually every 2 hours. If an interven-
tion is needed, they float the heels without hyperextending the knee
and maintain normothermia. PACU nurses note the length of surgery
and estimated blood loss as part of the CMunro Scale process, says
Ms. Kooiker.
Handoff communication between nurses at each stage of the surgi-
cal process is vital. Nurses enter the skin assessment results into the
4 4 • O U T PA T I E N T S U R G E R Y M A G A Z I N E • A U G U S T 2 0 1 9
