In this section
Note: This guideline is
currently under review.
Definition of terms
Pressure injuries are recognised as an international patient safety problem they increase morbidity and mortality.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.
The goal is to promote pressure injury prevention and optimal clinical care to patients with pressure injuries. The guideline specifically seeks to assist health professionals to:
Pressure injury- a localised injury to the skin and/or underlying tissue usually over a bony prominence or any skin surface, 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 7being 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.Extrinsic factors - originating outside of the body Intrinsic factors originating within the body
Source: Pan Pacific Clinical Practice Guideline for the Prevention and Management of Pressure Injury
A pressure injury can develop in as short as 30 minutes if there is high pressure in a small area. 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.
Intrinsic factors include:
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 and documented on the Primary Assessment flowsheet in the EMR.
This is completed at the following stages:
The following factors should be considered when completing a risk assessment:
See Clinical Guideline (Nursing): Nursing Assessment for more detailed assessment information.
The pressure injury risk assessment scores are reflected on the IP Summary in the EMR.
When an assessment identifies a patient at risk of pressure injury, interventions should be implemented immediately.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 is documented in the Primary Assessment flowsheet of the EMR.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 through the pressure injury prevention parent factsheet.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 patient’s 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:
1. Prevent friction and shearing forces during repositioning and transfers- Lower bed head prior to repositioning- Use slide sheets to move patient- Apply skin dressing
Observe patient closely for signs of friction particularly if the child is agitated.These techniques are to be used in conjunction with manual handling procedure and safe handling of patients and materials procedure2. Reducing Moisture- Apply barrier cream- Keep skin clean and dry- Investigate and manage incontinenceMoisture 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.Patients who are incontinent of urine and/or faeces should have an adequate evaluation to identify whether reversible causes exist.
Reversible causes include:
A bowel training program must be instituted for spinal cord injury patients. Refer to Spinal Cord injury Clinical Guideline (Acute management) 3. Skin InspectionInspect 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 pressure injury due to pressure, friction and shearing forces.
Regular inspection of the following areas is required:
Medical device related hospital acquired pressure injury can be prevented by frequently inspecting the skin where the following are in use:
Table 1 frequency of Skin Inspection
Table 2 Nutritional Interventions
5. Positioning and RepositioningPatients at risk of pressure injury should be suitably positioned to minimise pressure, friction and shear:
6. Relieving pressurePressure 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).Table 4.1 Characteristics of pressure redistribution support surfaces
(Adapted from the Pan Pacific Clinical Practice Guideline for the Prevention and Management of Pressure Injury)
Constant Low pressure Support (reactive)
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)
Pressure relieving devices
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
(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
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.
Available for hire from Pegasus
20+ Very High Risk
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
Alternating Pressure and Low Air Loss
Nimbus Range (mattress replacement).
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:
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.
Risk for patients undergoing surgery should be defined by:
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
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
Stage 2 pressure injury: partial thickness skin loss
Stage 3 pressure injury: full thickness skin loss
Stage 4 pressure injury: full thickness tissue loss
Unstageable pressure injury: depth unknown
Suspected deep tissue injury: depth unknown
Documentation and communication of pressure injuries
All pressure injuries need to be carefully documented.
If a pressure injury is identified:
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 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.
Pressure Injury Prevention Evidence Table
Please remember to read the disclaimer
The development of this nursing guideline was coordinated by Kylie Moon, Nursing Services, and approved by the Nursing Clinical Effectiveness Committee. Updated December 2012.