Introduction Show
Aim Definition of terms Pressure injury development
Prevention
Management
Referral Documentation/communication Discharge Evidence Table IntroductionInternational 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. AimThe 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. Definition of termsBlanching 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. Pressure injury developmentA pressure injury is defined as localised damage to the skin and/or underlying tissue as a result of pressure. Factors associated with increased riskSeveral 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. (Adapted from the Prevention and Treatment of Pressure Ulcers/Injuries International Guideline 2019) PreventionPrevention 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. Pressure injury risk assessmentPI 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.
(Adapted from the Glamorgan Risk Assessment Scale from the United Kingdom) Nursing responsibilitiesEvery 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 assessmentSkin 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. Conducting the assessmentComplete 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. Frequency of assessment 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. Patient and family educationParents 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. The 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. Nutrition and hydrationMalnourished 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 skin integrity.
Moisture control and skin careIncreased 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
Mobility and positioning
Friction and shear
Medical devicesAny 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. Key points
General advicePrior 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. High risk patient populations
|
Patient Weight Range | Bed Utilised | Pressure Mattress | Notes |
<3.5kg | Radiant warmer | Coziny 100 | Not compatible with x-ray due to artefact. Patient must be lifted and x-ray board placed directly under patient not mattress. |
<10kg | Radiant warmer | Coziny 200 | Replace foam mattress with the pressure mattress |
Cot | Coziny 200 | Place pressure mattress on top of the foam mattress | |
<25kg | Cot | Coziny 300 | Replace foam mattress with the pressure mattress |
Bed AND nursed 1:1 e.g. in PICU | Coziny 300 | Place pressure mattress on top of the foam mattress | |
16kg-150kg | Bed | Centrius Overlay | Place pressure mattress on top of the foam mattress |
16kg-200kg | Bed | Centrius full mattress replacement | Replace foam mattress with pressure mattress |
Pressure mattress ordering process
For ordering information please see the below document:
Link to 2022 Keystone pressure mattress ordering workflow
Management
Pressure injury stages
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.
Pressure injury/wound management
Basic principles
- Avoid positioning patients directly on an existing pressure injury or body surface that remains damaged or erythematous, where possible
- Ensure the patient is on the most suitable support surface. Consider referral to Occupational Therapy for further advice/support if required.
- Always consider patient nutrition and hygiene and refer for support if required
Wound management
- Utilise appropriate pain management (see comfort kids procedural support LINK)
- Clean the pressure injury with sterile water or 0.9% sodium chloride solution
- If required, debride dead or devitalised tissue. This can be done using autolytic debridement through dressing selection or surgical debridement
- Assess and document the size and appearance of the pressure injury in the LDA (see below)
- Select a wound dressing that promotes a warm, moist environment for wound healing (see table below)
- If the wound appears infected antibiotics can be used. Topical antiseptics are not routinely used on pressure injuries, but topical antimicrobials should be considered if clinically indicated
- Remove dressings with adhesive remover wipe or spray to gently remove tapes
- Do not use gauze to treat pressure injuries
- Wound management plan should be documented in the EMR progress notes
Stage | Management Goals | Dressing Selection |
Stage 1 Non-blanchable erythema | Protect skin to prevent further injury | Silicone adhesive, non-adherent foam or transparent hydrocolloid adhesive dressing
|
Stage 2 Partial thickness skin loss | Relieve pressure and protect wound from further trauma/ contamination | Silicone adhesive or non-adherent foam
REFERRAL TO STOMAL THERAPY CLINICAL NURSE CONSULTANT |
Stage 3 Full thickness skin loss | Relieve pressure and protect wound from further trauma/ contamination | Hydrogel, Adhesive foam, Hydrofiber or Silicone dressing
REFERAL TO STOMAL THERAPY CLINICAL NURSE CONSULTANT |
Stage 4 Full thickness tissue loss | Relieve pressure and protect wound from further trauma/ contamination | Alginate, Hydrogel, Adhesive foam, Hydrofiber or Silicone dressing
CONDSIDER REFERRING TO PLASTIC SURGERY TEAM |
Unstageable Depth unknown | Unable to determine prior to debridement | Surgical debridement required as determined by surgical 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
Referral
Stomal Therapy 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.
Physiotherapy/Occupational therapy
For patients at high risk of pressure injuries or with an existing pressure injury consider referral to:
- Occupational Therapy if additional support with assessment of causal factors and advice on pressure injury prevention or management plans, including selection of most appropriate support surface is required
- Physiotherapy if assistance/advice on positioning and repositioning, transferring and supporting mobility is required
Documentation/Communication
All pressure injuries need to be carefully documented. If a pressure injury is identified the following process should be followed;
EMR documentation
- Create an EMR progress note and document the following;
- Likely causal factors e.g. medical device related, moisture, immobility etc.
- PI staging, appearance, measurement (wound size and depth), exudate and odour
- Add the pressure injury as a “non-surgical wound” LDA on the Avatar, selecting “pressure ulcer” as the primary wound type
- Capture clinical image of the PI with patient/family consent) and upload to patient’s file
- Complete LDA assessment of pressure injury every shift
Communication
- Notify medical staff and nurse in charge of shift about the pressure injury
- Inform the patient, family and/or carers about the pressure injury and management plan
- Ensure a detailed description of what is observed, and the action taken is included in clinical handover
VHIMS
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.
Discharge
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.
Evidence table
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.