In this section
Note: This guideline is currently under review.
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.
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:
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.
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.
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 completed at the following stages:
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:
See Clinical Guideline (Nursing): Nursing Assessment for more detailed assessment information.
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
Patients at risk of pressure injury should be suitably positioned to minimise pressure, friction and shear:
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).
Constant Low pressure Support (reactive)
High Specification Foam: foam mattress made to high specifications
Support surface made by gel filled cells
Air - low air loss
A powered, air filled surface that allows air to escape from air cells
A powered, air filled surface that redistributes pressure by cyclic inflation and deflation of air cells.
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
Gel Pads -available in avariety of sizes
Available throughout RCH or purchase through material resources
Available for hire from ArjoHuntleigh
15+ High Risk
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
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 RCH - Refer Aeroscout
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:
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.
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
Unstageable pressure injury: depth unknown
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.
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 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.