Clinical Guidelines (Nursing)

Pressure injury prevention and management

  • Introduction

    Aim

    Definition of Terms

    Pressure Injury Development

    Prevention

    Management

    Patients in the Operating Room

    Patients in Intensive Care Unit

    The Orthopaedic Patient

    Documentation of pressure injuries

    Discharge

    Appendices

    References

    Evidence Table

    Introduction

    Excellent skin care is an attribute of quality nursing care. The prevalence of skin breakdown and pressure injuries (PI’s) has become a standard by which hospitals are evaluated and assessed, with the development of PI’s recognised as a patient safety problem as they can increase morbidity and mortality. Most PI’s are preventable if appropriate measures are implemented. 

    Aim

    The aim of this guideline is to increase awareness of pressure injuries amongst health care professionals at the Royal Children’s Hospital (RCH). The primary objectives are to provide the finest care to patients at risk of or with PI’s and optimally to promote their prevention. 
    The guideline ensures health care professionals:

    • Improve their knowledge of the underlying physiology of PI formation.
    • Recognise factors which contribute to PI’s.
    • Identify high risk patients.
    • Implement and document intervention and prevention strategies.
    • Prevent complications as a consequent to PI’s.
    • Enhance pressure injury management.
    • Provide adequate parent and carer education.

    Definition of Terms

    • Blanching Erythema - Reddened skin that becomes white or pale in appearance when light pressure is applied. 
    • Extrinsic Factors - Originating external to the body.
    • Intrinsic Factors - Originating internal to the body.
    • pH - Is the measure of the acidity or alkalinity of a fluid. Its value is measured from 0-14, with being neutral.
    • Pressure Injury - Is a localised area of tissue destruction that develops when soft tissue is compressed between a bony prominence, as a result of pressure, shearing forces and/or friction, or a combination of these.
    • Risk Assessment Scale - A formal grade used to help ascertain the degree of pressure injury risk. At the Royal Children’s Hospital the Glamorgan Risk Assessment Scale is currently used.
    • Re-perfusion Injury - A re-perfusion injury is a response that the tissues have that results in damage to the cells when blood supply returns back to the tissue after a period of ischemia or lack of oxygen. 
    • Induration – A hardened mass or formation of the skin tissue due to increase in fibrous elements commonly associated with inflammation and marked loss of elasticity and pliability of the skin. 

    Pressure Injury Development

    PI’s are any breach of skin integrity caused by unrelieved pressure on soft tissue that has been compressed between any external surface and bony prominences for a prolonged period of time. In addition to this, poor blood flow, friction, shear and tissue ischaemia can all contribute to PI’s. The deep fascia, subcutaneous fat, skin, bone and muscle can all be damaged by this unrelieved pressure.

     The tissues ability to tolerate the pressure including the intensity and duration are factors affecting PI development. 

    Localised areas of tissues that have prolonged pressure cause the occlusion of blood flow, preventing the supply of nutrients and oxygen to the tissue, resulting in ischaemia and re-perfusion injury, leading to cell obliteration and eventually tissue death. 

    Please see the Pressure Injury Staging Guide for stages of pressure area development found in Appendix 1.  

    Factors associated with increased risk of pressure injury

    In the prevention of PI’s, it is essential that patients at risk are identified and an individualised prevention plan is implemented. A risk factor is any element that either diminishes the skins tolerance to pressure or contributes to increased exposure of the skin to excess pressure. 
    Pressure Injury flow chart

    (Adapted from: Pan Pacific Clinical Practice Guideline for the Prevention and Management of Pressure Injury.)

    Intrinsic Factors

    These are factors that reduce the skin’s tolerance through impacting its lymphatic system, supporting structures and vascular bed. Conditions and chronic illnesses that impair oxygen delivery, sensation, tissue perfusion, lymphatic function are identified as increasing PI risk and include, but are not limited to: 

    • Smoking
    • Anaemia
    • Low Blood Pressure
    • Diabetes mellitus
    • Lymphodema
    • Elevated skin temperature
    • Dehydration
    • Impaired nutrition status
    • Renal failure or impairment
    • Circulatory abnormalities
    • Carcinoma
    • Peripheral arterial disease
    • Cardiopulmonary disease
    • Depressed Immune System

    Extrinsic Factors

    These are factors on the skins ability to tolerate pressure. 

    • Shear: is a mechanical force created from a tangential load that causes the body to slide against resistance between a contact surface and the skin. The dermis and epidermis (outer layers of the skin) remain stationary while the skeleton moves with the deep fascia, creating distortion in the lymphatic system and in the blood vessels between the outer layers of the skin.  This leads to capillary occlusion and thrombosis. 
    • Moisture: alters the resilience of the skin to external forces by causing softening, particularly the longer the skin is exposed. Moisture can occur due to: wound exudate, incontinence and perspiration. We must be mindful that some forms of moisture, create added risks of PI by exposing the skin to enzymes and bacteria in the fluid that raise the skin’s pH.
    • Friction: is another mechanical force that occurs when two surfaces move across one another, creating resistance between the contact surface and the skin’s surface that leads to shear.  

    Increased exposure to pressure

    Risk factors that increase exposure of the skin to PI’s are related to sensory perception, activity, the patient’s ability to change their body position and impaired mobility. Specific circumstances that fall into these categories include: 

    • Obesity
    • Cognitive impairment
    • Medication Use (Hyponotics, analgesics, sedatives, muscle relaxants)
    • Diabetes
    • Spinal Cord Injury (SCI)
    • Stroke
    • Multiple Sclerosis
    • Trauma
    • Post-op surgical
    • Patients sitting in wet clothing, wet nappy, and wet bed for long periods. 
    • Reduced skin sensation (paralysis, epidural, nerve blocks)
    • Patients lying/sitting in one place for too long. 

    Reduction in tissue tolerance

    This is the ability of the supporting structures and its skin to tolerate the effects of pressure. The skins surface acts as a cushion to protect the skeleton during transferring pressure loads. Factors that affect tissue tolerance include both intrinsic and extrinsic factors. 

    Factors contributing to reduced tissue (skin) tolerance:
    • Pre-admission history of prolonged unchanging pressure on body part(s)
    • Children younger than 36 months – have a disproportionately larger head in comparison to body size and an increased risk of PI development on the occipital region. 
    • Disproportionate weight distribution for prolonged periods of inactivity/immobility including:
    • Operation time/Position in operating theatre
    • Length of stay in NNU/PICU
    • Prolonged mechanical ventilation OR Non Invasive Ventilation
    • Decreased sensory perception due to chemical paralysis or neurological disturbances
    • Altered skin integrity due to fluid resuscitation, moisture, incontinence or oedema
    • Obesity – excessive fat accumulation for age
    • Compromised tissue oxygenation and perfusion – cardiac/septic patient.
    • Hypotension
    • Use of vasopressor medication
    • Hypothermia and/or use of therapeutic hypothermia
    • Oxygen saturations <95%
    • Capillary refill > 2 seconds
    • Poor nutrition status or patients who are NBM for extended period of time
    • Fluid restriction
    • Patients who experience rapid weight loss (due to poor nutrition or diuresis)

    Prevention

    Prevention requires an on-going risk assessment, consideration of casual factors, implementation of prevention strategies and the selection of an appropriate use of pressure relieving devices. When an assessment identifies a patient at risk of pressure injury, interventions should be implemented immediately.

    Education of patients and families

    Carers and parents are a fundamental part of the child’s care and can prevent and manage PI’s by working with the multidisciplinary team. Carers and parents should be informed of the risk of developing PI’s whilst in hospital and subsequently should be provided with literature that will assist them to understand and contribute in the development of effective and suitable strategies to prevent PI’s. 

    Factsheets should be made available to carers and parents who have a child that has been identified at risk of developing a pressure area. The carer/parent factsheet for Pressure Injury Prevention can be found on the intranet.

    Suggested preventative strategies should be discussed with the carers/parents or children of appropriate age, including: device management, repositioning and inspecting their skin. 

    Skin Integrity Assessment

    Children who are at risk of developing pressure injuries need to be identified so that preventative measures can be taken. In individuals that are at risk of developing nosocomial pressure related injuries, early recognition is considered to be an essential component in their care plan. Effective prevention remains in early risk identification. 

    To assist health care professionals in identifying a patient at risk of PI, an assessment tool or scale must be used. This is a record used to determine a score according to a series of parameters considered to be risk factors for PI’s. Certified risk assessment tools for children are effective for identifying those at risk and increasing awareness of potential pressure related injuries, however they cannot embody every possible circumstance. Therefore, clinicians need to use their experience, clinical judgment and knowledge to prevent tissue damage and protect the skin in conjunction with the screening tool. 

    All children that are inpatients should be evaluated which includes a visual inspection of the Integumentary system to determine its general condition in relation to factors which puts them at increased risk for PI development. This should be done:

    1. On admission or as soon as practical after the admission (within six hours)
    2. At the commencement of every shift as required nursing documentation or when a patient’s condition changes. 
    3. When the patient is transferred from one ward/department to another.
    4. Prior to discharge. 

    All patients have a screening tool assessment completed using Glamorgan Pressure Injury Risk Assessment Tool and documented on the Primary Assessment flowsheet in the EMR. Neonatal Intensive Care and Special Care Nurseries need to follow the Neonatal Infant and Skin Care Guideline

    How to complete a comprehensive Integumentary System Inspection:

    The status of the patient’s skin is the most important early indicator of the skin’s reaction to pressure exposure and the continuing risk of pressure injury. 

    • Complete a general visual check of the integumentary, which includes analysis of the entire skin surface to assess its integrity and identify any characteristics indicative of pressure damage.
    • Monitor and check the skin beneath dressings, prosthesis and devices when clinically appropriate. 
    • Check for areas of localised heat, skin breakdown, oedema, areas of redness that do not blanch and induration of the wound.

    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:

    • Sacrum
    • Heels
    • Elbows
    • Wrists
    • Temporal region of Skull
    • Ears
    • Shoulders
    • Back of Head especially in infants less than 36 months of age
    • Knees
    • Toes

    Glamorgan Pressure Injury Risk Assessment Tool 

    Document the appropriate score in the EMR  

    Pressure Injury Risk Assessment Scoring

    Pressure Injury Risk Assessment Category

    Version (final) pressure injury doc 15-1-2010 Adapted from the Glamorgan Risk Assessment Scale from the United Kingdom  

    Management

    Skin Care

    • Keep the skin clean and dry
    • Investigate and manage incontinence (Consider alternatives if incontinence is excessive for age)
    • Do not vigorously rub or massage the patients’ skin
    • Use a pH appropriate skin cleanser and dry thoroughly to protect the skin from excess moisture
    • Use water based skin emollients to maintain skin hydration where possible
    • Apply barrier cream
      • RCH Nappy goo for prophylactic nappy care to healthy skin
      • Sudocream for healthy skin/nappy rash
      • Calmoseptine Ointment for broken down skin in nappy region
      • Orabase Protective Paste for broken down skin in nappy region
    • Use chlorhexidine wipes daily ONLY around CVC sites and open wounds/open sternotomies

    Redistributing pressure

    Prevention strategies should involve the use of pressure relieving devices appropriately chosen for the patient, regular skin inspection and frequently redistributing the pressure by repositioning the patients frequently and safely. 

    • Employ appropriate manual handling techniques in line with Occupational Health and Safety guidelines when transferring and repositioning patients. Please adhere to Smart Move/Smart Lift guidelines.
    • Provide transfer assistance devices. Example: Hoist to reduce friction and shear forces. 
    • Provide the right positioning aids and use of appropriate support surfaces to help reduce friction and shear. 

    Positioning and repositioning the patient

    Patients at risk of pressure injury should be suitably positioned to redistribute pressure, repositioned regularly by minimising shear and friction forces on the skin. 

    Recommendations: 

    • For the patient to do so independently if able
    • Equipment can be used to promote independent mobility. E.g. overhead bed pole, side rails, walking frame.
    • Patient and/or carers may need reminders to reposition
    • For patients who are unable to assist moving themselves, it is recommended that they be repositioned every two hours
    • 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 The principles of pain management for children guide. Give analgesia five to thirty minutes prior to attending to pressure area care to reduce the patient’s pain on moving
    • Heels should be suspended off the bed using pillows or gel pads
    • Reposition tubes and face masks every two hours for pressure area care. Use barrier dressings such as: 
      • Comfeel for nasogastric tubes/ LFNP/HFNP. (DO NOT remove comfeel that is placed within twenty-four hours as it will cause shear of the skin). 
      • Mepilex for BIPAP and CPAP masks, elbows and wound drain sites. 
      • Cavilon Barrier Wipes underneath tubing/masks, particularly on the face, to reduce the risk of a pressure injury developing.
    • For high risk patients, limit time spent sitting in bed with head elevated > thirty degrees to no more than two hours due to the increased pressure on the sacrum. 
    • Positions may include: prone, seated in bed, seated in chair, left side lying, right side lying and supine. 
    • Monitor the patient’s level of discomfort or pain and ensure appropriate pain relief is provided to support and encourage mobility
    • Consider smaller more frequent shifts in position of patients who cannot tolerate major changes in body position to redistribute pressure. E.g. Patients with Pulmonary hypertension, On ECMO Support
    • The patient should be repositioned regardless of the support surface on which they are managed
    • When transferring, examining or repositioning patients, the use of proper devices and techniques is mandatory. This prevents PI to the patient and injury to the staff member.
    • To prevent shear forces on the sacrum, the head of the bed should be raised in conjunction with a knee block or pillows under the knee
    • Always check the positioning of the bony prominences and heels when repositioning the patient into any position
    • Lower the bed head before repositioning
    • Use slide sheets with every reposition
    • Consider Physiotherapy consultation for assistance/advice on transferring patients and repositioning

    These techniques are to be used in conjunction with manual handling procedure.A list of hospital available pressure relieving devices and their location are available in Appendix 2 – Types of Pressure Relieving Devices. A guide of how to hire pressure relieving devices is available in Appendix 3 – Hiring Process. For more information on obtaining a particular piece of equipment, please refer to Appendix 5 – Obtaining Pressure Relieving Devices. Once the equipment is no longer required, please follow the discard process in Appendix 4 – Discard Process. If you are having trouble selecting a device for your patient, additional advantages and disadvantages of pressure relieving devices can be found under Appendix 6 - Constant Reactive Support Devices.

    Prevention Strategies for device related

    There is a variety of different equipment or medical devices that may be required as a part of a patient’s treatment. It is significant to recognise that any foreign object that comes into direct contact with the patient’s integumentary system has the potential to cause PI. Therefore, healthcare workers must be vigilant with their inspection and monitoring of the patients skin, in order to prevent PI’s that are device related. The following devices can contribute to the formation of PI’s: 

    • Cervical collars
    • Casts and orthotics
    • Pressure stockings
    • Intermittent calf compressors
    • IV tubing and boards
    • Tapes
    • Pulse oximetry probes
    • Monitoring cords
    • Endotrachael tubes (CPAP and full vent)
    • Non-invasive masks
    • LFNP and HFNP
    • Excess linen 

    Strategies to help prevent device related pressure injuries include

    • Repositioning devices as appropriate e.g. oxygen delivery, saturation probes (min 2 hourly), monitoring electrodes
    • Protective barriers between the device and the patients skin e.g. hydrocolloid under NGT/oxygen tubing, foam pad under cables. 
    • Regular repositioning and inspection of the patient to ensure that they are not unintentionally lying on devices
    • Use the correct size equipment suitable to the patient’s anatomical size. E.g. nasal cannula, IDC. 
    • Use padding to soften hard surfaces. E.g. Foam padding under IV boards/electrical cords, cast padding under splints.
    • When equipment is secured to the patient using tapes, ensure that they are not applied too tightly and that the applicable tapes are utilised. Ensure where possible that they have some elasticity and stretch.
    • Use the minimal amount of strapping or tape to safely secure the device but allow for maximal visualisation of the patient’s skin. 

    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 following the Paediatric Nutritional Screening Tool Assessment. 
    • 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 interest in the prevention and treatment of
    • pressure injuries include protein, arginine, vitamin C, vitamin A, and zinc.

    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
    Patients who are incontinent of urine and/or faeces should have an adequate evaluation to identify whether a reversible causes exist. Reversible causes include:

    • polyuria due to glycosuria/ hypercalcemia
    • urinary tract infection
    • medications
    • change in mental status
    • restricted mobility
    • faecal impaction

    A bowel training program must be instituted for spinal cord injury patients. Refer to Spinal Cord injury Clinical Guideline (Acute management)

    Pressure redistributing equipment:

    Redistributing equipment are support surfaces that offer redistribution of pressure on which patients are placed to manage pressure load to their integumentary system. They are designed to alternate the area of the body in contact with the support surface and to reduce interface pressure through increasing the body surface area. 
    It is significant that weight be considered when selecting the right pressure mattress. Patients at high risk of PI, should be nursed on a high grade pressure redistributing mattress. Some options may need to be hired. 
    For these devices to be effective, there must be minimal layering in between the device and the person. For patients that are very high risk, these devices may allow a decrease in turning frequency overnight to 3-4 hourly to encourage rest patterns, however, this should be assessed on a solitary basis at RCH. 
    The following should NOT be used as pressure relieving devices:

    • Sheepskins 
    • Doughnut shaped gels – this type of device may impair lymphatic drainage and circulation.
    • Water filled gloves under heels – these are not effective as the water filled glove is unable to redistribute pressure and it only supports a small surface of the heel. 

    Characteristics of pressure redistribution support surfaces

    Pressure Injury Characteristics of pressure redistribution support services

    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 Glamorgan screening tool score. Selection of an appropriate device should take into consideration factors such as the individual’s level of mobility within the bed, his/her comfort and the need for microclimate control.

    Please consider the Sudden Infant Death Syndrome (SIDS) risk reduction recommendations when using pressure redistribution devices for infants. 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.

    Important Note
    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. A single sheet that can be kept dry and crease free is optimal. 

    Patients in the Operating Room

    In order to provide optimal patient care in the operating theatre, the multidisciplinary team needs to be aware of potential problems. In order to prevent PI’s a strategic plan of adequate implementation and appropriate intervention should be enforced for each patient at RCH. The assessment of PI prevention should be evaluated during the preoperative, intraoperative and postoperative phases. 

    Surgery that lasts longer than two hours has been associated with PI’s. As the operation time exceeds this, so does the prevalence of PI’s. Anaesthetised patients that are positioned on specialised frames in the prone position, may be at an even higher risk of developing PI’s in uncommon areas such as the: chest, iliac crest and face (tip of the nose, chin and forehead). 

    Literature suggests that PI’s that originate in the operating room may not appear for one to four days post operatively. This highlights the significance of prevention and the importance of a thorough integumentary assessment as the patient continues their journey through surgery and during the postoperative period. 

    Risks for patients undergoing surgery should be determined by:

    • Length of the operation
    • Increased hypotensive episodes intraoperatively
    • Low core temperature during surgery
    • Reduced mobility on day one postoperatively
    • Prolonged placement of complex equipment E g: neuro surgery head frame

    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.
    • Patient supports and patient positioning aids, including pressure care devices are utilized at this high risk time. 

    Postoperative Management

    In the postoperative phase, a full integumentary assessment is required. Any altered skin integrity must be documented on the EMR flowsheet and communicated to the multidisciplinary team. 

    Operative consideration

    Although doughnut gels are being phased out in pressure area care, they are still used in RCH theatres mindfully in some cases. Special consideration needs to apply to children who have had these in place as they may impact lymphatic drainage. 

    Patients in the Intensive Care Unit

    Patients admitted to the Paediatric Intensive Care Unit (PICU) have a higher incidence of PI’s and usually they are more severe. Effective prevention for these patients should be based on correctly identifying them at risk. 
    The ICU environment includes several main contributing factors:

    • Low cardiac output state
    • Inotrope and vasoconstrictor use
    • Impaired level of consciousness
    • Immobility
    • Poor peripheral blood flow
    • Decreased nutrition

    Patients should be repositioned fourth hourly and have existing PI’s assessed every second hour. However, if the patient is too haemodynamically unstable with pressure area care and repositioning, an alternative plan should be discussed with the multidisciplinary team. 
    Appendix 7 - Pressure Relieving Devices and Techniques
    Appendix 8 - Preventing Pressure Injuries
    Appendix 9 - What is the right treatment?
    Appendix 10 - How to document

    The Orthopaedic Patient

    Patients that have had orthopaedic surgery are considered to be high risk of PI’s due to the presence of fixed medical devices and due to their immobility. 

    Some patients may be in plaster casts, braces, hip spicas and traction. These devices can cause sheering injuries and/OR friction and should be regularly monitored and assessed. 

    The paediatric fractures guideline can provide some more information on the care of individual factures. 

    Documentation

    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.
    • Notify medical staff and nurse in charge of shift about the pressure injury and inform the patient, family and/or carers about the pressure injury and management plan.
    • Document in EMR 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 LDA Avatar. This is updated in the LDA Assessment flowsheets in the EMR.
    • An image can be captured on the ‘ROVER’ device and uploaded to the patients file. 
    • Notify incident on the hospital reporting system Victorian Health Incident Management System (VHIMS) and confirm the stage of the pressure injury is included.
    • Follow the guide on how to document in Appendix 10.

    Patients with identified Pressure Injuries should be managed as high or very high risk regardless of their identified Glamorgan Risk Assessment Score. This assessment should be documented in the EMR under the pressure prevention plan.

    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 2 or greater pressure injury or those with a Glamorgan risk score of ten or greater a Pressure Injury Prevention Plan should be commenced on EMR. The wound should be clinically assessed for the most appropriate dressing. Refer to the Wound Care Nursing Clinical Guideline and consult the Stomal Therapy Nurse Consultant for clinical guidance on appropriate assessment and management of the wound if clinically indicated.

    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 on the EMR 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 at the commencement of each shift. Once the patient’s risk score is below ten 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. 

    Consult Orthotics Department for the correct fitting of braces/splints/collars where appropriate.

    Consider referring patients with a pressure injury to a dietician, allied health, plastics department 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.

    Appendices

    1. Appendix 1 - Pressure Injury Staging Guide 
    2. Appendix 2 - Types of Pressure Relieving Devices
    3. Appendix 3 - Hiring Processes
    4. Appendix 4 - Discard Process
    5. Appendix 5 - Obtaining Pressure Relieving devices
    6. Appendix 6 - Constant Reactive Support Devices
    7. Appendix 7 - Pressure relieving devices and techniques
    8. Appendix 8 - Preventing pressure injuries
    9. Appendix 9 - What is the right treatment
    10. Appendix 10 - How to document

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    • Pan Pacific Clinical Practice Guideline for the Prevention and Management of Pressure Injury.
    • Pressure Injury Prevention and Management, Policy and Procedure (2015), The Sydney Children’s Hospital, Sourced from: http://www0.health.nsw.gov.au/policies/pd/2014/pdf/PD2014_007.pdf
    • Santamaria, N., Liu, W., Gerddtz, M., Sage, S., McCann, J., Freeman, A., Vassiliou, T., DeVincentis, S., W Ng, Ai., Manias, E., Knott, J. & Liew, D (2013).  The cost-benefit of using silicone multilayered foam dressings to prevent sacral and heel pressure ulcers in trauma and critically ill patients: a within-trial analysis of the Border Trial. International Wound Journal ISSN 1742-4801, 344-350  
    • Schluer, A. B., Schols, J. M. A., & Halfens, R. J. G, (2013), Pressure Ulcer Treatment in Pediatric Patients. Advances in skin & wound  care, 26(11), 504 – 510
    • Schindler, C.A., Mikhailov, T.A., Cashin, S.E., Malin, S., Christensen, M., & Winters, J.M. (2013). Under pressure: preventing pressure ulcers in critically ill infants. Journal for specialists in Pediatric Nursing. 18, 329-341
    • 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.

    Evidence table

    Pressure Injury Prevention Evidence Table

     

    Please remember to read the disclaimer


    The development of this nursing guideline was coordinated by Ange Alberti, PICU, CNS, and approved by the Nursing Clinical Effectiveness Committee. Updated January 2019.