Clinical Guidelines (Nursing)

Pressure Injury Prevention and Management

  • Note: This guideline is currently under review. 


    Introduction

    Excellent skin care is an attribute of quality care. Prevalence of skin breakdown and pressure injuries has become a standard by which hospitals are evaluated and assessed with pressure injuries recognised as an international patient safety problem. 

    Most pressure injuries are preventable if appropriate measures are implemented.  Prevention involves ongoing risk assessment of all patients, implementation of prevention strategies including skin inspection and repositioning patients at regular intervals, analysis of the causal factors in the event of pressure injury development and the selection of appropriate pressure relieving devices.

    Aim

    The aim of this guideline is to increase awareness of pressure injuries amongst health care professionals throughout the Royal Children's Hospital (RCH).The primary objectives are to promote prevention of pressure injuries and provide optimal care to patients at risk of, or with existing pressure injuries.

    The guideline specifically seeks to assist health professionals to:

    • improve knowledge of the underlying physiology of pressure injury formation
    • recognize factors which contribute to pressure injuries
    • identify high risk patients
    • implement and document intervention and prevention strategies
    • prevent or delay complications associated with pressure injuries
    • optimise management of pressure injuries
    • provide adequate parent and carer education

    Definition of terms

    Pressure injury - a localised injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, shear and/or friction, or a combination of these factors

    pH - a measure on a scale from 0 to 14 of the acidity or alkalinity of a solution, with 7 being neutral, greater than 7 is more alkaline and less than 7 is more acidic

    Blanching erythema - Reddened skin that blanches white under light pressure.

    Risk assessment scale - a formal scale or score used to help determine the degree of pressure injury risk. At the Royal Children's Hospital  the Glamorgan Risk Assessment Scale is currently used.

    Shear- is a mechanical force created from parallel loads that cause the body to slide against resistance between the skin and a contact surface. The outer layers of the skin (the epidermis and dermis) remain stationary while deep fascia moves with the skeleton, creating distortion in the blood vessels between the dermis and deep fascia. This leads to thrombosis and capillary occlusion.

    Friction- is a mechanical force that occurs when two surfaces move across one another, creating resistance between the skin and contact surface that leads shear.

    Extrinsic factors - originating outside of the body

    Intrinsic factors originating within the body

    Moisture - alters resilience of the epidermis to external forces by causing maceration, particularly when the skin is exposed for prolonged periods. Moisture can occur due to spilt fluids, incontinence, wound exudate and perspiration.

    Pressure injury development

    A pressure injury can develop in as short as 30 minutes if there is high pressure in a small area. Increased pressure, over short periods of time and slight pressure for long periods of time, has been shown to cause equal damage.

    A pressure injury occurs when vessels collapse under external pressure, blood supply to the cells is cut off, limiting oxygen supply and decreasing nutrients to the cells which results in tissue hypoxia, leading to the development of localized tissue ischemia, cellular death and tissue necrosis.

    Factors associated with increased risk of pressure injury

    1. Intensity and duration of pressure
    2. Tolerance of the skin and supporting surfaces (including soft tissue) to endure the effects of pressure without incidence

    Factors contributing to the intensity and duration of pressure

    1. Reduced   mobility
    2. Reduced activity
    3. Reduced sensory perception

    Factors contributing to reduced tissue (skin) tolerance

    Intrinsic factors include:

    1. Nutrition - Inadequate nutrition is a major risk factor associated with the development of pressure injuries. Children must be given adequate nutrients to reduce the risk of developing pressure injuries and support healing
    2. Tissue perfusion, and oxygenation - tissue damage occurs when cells are deprived of oxygen and nutrients, combined with an accumulation of metabolic waste products for a specific period of time.

    Extrinsic factors

    1. Moisture - Moisture macerates the surrounding skin, causing superficial erosion of the epidermis. Primary sources of skin moisture include perspiration, urine, feces, and drainage from wounds or fistulas.
    2. Friction - is a mechanical force that occurs when two surfaces rub together, creating resistance between the skin and contact surface that leads to shear. Typically this type of superficial injury is seen on heels and elbows, resulting from repositioning.
    3. Shear - is a mechanical force created from parallel loads, such as movement on a bed sheet which creates occlusion by laterally displacing the tissue. Bones move against the subcutaneous tissue, while the epidermis and dermis remain, essentially, in the same position against the supporting surface. The outer layers of the skin (the epidermis and dermis) remain stationary while deep fascia moves with the skeleton causing a decrease in blood flow to the skin, eventually leading to breakdown. Shear forces are a significant risk for pressure injury formation.

    Assessment

    As with the adult population, early recognition of an at-risk infant, child or adolescent is critical.

    All patients have a risk assessment completed using the  Revised Glamorgan Paediatric Pressure Ulcer Risk Assessment Scale completed at the following stages:

    1. On admission or as soon as practical after the admission (within 6 hours)
    2. Daily or when a patient's condition changes
    3. When the patient is transferred from one ward/department to another
    4. Prior to  discharge

    The Glamorgan risk assessment score is documented in the Patient Care Record (MR856/A) in most of the inpatient areas and in the Progress Notes (MR660/A), where the Patient Care Record is not utilised. In Medical Short Stay (Dolphin Ward) risk assessment scores are captured on the Short Stay Clinical Path (MR925-81/A) and in the Paediatric Intensive Care Unit (Rosella Ward), risk scores are captured on the PICU Management Plan (MR855/A).

    The Glamorgan Risk Assessment Scale does not replace clinical judgment, if a patient does not present with a high risk score but is thought to be high risk by medical or nursing staff, allied health, parents or carers extra precautions to protect such patients should be documented and auctioned. 

    The following factors should be considered when completing a risk assessment:

    • Pre-admission history of prolonged unchanging pressure on body part(s)
    • Children younger than 36 months - have disproportionately large head in comparison to body size and an increased risk of pressure injury development on and  around occipital region
    • Disproportionate weight distribution for prolonged periods of Immobility/inactivity including:
      • Length of stay in PICU/NNU
      • Operation time
    • Decreased sensory perception due to chemical paralysis or neurological disturbances
    • Prolonged mechanical ventilation
    • Altered skin integrity due to oedema, fluid resuscitation or moisture including incontinence and perspiration.
    • Obesity - excessive fat accumulation
    • Compromised tissue perfusion & oxygenation - for example a cardiac diagnosis
    • Hypotension
    • Use of vasopressor medication
    • Hypovolaemia
    • Hypothermia
    • Oxygen saturations <95%
    • Capillary refill time > 2 seconds
    • Poor nutrition status or patients who are Nil By Mouth (NBM) for extended periods
    • Patients who experience rapid weight loss (due to diuresis or poor nutrition)  
    • Fluid restriction

    See Clinical Guideline (Nursing): Nursing Assessment for more detailed assessment information.

      Interventions and prevention

      When an assessment identifies a patient at risk of pressure injury, interventions should be implemented immediately.

      Glamorgan Risk Assessment score equal to or greater than 10 necessitates the implementation of a Pressure Injury Prevention Plan MR

      For all patients identified at risk, i.e., those with a Glamorgan risk score of 10 or greater; a Pressure Injury Prevention Plan must be commenced. The plan will be developed in collaboration with the child's parent or carer and will be specific to the patient's individual needs and risk category. Ensure parents and carers receive adequate education of pressure injury prevention pressure injury prevention parent fact sheet

      The plan will remain in use and visible in the bedside charts until the patients Glamorgan risk score changes. If the risk score increases a new plan will be implemented as the patients needs may have changed.

      Patient risk should continue to be assessed daily, once the patient's risk score is below 10 and the patient's risk of developing a pressure injury is reduced, a management plan is no longer required, however it is important that simple preventive measures are maintained.

      The following prevention strategies should be considered for patients at risk

      Prevent friction and shearing forcesduring repositioning and transfers 

      • a precaution which is implemented for all patients regardless of identified risk. As outlined in the RCH Smart Lift Program the use of assistive devices such as slide sheets, transfer boards, or hoists may assist in minimizing tissue injury. Never 'drag' a patient across a bed or a chair. Lowering the head of the bed, as much as tolerated before repositioning, will also help minimize friction and shear. Before raising the head-of-bed, move the patient up the bed and raise the knee bend, this assists in avoiding shear from the patient slipping down the bed.
      • Mechanical injury from friction can also be reduced with application of a barrier dressing, such as transparent films or hydrocolloids, over at risk areas. Care needs to be taken when removing these products to avoid further damage to skin.
      • Observe patient closely for signs of friction particularly if the child is agitated.
      • These techniques are to be used in conjunction with manual handling policy  and safe handling of patients and materials policy 

      Reducing Moisture

      • Moisture on the skin increases the risk of pressure injury development. This is also true if the skin is too dry, as it may cause skin to breakdown.
      • Maceration of skin can be prevented by managing excessive moisture, which can be achieved through cleansing at appropriate intervals and the use of skin barriers and absorbent materials. Briefs, nappies, absorbent underpads or absorbent sheets may be used if they are the type that removes moisture from the patient.
      • Areas which may be subjected to excessive moisture include the perineum and wound sites caused by drains or tubes.
      •  
      • Patients who are incontinent of urine and/or faeces should have an adequate evaluation to identify whether reversible causes exist. Reversible causes include:
        • urinary tract infection
        • medications
        • change in mental status
        • fecal impaction
        • polyuria due to glycosuria or hypercalcemia
        • restricted mobility
      • A bowel training program must be instituted for spinal cord injury patients. Refer to Spinal Cord injury Clinical Guideline (Acute management)

      Skin Inspection

      • Skin status is the most significant early indicator of the skin's response to pressure exposure and the ongoing risk of pressure injury. Inspect the skin of all patients on admission and at each repositioning to identify indications of pressure injury including: blanching response, localised heat, oedema, induration and skin breakdown. Particular attention should be paid to areas of bony prominence which are at an increased risk for presssure injury due to pressure, friction and shearing forces.  Regular inspection of the following areas is required:
        • Sacrum
        • Heels
        • Elbows
        • Temporal region of Skull
        • Shoulders
        • Back of Head especially in infants less than 36 months of age
        • Toes
        • Areas where there are external forces exerted ( eg: face Bipap mask, neck collar, ETT, plasters, nasogastric tube, drains, tubes, splints, tapes, or foreign objects in the bed)
        • chin and nostrils (nares) from signs of damage from oxygen devices
        • Strict circulatory observations for all children with plaster casts, orthosis and bandages note for any signs of irritation or pain
       Level of Risk (Glamorgan)  Frequency of skin inspection
       10+ At Risk  Skin should be inspected at least twice a day
       15+ High Risk  Skin should be inspected with each repositioning
       20+ Very High Risk  Skin should be inspected hourly

      Nutrition

      • Offer frequent fluids and diet to at risk patients to maintain adequate nutrition and hydration.
      • High or very high risk patients should be referred to a dietician for a nutritional assessment and appropriate dietary recommendations to prevent compromise to skin integrity.
      • Patients identified as being malnourished or with nutritional deficits should also be referred to a dietitian.
      • Nutritional support should be designed to prevent or correct nutritional deficits, maintain or achieve positive nitrogen balance, and restore or maintain serum albumin levels. Nutrients that have received primary attention in the prevention and treatment of pressure injuries include protein, arginine, vitamin C, vitamin A, and zinc.
       Level of Risk (Glamorgan)  Nutritional interventions
       10+ At Risk Offer frequent fluids and diet to maintain adequate nutrition and hydration
       15+ High Risk Consider referral to a dietician for nutritional assessment and appropraite dietary recommendations
       20+ Very High Risk Consider referral to a dietician for nutritional assessment and appropraite dietary recommendations

      Positioning and Repositioning

      Patients at risk of pressure injury should be suitably positioned to minimise pressure, friction and shear:

      • It is recommended for patients who are unable to reposition themselves that the repositioning timeframe (including turning) is every 2 hours. Positions may include; side lying, left side lying, right side lying, prone, seated in a bed or seated in a chair
      • Where possible the preferred method of repositioning is for the patient to do so independently if able.
      • Patients in pain are at an increased risk of pressure injury. If pain is managed appropriately they are able to move or be moved at frequent intervals. Monitor the patient's level of pain and ensure appropriate pain relief is provided. Refer to Pain Management Clinical Practice Guidelines
      • Repositioning should be performed regardless of the support surface on which the patient is managed.
      • Massaging of bony prominences can be harmful and should be avoided.
      • Reposition tubes and face masks every two hours
      • For patients who require monitoring - probes or electrodes should be rotated 2-4 hourly.
      • A 30 degree or lower elevation is recommended for high risk patients, raise bed head for short periods only
      • When repositioning the patient in any position always check the positioning of heels and other bony prominences.
      • Heels should be suspended off the bed using pillows or gel pads.
      • Consider more frequent, smaller shifts in position for patients who cannot tolerate frequent and/or major changes in body position
      • Consider Physiotherapy consultation for assistance/advice on transferring patients and repositioning.
       Level of Risk (Glamorgan) Positioning and repositioning
       10+ At Risk Relieve pressure by helping the child to move and repositioning equipment and devices every two hours
       15+ High Risk Reposition child / equipment / devices at least every two hours
       20+ Very High Risk Reposition child / equipment / devices at least every two hours

      Relieving pressure

      Pressure redistribution surfaces are support surfaces on which patients are placed to manage pressure load to tissue, microclimate, moisture shear and/or friction. They include beds, trolleys and operating table mattresses; integrated bed systems; and seat cushions and overlays. Pressure redistribution surfaces are designed to reduce interface pressure through increasing the body surface area or alternating the area of the body in contact with the support surface (i.e. pressure reduction and pressure relief), (National Pressure Ulcer Advisory Panel, 2009).

      Pressure relieving devices support the redistribution of body weight but do not negate the need for regular turning / pressure area care. For some high risk and very high risk patients the use of a pressure relieving device may allow a decrease in overnight turning frequency to 3- 4 hourly to ensure adequate sleep patterns, this should be assessed on an individual basis.

      Two primary pressure redistribution support surfaces are constant low pressure support surfaces (also called reactive) and alternating pressure support surfaces (also called active).

      pressure redistribution

      Constant Low pressure Support (reactive)

      Foam

      High Specification Foam: foam mattress made to high specifications

      Benefits  Disadvantages
      • Light weight
      • Easily maintained
      • Easily customized
      • Fast compression
      • Increases insulation and temperature
      • Can be difficult to launder if not covered appropriately

      Gel

      Support surface made by gel filled cells

      Benefits  Disadvantages
      • Allows posture control
      • Heat conductor
      • Heavy in weight
      • Requires maintenance
      • Can experience leaks
      • Increase skin moisture
      • Minimal immersion

      Air - low air loss

      A powered, air filled surface that allows air to escape from air cells

      Benefits  Disadvantages
      • High level pressure redistribution
      • Light
      • Customisable inflation properties
      • Continuous  full body pressure redistribution
      • Flow of air assists in managing heat and humidity regulation of the skin
      • Reduced posture control
      • Can experience leaks
      • Can make  patient transfers in and out of bed difficult
      • Pump noise may be problematic
      • May contribute to dehydration
      • Contraindicated for unstable or suspected unstable spinal injury 

      Alternating pressure

      A powered, air filled surface that redistributes pressure by cyclic inflation and deflation of air cells.

      Benefits  Disadvantages
      • Cyclic pressure - redistribution by changes in loading and unloading
      • Continuous change of contact points
      • Maintains postural support
      • More suited to patients who cannot be turned (or who request not to be turned)
      • Potential for bottoming out if settings/pressure incorrectly set
      • Pump noise may be problematic
      • Contraindicated for unstable or suspected unstable spinal injury

      Decisions about an appropriate pressure relieving device to use for pressure injury prevention should be based on an overall assessment of the patient and their risk assessment score. Selection of an appropriate device should take into consideration factors such as the individual's level of mobility within the bed, his/hercomfort and the need for microclimate control.

      Please consider the Sudden Infant Death Syndrome (SIDS) risk reduction recommendations when using pressure redistribution devices for infants. Safe Sleeping | Sids and Kids. Monitoring is required for infants nursed outside of these recommendations.

      Consider Occupational Therapist consultation for assistance with assessment of causal factors and advice on appropriate pressure relieving devices.

      Table - Pressure relieving devices

      Level of risk (Glamorgan) Equipment Option Pressure relieving devices Location 
       10+ At Risk Constant Low Pressure Support Foam - consider the use on gel pads in combination with MacMedMattress - (Full mattress). Cot and Bed Sizes available

      Gel Pads -available in avariety of sizes

      Readily available on most patient beds throughout RCH, check mattress labelling.

      Available throughout RCH or purchase through material resources

        Alternating Pressure AlphaXcell -(mattress overlay). Bed size - 40kg to 140kg Available RCH - Refer Aeroscout

      Available for hire from ArjoHuntleigh

      15+ High Risk

      Low Air Loss

      KCI Therakair(mattress replacement).Bed Size - up to 135kg

      KCI First Step Plus(mattress overlay).Cot Size - up to 25kg

      Breeze(mattress replacement).Bed Size - 20kg to140kg

      Available RCH - Refer Aeroscout

      Available RCH - Refer Aeroscout  

      Available for hire from ArjoHuntleigh

       

      Alternating Pressure

      NODEC-AirStream A (ASA)(mattress overlay).Bed Size - up to178kg. Soft settings for patients <50 kg, full settings for patients/>50kg

      Coziny(mattress overlay).Isolet and Cot Size.

      • Coziny 200 Isolet size - 2.5 - 4.5kg  
      • Coziny 300 Cot Size - 4.5 - 25kg

      Available for hire from Pegasus

       

       

      Available for hire from Pegasus

      20+ Very High Risk

      Low Air Loss

      Caritel Neo(mattress replacement).For neonates - 500g plus

      Caritel Juve(Mattress replacement).Cot Size

      Caritel Optima(Mattress replacement).Bed Size - Up to 300kg

      Therapulse II(Full Bed System).Bed Size - up to 135kg

      Breezewith pulsation (mattress replacement). Bed Size - 20kg to 140kg

      Available for hire from Pegasus

      Available for hire from Pegasus

      Available for hire from Pegasus

      Available RCH - Refer Aeroscout

      Available for hire from ArjoHuntleigh

        Alternating Pressure and Low Air Loss

      Nimbus Range (mattress replacement).

      • Cot   - 6kg to 25kg
      • Bed Size - 20kg to 250kg

      Available for hire from ArjoHuntleigh

      It is important to note that the use of sheets, overlay sheets, pillows and towels potentially alter the pressure relieving qualities of the mattress.  Try to avoid using plastic lined continence overlay sheets on air filled pressure relieving devices where possible. 

      The following should not be used as pressure redistribution devices:

      • Water-filled gloves under heels: are not effective due to the small surface area of the heel.  A water-filled glove is unable to redistribute any pressure
      • Synthetic sheepskins
      • Australian Medical Sheepskins: may reduce pressure injury development; however these require laundering specifications that RCH are currently unable to provide.  Therefore we do not recommend the use of Australian Genuine Sheepskins as a pressure relieving device whilst in hospital
      • Doughnut-type device: may impair lymphatic drainage and circulation and may contribute to pressure injuries

      Obtaining pressure relieving devices

      Once it has been determined if and what type of pressure relieving device is required, locating and obtaining the device will be the next step. Below are links to pdfs outlining the process for obtaining devices within the RCH and those that need to be hired.

      Patients in the operating room

      Risk for patients undergoing surgery should be defined by:

      1. Length of the operation
      2. Increased hypotensive episodes intraoperatively
      3. Low core temperature during surgery
      4. Reduced mobility on day one postoperatively

      The RCH operating tables are all fitted with high density pressure-redistributing foam to reduce the risk of pressure injury development.

      • Consider the use of Gel Pads and Perplex boxes for complex theatre cases
      • Patients should be positioned to reduce the risk of pressure injury development during surgery
      • Heels should be completely elevated in such a way as to distribute the weight of the leg along the calf without putting all the pressure on the Achilles tendon. The knee should be in slight flexion
      • Hyperextension of the knee may cause obstruction of the popliteal vein, and this could predispose the individual to deep vein thrombosis
      • Pay attention to pressure redistribution prior to and after surgery. Position the individual in a different posture preoperatively and postoperatively than the posture adopted during surgery where possible

      Assessment and documentation of pressure injuries

      In the event that a pressure injury occurs, accurate assessment and documentation is an essential part of determining appropriate treatment. Pressure Injuries are staged according to the 2009 National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel (NPUAP/EUPAP), Injury Classification System which is replicated in the following table.

      Stage I pressure injury: non-blanchable erythema

      • Intact skin with non-blanchable redness of a localised area usually over a bony prominence
      • Darkly pigmented skin may not have visible blanching; its colour may differ from the surrounding area
      • The area may be painful, firm, soft, warmer or cooler compared to adjacent tissue.
      • May be difficult to detect in individuals with dark skin tones
      • May indicate "at risk" persons (a heralding sign of risk)
       

      stage 1 pressure injury

       
      Stage 2 pressure injury:  partial thickness skin loss  
      • Partial thickness loss of dermis presents as a shallow, open wound with a red-pink wound bed, without slough.
      • May also present as an intact or open/ruptured serum-filled blister.
      • Presents as a shiny or dry, shallow ulcer without slough or bruising (nb bruising indicates suspected deep tissue injury).
      • Stage II Pressure Injury should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation
       

      Stage 2 pressure injury

       
      Stage 3 pressure injury:  full thickness skin loss  
      • Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunnelling.
      • The depth of a stage 3 pressure injury varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and can be shallow. In contrast, areas of significant adiposity can develop extremely deep injuries. Bone or tendon is not visible or directly palpable
       

      Stage 3 pressure injury

       
      Stage 4 pressure injury:  full thickness tissue loss  
      • Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed.
      • The depth of a stage 4 pressure injury varies by anatomical location. Stage 4 injuries can extend into muscle and/or supporting structures (e.g. fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone or tendon is visible or directly palpable.
       

      Stage 4 pressure injury

       

      Unstageable pressure injury: depth unknown

       
      • Full thickness tissue loss in which the base of the pressure injury is covered by slough (yellow, tan, grey, green or brown) and/or eschar (tan, brown or black) in the pressure injury bed
      • Until enough slough/eschar is removed to expose the base of the pressure injury, the true depth, and therefore the stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as the body's natural biological cover and should not be removed
       

      unstageable pressure injury

       
      Suspected deep tissue injury: depth unknown  
      • Purple or maroon localised area or discoloured, intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue
      • Deep tissue injury may be difficult to detect in individuals with dark skin tone.
      • Evolution may include a thin blister over a dark wound bed. The pressure injury may further involve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment
       

      suspected deep tissue injury

       

      Documentation and communication of pressure injuries

      All pressure injuries need to be carefully documented.

      If a pressure injury is identified:

      • Determine and document likely causal factors.
      • Document Pressure Injury appearance, measurement of the wound size and depth, exudate, odour and stage. Pressure injuries should be classified using the NPUAP/EPUAP Pressure Injury Classification System.
      • Notify medical staff and nurse in charge of shift of pressure injury
      • Notify the patient, family and/or carers of the pressure injury and management plan
      • Document in progress notes and handover a detailed description of what is observed and the action taken.
      • Document assessment and treatment plan for  stages 2 and above pressure injury on Wound Assessment and Treatment Plan
      • Notify incident on the hospital reporting systemVictorian Health Incident Management System (VHIMS),be sure to include the stage of the pressure injury

      Management

      • Patients with identified Pressure Injuries should be managed as high or very high risk regardless of their identified Glamorgan Risk Assessment Score. A  Pressure Injury Prevention Plan MR should be implemented immediately along with appropriate preventative measures, as outlined in 'interventions and prevention'
      • Patients should not be positioned directly on an existing pressure injury or body surface that remains damaged or erythematous from a previous damage
      • Activity should be increased as soon as patient is able
      • For patients with a stage 1 pressure injury, transparent hydrocolloid adhesive dressing (such as Comfeel) can be applied to the affected site for up to a week or changed when soiled or wet
      • For patients with a stage 2 or greater pressure injury a  Wound Care Assessment And Treatment Plan should be commenced. The wound should be clinically assessed for the most appropriate dressing. Refer to the Wound Care Clinical Guideline and consult Stomal Therapy Nurse Consultant for clinical guidance on appropriate assessment and management of the wound
      • Consult Orthotics Department for the correct fitting of braces/splints/collars where appropriate
      • Consider referring patients with a pressure injury to a dietician for assessment, treatment and ongoing monitoring

      Discharge

      Ensure the appropriate measures and equipment are in place in the home prior to discharge by referral to an Occupational Therapist.

      Goals of care

      Patients who are returning home with considerable changes to their mobility should have goals of care established by the multidisciplinary team in collaboration with the patient and their caregivers. Particularly those patients receiving palliative care, appropriate goals should be established and included in the patient's management plan. Multiple risk factors and general poor health significantly increases the risk of pressure injuries. Palliative care may have a stronger focus on managing symptoms, comfort and quality of life.

      Education

      Education of patients, parents and carers is essential in the prevention and management of pressure injuries. Patients and their families should have a clear understanding of the potential impact of a pressure injury and the importance of its prevention, contributing risk factors and strategies that assist in reducing the risk. This is particularly important when patients are in a home care environment or being discharged from an inpatient area. Families and carers of patients discharged with risk factors should receive a pressure injury prevention parent factsheet and discuss suitable prevention strategies relevant to their child prior to discharge.

      Companion documents

      1. Revised Glamorgan Paediatric Pressure Ulcer Risk Assessment Scale
      2. Pressure Injury Prevention Plan
      3. Wound Care Assessment and Treatment Plan
      4. Parent factsheet - Pressure Injury Prevention
      5. Clinical Guideline (Nursing): Nursing Assessment

      References

      • Pan Pacific Clinical Practice Guideline for the Prevention and Management of Pressure Injury
      • Australian Commission on Safety and Quality in Health Care. (2011) Preventing and Managing Pressure Injuries, Standard 8.
      • Butler. C. T. (2006) Paediatric Skin care: Guidelines for Assessment, prevention and Treatment. Paediatric Nursing, 32(5), 443-450.
      • Schindler, C.A., Mikhailov, T.A., Fischer, K., Lukasiewicz, G., Kuhn, E.M., Duncan, L. (2007) Skin Integrity in Critically Ill and Injured Children. 16(6), 568-574.
      • Suddaby, E. C.,Barnett, S. D., Facteau, L. (2006) Skin breakdown in Acute Paediatrics. Dermatology Nursing, 18(2), 155-166.
      • Novartis nutrition Corporation. (2006). An overview of the role of nutrition support in wound care.
      • Australian Wound Management Association Inc, Clinical Practice Guidelines for the Prediction and Prevention of Pressure Ulcers. 2001, West Leederville: Cambridge Publishing.
      • Institute for Clinical Systems Improvement (ICSI), Pressure ulcer prevention and treatment. Health care protocol. 2010, Bloomington (MN): ICSI.
      • Best Practice Information Sheets - Joanna Briggs Institute.(2008) Pressure ulcers - Prevention of Pressure related Damage. 12(2) 1-4.
      • National Pressure Ulcer Advisory Panel. (Revised 2007) Pressure Ulcer Prevention Points. www.npuap.org
      • National Pressure Ulcer Advisory Panel (NPUAP) and European Pressure Ulcer Advisory Panel (EPUAP), Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. 2009, Washington DC: NPUAP.
      • National Pressure Ulcer Advisory Panel (NPUAP) and European Pressure Ulcer Advisory Panel (EPUAP), Pressure Ulcer Prevention, Quick reference Guide. (2009)

      Evidence table

      Pressure Injury Prevention Evidence Table

       

      Please remember to read the disclaimer

      The development of this clinical guideline was coordinated by Kylie Moon, Nursing Services. Approved by the Clinical Effectiveness Committee. Authorised by Bernadette Twomey, Executive Director Nursing Services. First published March 2012 (replacing Pressure Ulcers Prevention & Management Procedure published July 2009). Current as of December 2012.