In this section
Note: This guideline is currently under review.
Definition of Terms
Pressure Injury Development
Patients in the Operating Room
Patients in Intensive Care Unit
The Orthopaedic Patient
Documentation of pressure injuries
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.
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:
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.
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.
(Adapted from: Pan Pacific Clinical Practice Guideline for the Prevention and Management of Pressure Injury.)
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:
These are factors on the skins ability to tolerate pressure.
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:
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.
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.
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.
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:
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.
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:
Document the appropriate score in the EMR
Version (final) pressure injury doc 15-1-2010 Adapted from the Glamorgan Risk Assessment Scale from the United Kingdom
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.
Patients at risk of pressure injury should be suitably positioned to redistribute pressure, repositioned regularly by minimising shear and friction forces on the skin.
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.
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:
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 breakdownPatients who are incontinent of urine and/or faeces should have an adequate evaluation to identify whether a 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)
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:
Characteristics of pressure redistribution support surfaces
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 NoteIt 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.
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:
The RCH operating tables are all fitted with high density pressure-redistributing foam to reduce the risk of pressure injury development.
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.
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 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:
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 TechniquesAppendix 8 - Preventing Pressure InjuriesAppendix 9 - What is the right treatment?Appendix 10 - How to document
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.
All pressure injuries need to be carefully documented. If a pressure injury is identified:
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.
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.
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.