In this section
Definition of terms
Pressure injury development
International data indicates that hospitalised children and neonates experience pressure injuries at a high incidence rate, up to 27% (EPUAP/NPIAP/PPPIA, 2019). Children and neonates are at higher risk due to their relatively larger skin surface area, increased nutritional requirements and risk of nutritional deficiencies, immature skin and the use of medical devices. Pressure injuries are associated with increased morbidity and hospital stay, as well hospital costs. Most pressure injuries are preventable if appropriate evidence-based measures are implemented, including comprehensive risk assessment, skin care and targeted prevention strategies.
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 evidence-based guidance for the prevention, assessment and management of pressure injuries.
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.
Pressure Injury (PI) - 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 a modified 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.
A pressure injury is defined as localised damage to the skin and/or underlying tissue as a result of pressure.
PIs commonly occur over bony prominences, however in the paediatric population, PIs are more commonly associated with a medical device or object. In addition to pressure, poor blood flow, friction, shear, and tissue ischaemia can all contribute to the develop of a PI. The deep fascia, subcutaneous fat, skin, bone, and muscle can all be damaged by unrelieved pressure.
The tissues’ ability to tolerate the pressure including the intensity and duration, are factors affecting PI development. Prolonged pressure on a localised area of tissue causes the occlusion of blood flow, preventing the supply of nutrients and oxygen to the tissue, resulting in ischaemia and re-perfusion injury. This leads to cell obliteration and eventually tissue death.
Several factors may influence an individual’s risk of developing pressure injuries. In the prevention of PIs, it is essential that patients at risk are identified so an individualised prevention plan can be implemented to mitigate the risks. 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.
from the Prevention and Treatment of Pressure Ulcers/Injuries International
Prevention requires an on-going risk assessment, consideration of casual factors, implementation of prevention strategies and the selection of an appropriate use of support surfaces. When an assessment identifies a patient at risk of pressure injury, interventions should be implemented immediately.
PI risk assessment tools are the key to determining if a patient is susceptible to PIs. Validated 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 risk screening tool.
The pressure injury risk assessment tool used at RCH is a modified Glamorgan Pressure Injury Risk Assessment Tool.
(Adapted from the Glamorgan Risk Assessment Scale from the United Kingdom)
Every inpatient at RCH should have a Glamorgan Pressure Injury Risk Assessment Tool completed:
Once completed, the risk assessment should be documented on the Primary Assessment flowsheet within the EMR.
Any patient deemed “At Risk” (risk score of +10) of pressure injury should have an individualised prevention plan developed and documented in the Primary Assessment flowsheet in the EMR. This plan should be reviewed for appropriateness following every pressure injury risk assessment completion.
If a patient’s pressure injury risk assessment score changes, a new pressure injury prevention plan needs to be completed and implemented to address the new level of risk.
Skin assessment is key to pressure injury prevention, classification/diagnosis, and treatment. All inpatients should have a skin assessment to determine its’ general condition and identify factors that increase the risk for PI development. 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 skin including 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. High risk areas include; sacrum, heels, elbows, wrists, temporal region of skill, ears, shoulders, back of head (especially in
children less than 36 months of age), knees, and toes.
As with the pressure injury risk assessment tool, a patient’s skin should be assessed;
Document skin assessment findings in the Focused Assessment Flowsheet within the EMR.
Parents and carers play a vital role in the care of their child; and therefore, their engagement is vital in helping to prevent the formation of pressure injuries. Carers and parents should be educated around the risk of their child developing pressure injuries whilst in hospital and be provided
with effective and age-appropriate strategies to mitigate these risks.
PI prevention factsheet should be provided to all carers and parents of patients that have been identified to be at risk of developing a pressure injury.
Malnourished children are at increased risk of pressure injury development due to their compromised ability to maintain healthy skin and mucosa. Hydration and nutritional support should be aimed at preventing and correcting these deficits.
Maintenance of a positive nitrogen balance and serum albumin levels are vital in maintaining adequate skin integrity and hydration. Monitoring patient weight loss as well as protein and micronutrient intake have been identified as key factors in nutrition to support immunity and
Increased moisture on the skin or excessive dryness can exacerbate pressure injury development due to the risk of skin breakdown and altered skin integrity.
Keep the skin clean and dry
Investigate and manage incontinence
Apply barrier creams
Barrier wipes e.g. 3MTM CavilonTM No Sting Barrier
These wipes create a transparent barrier preventing incontinence associated skin irritation and nappy rash without impacting the absorbency of incontinence products. When used in nappy cares, barrier wipes have been shown to decrease redness and pain by preventing breakdown and can be used in a similar way to
traditional barrier creams. Barrier wipes also allow for ongoing integumentary assessments and do not require removal.
Zinc-oxide based creams e.g. Sudocrem®
Zinc-oxide based creams e.g. Sudocrem®
Consultation with medical team/Stomal Therapy Clinical Nurse Consultant if required.
Any object that comes into direct contact with the patient’s skin has the potential to cause a pressure injury. This is exacerbated in the paediatric inpatient population with device related pressure injuries causing the majority of all paediatric pressure injuries due to the immature skin
barrier and decreased tissue tolerance. With increasing complexity of care and advances in technology, incorporating more devices into patient care, nurses must correctly assess and protect a patient’s skin from the formation of device related pressure injuries.
Prior to the application of medical devices and associated preventative dressings, barrier products (e.g. 3MTM CavilonTM No Sting Barrier Wipes) should be used as a transparent barrier to protect the patients skin. These products repel moisture and provide protection from fluids and friction,
which can prevent skin breakdown in areas with frequent dressing changes or repositioning.
Dressings should be changed as appropriate or when soiled, however removal within the first 24 hours of application should be avoided due to the increased risk of sheering force that can cause trauma to patient skin.
Where appropriate adhesive removal products (e.g. Convacare® removal wipes) should be used to promote comfort and reduce skin trauma when dressings are difficult to remove.
Pressure injuries that originate in the operating room may not appear until one to four days post-operatively, highlighting the importance of thorough skin assessment and prevention interventions as the child continues their journey through the pre-operative,
surgery and post-operative phase at the RCH.
Before going to theatre, the perioperative nurse performs a pre-operative assessment to assess for factors that may increase an individual child’s risk for pressure injury during surgery. Assessment taken should be documented on the pre-operative assessment through EMR. Factors that should be assessed include:
Research suggests surgery that lasts longer than two hours has been associated with an increased risk of PIs. Anaesthetised patients that are positioned on specialised frames in the prone position, may be at an even higher risk of developing PIs in uncommon areas such as the: chest, iliac crest, face (tip of
the nose, chin and forehead) and heels.
There are many factors that contribute to the incidence of PI’s in the operating theatre such as:
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. Other methods of managing a patient to reduce the risk of pressure injuries include:
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.
Pressure injury prevention in this specialised population should be managed carefully, considering the effect of various dressing and barrier products on underdeveloped skin. Consultation with neonatal specialists is suggested before application of new products.
Please refer to the
Neonatal and infant skin care Clinical guideline for further information on the management of neonatal skin and prevention of pressure injuries.
Patients admitted to the Paediatric Intensive Care Unit (PICU) have a higher incidence of PI’s and are usually more severe due to patient complexities and prolonged length of stay.
The ICU environment has several main contributing factors:
Patients should have existing PIs assessed every second hour and be repositioned based on their mobility status identified daily on medical ward from the ‘Early Mobilisation Traffic Light Guideline’. If the patient is identified as too clinically unstable to attend to major pressure area care and repositioning, an alternative pressure injury prevention plan needs to be discussed with the multidisciplinary team.
Orthopaedic patients are considered to be at high risk of pressure injuries due to the prolonged presence of fixed devices such as external fixation, traction, plasters casts and braces. These devices can cause sheering force and friction, so should be regularly monitored and
assessed. These patients are also at higher risk of immobilisation due to painful procedures and extended periods of bed rest or reduced weight bearing capacity.
Support surfaces are devices (e.g. air mattresses, cushions) that are used to assist with pressure redistribution to manage the pressure load on the integumentary system. Support surfaces typically support pressure redistribution through either immersion to increase the body surface area in contact with the surface,
or by alternating and offloading the area of the body in contact with the support surface.
Decisions about an appropriate support surface to use for pressure injury prevention should be based on an overall assessment of the patient, including their weight, and their Glamorgan screening tool score. Selection of an appropriate support surface should also take into consideration factors such as the
individual’s level of mobility within the bed, his/her comfort, and the need for microclimate control. The LINK Bariatric Procedure should be referred to for guidance regarding suitable support surfaces for patients above 100kg.
For support surfaces to be effective, there must be minimal layering in between the device and the person. The use of additional sheets, kylie pads, dry-flows and towels can alter the pressure relieving qualities of pressure redistribution equipment and should be avoided where possible. A single
sheet that can be kept dry and crease free is optimal.
Please note: support surfaces facilitate the redistribution of body weight but do not negate the need for regular repositioning of patients or pressure area care. For patients that are very high risk, these surfaces may allow a decrease in turning frequency overnight to 3-4
hourly to encourage rest patterns, however, this should be considered carefully on a case-by-case basis. If the patient is spending time sitting with the bed head raised, the mattress should be checked to ensure it is not ‘bottoming out’ underneath the patient.
Please consider the sudden infant death syndrome (SIDS) risk reduction recommendations when using support surfaces for infants. Monitoring is required for infants nursed outside of these recommendations.
Consider Occupational Therapy referral for assistance with assessment of causal factors and advice on pressure injury prevention or management plans, including selection of most appropriate support surfaces.
The following should NOT be used as a support surface:
*Note: doughnut shaped gel rings are still currently used in special
circumstances in operating theatres only with careful consideration and
application. Assessment of the occiput and surrounding tissue should take place
before and after doughnut shaped gel ring use.
Characteristics of support surfaces
Please see the table below for further information regarding the pressure mattresses available for use at RCH.
At RCH, all pressure mattresses available for patient use are on consignment (externally managed Keystone Healthcare Supplies) and are available through bed pool.
Pressure mattress ordering process
For ordering information please see the below document:
Link to 2022 Keystone pressure mattress ordering workflow
Pressure injury staging or classification describes the extent of skin and tissue damage. Staging of a pressure injury is essential for the development and implementation of a management plan.
Quick reference table:
Adapted from the National Pressure Injury
Advisory Panel (NPIAP) Pressure Injury and Stages Poster September 2016
For further information regarding pressure injury staging please refer to the
NPIAP Pressure Injury Staging Poster.
or non-adherent foam
REFERRAL TO STOMAL THERAPY CLINICAL NURSE CONSULTANT
Adhesive foam, Hydrofiber or Silicone dressing
REFERAL TO STOMAL THERAPY CLINICAL NURSE CONSULTANT
Hydrogel, Adhesive foam, Hydrofiber or Silicone dressing
CONDSIDER REFERRING TO PLASTIC SURGERY TEAM
For further information regarding dressing types/ordering and wound management please refer to the RCH dressing selection resources:
Wound Dressing Product Reference Guide
Dressing and Wound Management Poster
Dressing Supplies Ordering
Clinical Nurse Consultant/Plastic Surgery Team
Every pressure injury that is Stage 2 or above, should be referred to the Stomal Therapy Clinical Nurse Consultant for opinion and management.
For a Stage 4 pressure injury and above, a referral to Plastic Surgery Team should be considered.
For patients at high risk of pressure injuries or with an existing pressure injury consider referral to:
All pressure injuries need to be carefully documented. If a pressure injury is identified the following process should be followed;
Report the pressure injury on the hospital reporting system
Victorian Health Incident Management System (VHIMS) and confirm the stage of the pressure injury is included.
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 EMR under the pressure prevention plan.
If the patient is being discharged with a change in their function and associated higher level of pressure care risk than pre-admission, an appropriate management plan must be in place. This may include:
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 factsheet and discuss suitable prevention strategies relevant to their child prior to discharge.
Equipment: If the patient is currently on a support surface and requires this for use on discharge, refer to Occupational Therapy.
Pressure Injury Prevention Evidence Table
Please remember to
read the disclaimer
The development of this nursing guideline was coordinated by Lexie Miller, Improvement Manager, Jade Grillo, Platypus, and Ashlee Cruz, Occupational Therapy, and approved by the Nursing Clinical Effectiveness Committee. Updated April 2022.