CMUNRORISK

CMUNRO RISKASSESSMENT
ASSESSMENTSCALE
SCALE
FORSURGICAL-RELATED
FOR SURGICAL-RELATEDPRESSURE
PRESSUREINJURY
INJURY

SAMSUL MAARIF

The 19th Continuing Education

The 19th Continuing Education
Indonesian Operating Room Nurses Association
Indonesian Operating Room Nurses Association
Malang, 16 November 2019
Malang, 16 November 2019
 THEOBJECTIVE
THE OBJECTIVE
To develop the munro scale,
To develop the munro scale,
to obtain instrument that
to obtain instrument that
have better validity and
have better validity and
reliability
reliability

To identify the strength

To identify the strength
and weakness of cmunro
and weakness of cmunro
as risk assessment scale
as risk assessment scale

To understand the
To understand the
cmunro risk assessment
cmunro risk assessment
scale for pressure
scale for pressure
injury
injury
 BACKGROUND
BACKGROUND
A systematic review enrolled 17 articles with 5.451 patients that
investigated the incidence of surgery-related pressure injuries from
10 countries : The incidence was varied (averaging 15%)
Chen, et all (2012). https://www.woundsresearch.com
/article/incidence-pressure-ulcers-surgical-patients-last-5-years-systematic-review

Pressure injuries pose significant economic burden to patients,

prolong their hospitalization time, reduce their quality of life, and
increase their incidence of other complications
Pressure injury must being used as one of the key indicators of
nursing CARE in the operation room
 BACKGROUND
BACKGROUND
• A PILOT STUDY WAS CONDUCTED TO EVALUATE CONSISTENCY
• A PILOT STUDY WAS CONDUCTED TO EVALUATE CONSISTENCY
BETWEEN SUB EPIDERMAL MOISTURE SCANNER TECHNOLOGY AND
BETWEEN SUB EPIDERMAL MOISTURE SCANNER TECHNOLOGY AND
ULTRASOUND EXAMINATIONS OF SUSPECTED DEEP TISSUE INJURY
ULTRASOUND EXAMINATIONS OF SUSPECTED DEEP TISSUE INJURY
• SUB EPIDERMAL MOISTURE SCANNER READINGS WERE ABNORMAL 3
• SUB EPIDERMAL MOISTURE SCANNER READINGS WERE ABNORMAL 3
DAYS BEFORE APPEARANCE OF A HYPOECHOIC LESION IN THE
DAYS BEFORE APPEARANCE OF A HYPOECHOIC LESION IN THE
ULTRASOUND
ULTRASOUND
• SUB EPIDERMAL MOISTURE SCANNER DETECTED A LESION EARLIER
• SUB EPIDERMAL MOISTURE SCANNER DETECTED A LESION EARLIER
THAN ULTRASOUND.
THAN
Gefen ULTRASOUND.
and Gershon, (2018) https://www.ncbi.nlm.nih.gov/pubmed/30256748
SURGICAL-RELATED PRESSURE INJURY

PRESSURE
PRESSURE INJURY
INJURY THAT
THAT APPEAR
APPEAR
WITHIN
WITHIN THE
THE FIRST
FIRST 72
72 HOURS
HOURS AFTER
AFTER
SURGERY,
SURGERY, WERE
WERE SUBJECTED
SUBJECTED TOTO
PRESSURE
PRESSURE DURING
DURING THE
THE OPERATION
OPERATION
PRESSURE ULCER
STAGING
 RISKFACTOR
RISK FACTOR
• CURRENT SMOKING HISTORY
• CURRENT SMOKING HISTORY
• INTRAOPERATIVE BODY TEMPERATURE OF >38.3°C AND
• INTRAOPERATIVE BODY TEMPERATURE OF >38.3°C AND
<36°C
<36°C
• BOTH TOO HIGH AND TOO LOW BMI SCORES
• BOTH TOO HIGH AND TOO LOW BMI SCORES
• INTRAOPERATIVE HYPOTENSION
• INTRAOPERATIVE HYPOTENSION
• MALNUTRITION (LOW SERUM ALBUMIN LEVEL)
• MALNUTRITION (LOW SERUM ALBUMIN LEVEL)
• CO-MORBIDITIES
• CO-MORBIDITIES
DIABETES,
Spruce, L. (2017).HEART DISEASE, VASCULAR DISEASE
https://www.sciencedirect.com/science/article/abs/pii/S0001209216308298
DIABETES, HEART DISEASE, VASCULAR DISEASE
 RISK
RISK
FACTORS
FACTORS
DEMOGRAPHIC CO-MORBIDITY
DEMOGRAPHIC CO-MORBIDITY
• AGE ≥75 YEARS •ANAEMIA
• AGE ≥75 YEARS • ANAEMIA
• BMI < 23 •HYPERTENSION
• BMI < 23 • HYPERTENSION
• ASA SCORE GRADE ≥ •RESPIRATORY
• ASA SCORE GRADE ≥ • RESPIRATORY
3 DISEASE
Aloweni,
3
Aloweni,
DISEASE
et all (2017) https://onlinelibrary.wiley.com/doi/full/10.1111/iwj.13007
et all (2017) https://onlinelibrary.wiley.com/doi/full/10.1111/iwj.13007
 RISKFACTORS
RISK FACTORS

• INTRAOPERATIVE VASOPRESSOR USE

• INTRAOPERATIVE VASOPRESSOR USE
• SKIN TURGOR
• SKIN TURGOR
• DIASTOLIC BLOOD PRESSURE LESS THAN OR EQUAL TO 60
• DIASTOLIC BLOOD PRESSURE LESS THAN OR EQUAL TO 60
MM B.
Celik, HG
MM HG& Ogce, F. (2019) https://www.ncbi.nlm.nih.gov/pubmed/31246295
 RISKFACTOR
RISK FACTOR
INCREASING OPERATIVE DURATION WERE SHOWN
INCREASING OPERATIVE DURATION WERE SHOWN
TO BE STATISTICALLY SIGNIFICANT FACTORS IN
TO BE STATISTICALLY SIGNIFICANT FACTORS IN
THE DEVELOPMENT OF PRESSURE INJURY
THE DEVELOPMENT OF PRESSURE INJURY
Wright, et all (2014) https://www.joms.org/article/S0278-2391(14)00445-5/fulltext
 PREVALENCERATE
PREVALENCE RATEBASED
BASEDON
ONLENGTH
LENGTHOF
OF
SURGERY
SURGERY

Length of Surgery Prevalence Rate

3-4 hrs 5.8-6.0%

4-5 hrs 8.9%

5-6 hrs 9.9%

> 6 hrs 9.9%

> 7 hrs 13.2%

 RISKFACTORS
RISK FACTORS

• •PREOPERATIVE
PREOPERATIVESKIN
SKINUNDER
UNDERCOMPRESSION,
COMPRESSION,

• •PREOPERATIVE
PREOPERATIVEPHYSICAL
PHYSICALACTIVITY,
ACTIVITY,
• SURGICALPOSITION
• SURGICAL POSITION
XIONG ET ALL. (2019)
XIONG ET ALL. (2019)
HTTPS://WWW.NCBI.NLM.NIH.GOV/PUBMED/30375697
HTTPS://WWW.NCBI.NLM.NIH.GOV/PUBMED/30375697
 HOWTO
HOW TOIDENTIFY
IDENTIFYTHOSE
THOSEAT
ATRISK?
RISK?

• RISK ASSESSMENT IS THE PROCESS OF

• RISK ASSESSMENT IS THE PROCESS OF
IDENTIFYING THOSE AT RISK
IDENTIFYING THOSE AT RISK
• RISK ASSESSMENT IS THE INITIAL STEP OF
• RISK ASSESSMENT IS THE INITIAL STEP OF
PRESSURE INJURY PREVENTION
PRESSURE INJURY PREVENTION
• PREVENTION MUST BE CARRIED OUT ESPECIALLY
• PREVENTION MUST BE CARRIED OUT ESPECIALLY
FOR THOSE AT HIGH RISK
FOR THOSE AT HIGH RISK
• ASSESS AND PERIODICALLY REASSESS SO YOU
• ASSESS AND PERIODICALLY REASSESS SO YOU
CAN TAKE ACTION
CAN TAKE ACTION
RISK ASSESSMENT SCALE
FOR PRESSURE INJURY

• NORTHON SCALE
• WATERLOW SCALE
• BRADEN SCALE
• SCOTT TRIGGERS SCALE
• MUNRO SCALE
The Munro Pressure injury Risk
Assessment Scale (Munro Scale) is the
world’s first scale for surgical patients
 CASSENDRAA.A.MUNRO,
CASSENDRA MUNRO,MSN,
MSN,RN,
RN,RNFA,
RNFA,CNOR
CNOR

• SHE IS THE CREATOR OF THE MUNRO PRESSURE ULCER RISK

• SHE IS THE CREATOR OF THE MUNRO PRESSURE ULCER RISK
ASSESSMENT SCALE FOR PERIOPERATIVE PATIENTS (MUNRO SCALE.)
ASSESSMENT SCALE FOR PERIOPERATIVE PATIENTS (MUNRO SCALE.)
• CASSENDRA HAS BEEN A PERIOPERATIVE NURSE FOR OVER 19 YEARS
• CASSENDRA HAS BEEN A PERIOPERATIVE NURSE FOR OVER 19 YEARS
AND A MEMBER OF AORN FOR OVER 16 YEARS.
AND A MEMBER OF AORN FOR OVER 16 YEARS.
• CLINICAL COORDINATOR FOR HIP AND PELVIS, CLINICAL NURSE
• CLINICAL COORDINATOR FOR HIP AND PELVIS, CLINICAL NURSE
SPECIALIST, THE PERIOPERATIVE EDUCATOR FOR THE DEPARTMENT
SPECIALIST, THE PERIOPERATIVE EDUCATOR FOR THE DEPARTMENT
OF SURGERY
OF SURGERY
• PROFESSIONAL PRACTICE MANAGER AT A LARGE HOSPITAL IN LOS
• PROFESSIONAL PRACTICE MANAGER AT A LARGE HOSPITAL IN LOS
ANGELES, CALIFORNIA.
ANGELES, CALIFORNIA.
 TheMunro
The MunroScale
Scaleisiscomposed
composedofofthree
threeseparate
separatetime
time
frames
frames
Pre-op risk factors Intraoperative risk Postoperative
Patients are factors include physical risk, completed in
scored on their status/ASA score, type the PACU,
mobility, of anesthesia, body
temperature,
evaluates
nutritional status,
hypotension, moisture, perioperative
body mass index,
surface/motion and duration and
weight loss, age surgical position blood loss
and comorbidities
Communicating the increased risk to those
giving post-operative care would add valuable
information about what might  need to be done
or what products may need to be added to
prevent evolution of skin damage after surgery
 THESTRENGTH
THE STRENGTHOFOFMUNRO
MUNRO
SCALE
SCALE
• THE MUNRO SCALE, IS THE WORLD’S FIRST SCALE FOR PRESSURE
• THE MUNRO SCALE, IS THE WORLD’S FIRST SCALE FOR PRESSURE
INJURY RISK ASSESSMENT FOR SURGICAL PATIENTS
INJURY RISK ASSESSMENT FOR SURGICAL PATIENTS
• THE MUNRO SCALE IS COMPOSED OF THREE SEPARATE TIME
• THE MUNRO SCALE IS COMPOSED OF THREE SEPARATE TIME
FRAMES
FRAMES
• THE SCALE INCLUDES 15 ITEMS, AND THE INCLUDED FACTORS,
• THE SCALE INCLUDES 15 ITEMS, AND THE INCLUDED FACTORS,
SUCH AS “BMI”, “ANESTHESIA TYPE”, “INTRAOPERATIVE
SUCH AS “BMI”, “ANESTHESIA TYPE”, “INTRAOPERATIVE
TEMPERATURE CHANGE”, “PERIOPERATIVE BLOOD LOSS”,
TEMPERATURE CHANGE”, “PERIOPERATIVE BLOOD LOSS”,
“POSITION” AND “PERIOPERATIVE DURATION”, WERE ALL RELATED
“POSITION” AND “PERIOPERATIVE DURATION”, WERE ALL RELATED
TO THE SURGICAL AND NOT INCLUDED IN THE BRADEN, NORTON,
TO THE SURGICAL AND NOT INCLUDED IN THE BRADEN, NORTON,
AND WATERLOW SCALES
AND WATERLOW SCALES
 CRITICAL
CRITICAL
QUESTION
QUESTION
• SEVERAL RISK FACTOR, SUCH AS DURATION OF
• SEVERAL RISK FACTOR, SUCH AS DURATION OF
SURGERY, NUTRITIONAL STATUS (HYPOALBUMIN
SURGERY, NUTRITIONAL STATUS (HYPOALBUMIN
SERUM) AND CO-MORBIDITY (ANEMIA) NOT INCLUDED
SERUM) AND CO-MORBIDITY (ANEMIA) NOT INCLUDED
IN THE CMUNRO SCALE ???
IN THE CMUNRO SCALE ???
•
• ININCONTRAST,
CONTRAST, LENGTH OF NPO STATUS AND TYPE OF
LENGTH OF NPO STATUS AND TYPE OF
ANESTHESIA THAT NOT YET WIDELY KNOWN ITS
ANESTHESIA THAT NOT YET WIDELY KNOWN ITS
RELATION TO THE PRESSURE INJURY INCIDENTS, BUT
RELATION TO THE PRESSURE INJURY INCIDENTS, BUT
HAVE BEEN INCLUDED IN THE CMUNRO SCALE ???
HAVE BEEN INCLUDED IN THE CMUNRO SCALE ???
As an Assessment Instrument,
How is the Level of Validity &
Reliability
the Munro Scale???
 TOANSWER
TO ANSWERTHIS
THIS
QUESTION
QUESTION
• SEARCH FOR ARTICLES WAS DONE THROUGH THE
• SEARCH FOR ARTICLES WAS DONE THROUGH THE
EBSCHO, PUBMED AND PROQUEST DATABASES
EBSCHO, PUBMED AND PROQUEST DATABASES
• THE KEYWORD USED ARE “MUNRO SCALE” AND
• THE KEYWORD USED ARE “MUNRO SCALE” AND
“PRESSURE INJURY” THIS IDENTIFICATION PROCESS, TWO
“PRESSURE INJURY” THIS IDENTIFICATION PROCESS, TWO
ARTICLES WERE OBTAINED FROM PUBMED, ONE FROM
ARTICLES WERE OBTAINED FROM PUBMED, ONE FROM
EBSCHO AND ONE FROM PROQUEST
EBSCHO AND ONE FROM PROQUEST
•
• ININTHE
THE SCREENING PROCESS WAS FOUND THAT ALL
SCREENING PROCESS WAS FOUND THAT ALL
ARTICLES DID NOT EXPLAIN THE VALIDITY & RELIABILITY
ARTICLES DID NOT EXPLAIN THE VALIDITY & RELIABILITY
OF MUNRO SCALE
OF MUNRO SCALE
 ARTICLES THAT EXPLAIN VALIDITY & RELIABILITY
ARTICLES THAT EXPLAIN VALIDITY & RELIABILITY
OF PRESSURE INJURY RISK ASSESSMENT SCALE
OF PRESSURE INJURY RISK ASSESSMENT SCALE

• THE PURPOSE OF THE STUDY WAS TO
• THE PURPOSE OF THE STUDY WAS TO
DEVELOP AND COMPARE 3 PREDICTIVE
DEVELOP AND COMPARE 3 PREDICTIVE
MODELS FOR PRESSURE INJURY
MODELS FOR PRESSURE INJURY
OCCURRENCE IN SURGICAL PATIENTS.
OCCURRENCE IN SURGICAL PATIENTS.
• CONCLUSSION : THE SCOTT TRIGGERS
• CONCLUSSION : THE SCOTT TRIGGERS
TOOL, WHICH CONSISTS OF ESTIMATED
TOOL, WHICH CONSISTS OF ESTIMATED
SURGERY TIME AND SERUM ALBUMIN
SURGERY TIME AND SERUM ALBUMIN
LEVEL WAS THE BEST FITTING MODEL
LEVEL WAS THE BEST FITTING MODEL
PARK, & HWANG, (2019) :
PARK, & HWANG, (2019) :
HTTPS://DOI.ORG/10.1097/WON.0000000000000544
HTTPS://DOI.ORG/10.1097/WON.0000000000000544
• THE PURPOSE OF THE STUDY WAS TO IDENTIFY THE
• THE PURPOSE OF THE STUDY WAS TO IDENTIFY THE
RELIABILITY AND VALIDITY OF A CHINESE VERSION OF
RELIABILITY AND VALIDITY OF A CHINESE VERSION OF
THE MUNRO SCALE
THE MUNRO SCALE
• METHODS : A CHINESE VERSION OF THE MUNRO SCALE
• METHODS : A CHINESE VERSION OF THE MUNRO SCALE
WAS DEVELOPED USING BRISLIN’S TRANSLATION
WAS DEVELOPED USING BRISLIN’S TRANSLATION
MODEL AND CULTURAL ADAPTATION
MODEL AND CULTURAL ADAPTATION
• CONCLUSSION : THE CHINESE VERSION OF THE MUNRO
• CONCLUSSION : THE CHINESE VERSION OF THE MUNRO
SCALE SHOWED A HIGH DEGREE OF RELIABILITY,
SCALE SHOWED A HIGH DEGREE OF RELIABILITY,
HIGH CONTENT VALIDITY, AND ACCEPTABLE
HIGH CONTENT VALIDITY, AND ACCEPTABLE
CONSTRUCT VALIDITY
CONSTRUCT VALIDITY
DONGXUE LI, JIA TANG, X. G. (2018).
DONGXUE LI, JIA TANG, X. G. (2018).
HTTP://WWW.IJCEM.COM/FILES/IJCEM0065427.PDF.
HTTP://WWW.IJCEM.COM/FILES/IJCEM0065427.PDF.
CONCLUSSION
The Munro Pressure injury Risk Assessment Scale,
is the world’s first scale for surgical patients
Research on the cmunro scale is still rarely done, the
level of validity & reliability of munro scale is not yet
known.
some important risk factors, not yet included in the
munro scale, such as low serum albumin, anemia &
duration of surgery
There is an opportunity to modify and develop the
munro scale, to obtain instrument that have better
validity and realibility
REFERRENCES
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 REFERRENCE
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