Repositioning to Prevent Pressure Sores — What Is the Evidence?

Note: This guideline is currently under review.

Introduction

Aim

Definition of Terms

Pressure level Injury Development

Prevention

Management

Patients in the Operating Room

Patients in Intensive Care Unit

The Orthopaedic Patient

Documentation of pressure injuries

Discharge

Appendices

References

Testify Table

Introduction

Splendid skin intendance is an attribute of quality nursing intendance. 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 among health intendance professionals at the Royal Children's Hospital (RCH). The primary objectives are to provide the finest intendance to patients at run a risk of or with PI's and optimally to promote their prevention.
The guideline ensures wellness intendance professionals:

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

Definition of Terms

• Blanching Erythema - Reddened peel that becomes white or pale in appearance when light force per unit area is applied.
  
• Extrinsic Factors - Originating external to the body.
  
• Intrinsic Factors - Originating internal to the torso.
  
• pH - Is the measure of the acidity or alkalinity of a fluid. Its value is measured from 0-fourteen, with being neutral.
  
• Pressure level Injury - Is a localised area of tissue devastation that develops when soft tissue is compressed between a bony prominence, every bit a outcome of pressure, shearing forces and/or friction, or a combination of these.
  
• Chance Cess Scale - A formal grade used to assist define the degree of pressure injury risk. At the Majestic Children'due south Hospital the Glamorgan Risk Cess 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 menstruation of ischemia or lack of oxygen.
  
• Induration – A hardened mass or formation of the pare 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'southward are any breach of skin integrity caused by unrelieved pressure level on soft tissue that has been compressed betwixt whatever external surface and bony prominences for a prolonged period of time. In improver to this, poor blood flow, friction, shear and tissue ischaemia can all contribute to PI's. The deep fascia, subcutaneous fat, skin, os and muscle tin all be damaged by this unrelieved pressure level.

 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 encounter the Force per unit area Injury Staging Guide for stages of force per unit area area development establish in Appendix 1.

Factors associated with increased gamble of pressure level injury

In the prevention of PI'due south, it is essential that patients at chance are identified and an individualised prevention plan is implemented. A gamble gene is whatever element that either diminishes the skins tolerance to pressure or contributes to increased exposure of the skin to excess pressure level.

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

Intrinsic Factors

These are factors that reduce the skin'south tolerance through impacting its lymphatic system, supporting structures and vascular bed. Weather and chronic illnesses that impair oxygen delivery, awareness, tissue perfusion, lymphatic function are identified equally increasing PI risk and include, merely are non 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 Arrangement
  

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

Increased exposure to force per unit area

Run a risk factors that increment exposure of the peel to PI'due south are related to sensory perception, activeness, the patient's ability to alter their body position and impaired mobility. Specific circumstances that autumn into these categories include:

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

Reduction in tissue tolerance

This is the ability of the supporting structures and its peel 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 torso role(southward)
  
• 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.
  
• Asymmetric 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 Not Invasive Ventilation
  
• Decreased sensory perception due to chemical paralysis or neurological disturbances
  
• Altered pare integrity due to fluid resuscitation, moisture, incontinence or oedema
  
• Obesity – excessive fat aggregating for age
  
• Compromised tissue oxygenation and perfusion – cardiac/septic patient.
  
• Hypotension
  
• Use of vasopressor medication
  
• Hypothermia and/or employ of therapeutic hypothermia
  
• Oxygen saturations <95%
  
• Capillary refill > two seconds
  
• Poor nutrition status or patients who are NBM for extended menstruation of time
  
• Fluid restriction
  
• Patients who experience rapid weight loss (due to poor diet or diuresis)
  

Prevention

Prevention requires an on-going risk assessment, consideration of coincidental factors, implementation of prevention strategies and the selection of an appropriate apply of force per unit area relieving devices. When an cess identifies a patient at risk of pressure injury, interventions should be implemented immediately.

Educational activity of patients and families

Carers and parents are a central role 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'due south whilst in infirmary and after should exist provided with literature that will assist them to understand and contribute in the development of constructive and suitable strategies to prevent PI'south.

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

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

Skin Integrity Assessment

Children who are at take chances of developing pressure injuries need to be identified so that preventative measures can be taken. In individuals that are at hazard of developing nosocomial pressure related injuries, early recognition is considered to be an essential component in their care plan. Effective prevention remains in early take a chance 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 tape used to determine a score co-ordinate to a series of parameters considered to be risk factors for PI'southward. Certified run a risk assessment tools for children are effective for identifying those at risk and increasing sensation of potential pressure related injuries, withal they cannot embody every possible circumstance. Therefore, clinicians demand to utilize their feel, clinical judgment and cognition to preclude tissue impairment 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 gamble for PI development. This should exist done:

1. On admission or as presently as practical subsequently the access (inside vi 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 i ward/department to some other.
   
4. Prior to belch.

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

How to consummate a comprehensive Integumentary Arrangement Inspection:

The status of the patient'due south peel is the most important early indicator of the skin's reaction to pressure exposure and the standing risk of pressure injury.

• Complete a general visual check of the integumentary, which includes analysis of the entire skin surface to appraise its integrity and place whatsoever characteristics indicative of pressure damage.
  
• Monitor and check the skin beneath dressings, prosthesis and devices when clinically appropriate.
  
• Bank 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 force per unit area, friction and shearing forces. Regular inspection of the post-obit areas is required:

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

Glamorgan Pressure Injury Risk Assessment Tool

Certificate the appropriate score in the EMR

Version (concluding) pressure level injury doc 15-i-2010 Adapted from the Glamorgan Gamble Assessment Calibration from the Great britain

Management

Skin Care

• Keep the skin clean and dry
  
• Investigate and manage incontinence (Consider alternatives if incontinence is excessive for historic period)
  
• Do not vigorously rub or massage the patients' peel
  
• Utilise a pH appropriate pare cleanser and dry thoroughly to protect the skin from backlog wet
  
• Use h2o based skin emollients to maintain peel hydration where possible
  
• Utilize bulwark cream
  
  • RCH Nappy goo for condom nappy care to good for you skin
    
  • Sudocream for healthy pare/nappy rash
    
  • Orabase Protective Paste for broken down skin in nappy region
    
• Apply chlorhexidine wipes daily Merely effectually CVC sites and open wounds/open sternotomies
  

Redistributing pressure level

Prevention strategies should involve the use of force per unit area 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 treatment techniques in line with Occupational Wellness and Rubber guidelines when transferring and repositioning patients. Please attach to Smart Move/Smart Elevator guidelines.
  
• Provide transfer assist devices. Instance: Hoist to reduce friction and shear forces.
  
• Provide the right positioning aids and use of appropriate support surfaces to assist reduce friction and shear.
  

Positioning and repositioning the patient

Patients at gamble of pressure injury should exist suitably positioned to redistribute pressure, repositioned regularly past 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 rail, 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 2 hours
  
• Patients in hurting are at an increased hazard of pressure injury. If hurting is managed appropriately they are able to move or be moved at frequent intervals. Monitor the patient's level of pain and ensure advisable pain relief is provided. Refer to The principles of hurting management for children guide. Requite analgesia v to thirty minutes prior to attention to pressure surface area care to reduce the patient's pain on moving
  
• Heels should exist suspended off the bed using pillows or gel pads
  
• Reposition tubes and confront masks every two hours for pressure level area care. Utilize barrier dressings such as:
  
  • Comfeel for nasogastric tubes/ LFNP/HFNP. (DO NOT remove comfeel that is placed within twenty-four hours as information technology 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 up, to reduce the risk of a pressure injury developing.
    
• For high take a chance patients, limit time spent sitting in bed with head elevated > thirty degrees to no more 2 hours due to the increased force per unit area on the sacrum.
  
• Positions may include: prone, seated in bed, seated in chair, left side lying, correct side lying and supine.
  
• Monitor the patient'south level of discomfort or hurting and ensure appropriate pain relief is provided to support and encourage mobility
  
• Consider smaller more than frequent shifts in position of patients who cannot tolerate major changes in torso position to redistribute pressure. E.g. Patients with Pulmonary hypertension, On ECMO Support
  
• The patient should exist 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 preclude 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 cheque 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 listing of hospital bachelor pressure relieving devices and their location are available in Appendix 2 – Types of Pressure Relieving Devices. A guide of how to rent pressure relieving devices is available in Appendix 3 – Hiring Process. For more data on obtaining a detail piece of equipment, delight refer to Appendix 5 – Obtaining Pressure Relieving Devices. In one case the equipment is no longer required, please follow the discard process in Appendix four – Discard Process. If you are having problem selecting a device for your patient, boosted advantages and disadvantages of pressure relieving devices can be establish nether Appendix 6 - Abiding Reactive Support Devices.

Prevention Strategies for device related

There is a variety of dissimilar equipment or medical devices that may be required equally a part of a patient'due south treatment. It is significant to recognise that any strange object that comes into direct contact with the patient'southward integumentary arrangement has the potential to crusade 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 post-obit devices tin can contribute to the formation of PI's:

• Cervical collars
  
• Casts and orthotics
  
• Pressure stockings
  
• Intermittent calf compressors
  
• 4 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 assistance prevent device related force per unit area injuries include

• Repositioning devices every bit advisable eastward.chiliad. oxygen delivery, saturation probes (min 2 hourly), monitoring electrodes
  
• Protective barriers betwixt the device and the patients peel e.g. hydrocolloid nether NGT/oxygen tubing, foam pad under cables.
  
• Regular repositioning and inspection of the patient to ensure that they are not unintentionally lying on devices
  
• Utilize the right size equipment suitable to the patient's anatomical size. East.1000. nasal cannula, IDC.
  
• Utilise padding to soften hard surfaces. E.g. Foam padding under Four boards/electrical cords, bandage padding under splints.
  
• When equipment is secured to the patient using tapes, ensure that they are not applied besides tightly and that the applicable tapes are utilised. Ensure where possible that they have some elasticity and stretch.
  
• Apply the minimal corporeality 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 acceptable nutrition and hydration
  
• High or very high-risk patients should be referred to a dietician post-obit the Paediatric Nutritional Screening Tool Assessment.
  
• Nutritional support should be designed to prevent or right nutritional deficits, maintain or reach positive nitrogen residuum, and restore or maintain serum albumin levels. Nutrients that accept received principal involvement in the prevention and treatment of
• pressure injuries include protein, arginine, vitamin C, vitamin A, and zinc.
  

Wet

Moisture on the skin increases the chance of force per unit area injury development. This is also true if the skin is too dry out, as information technology may cause skin to breakdown
Patients who are incontinent of urine and/or faeces should take an adequate evaluation to identify whether a reversible causes be. 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 string injury patients. Refer to Spinal Cord injury Clinical Guideline (Acute direction)

Pressure redistributing equipment:

Redistributing equipment are support surfaces that offering redistribution of pressure level on which patients are placed to manage pressure load to their integumentary organisation. They are designed to alternate the area of the torso in contact with the support surface and to reduce interface force per unit area through increasing the body surface expanse.
It is significant that weight be considered when selecting the right pressure mattress. Patients at high take a chance of PI, should be nursed on a high grade pressure redistributing mattress. Some options may demand to be hired.
For these devices to be constructive, in that location must be minimal layering in between the device and the person. For patients that are very loftier risk, these devices may allow a decrease in turning frequency overnight to three-four hourly to encourage rest patterns, notwithstanding, this should be assessed on a solitary ground at RCH.
The post-obit should Not be used as pressure relieving devices:

• Sheepskins
  
• Doughnut shaped gels – this type of device may impair lymphatic drainage and apportionment.
  
• Water filled gloves nether heels – these are non effective as the h2o filled glove is unable to redistribute pressure and it merely supports a small surface of the heel.

Characteristics of pressure redistribution support surfaces

Decisions nigh an advisable pressure relieving device to utilise for pressure level injury prevention should exist based on an overall assessment of the patient and their Glamorgan screening tool score. Selection of an advisable device should take into consideration factors such equally the private's level of mobility within the bed, his/her comfort and the demand for microclimate control.

Delight consider the Sudden Infant Death Syndrome (SIDS) gamble reduction recommendations when using pressure redistribution devices for infants. Monitoring is required for infants nursed outside of these recommendations. Consider Occupational Therapist consultation for aid with assessment of causal factors and communication on appropriate force per unit area relieving devices.

Important Note
It is important to notation that the apply of sheets, overlay sheets, pillows and towels potentially alter the pressure relieving qualities of the mattress.  Endeavour to avoid using plastic lined continence overlay sheets on air filled pressure level relieving devices where possible. A single sheet that tin exist kept dry and pucker free is optimal.

Patients in the Operating Room

In society to provide optimal patient care in the operating theatre, the multidisciplinary team needs to be aware of potential problems. In gild to prevent PI'due south a strategic plan of acceptable implementation and advisable intervention should exist enforced for each patient at RCH. The cess of PI prevention should be evaluated during the preoperative, intraoperative and postoperative phases.

Surgery that lasts longer than ii hours has been associated with PI's. As the performance fourth dimension 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 college gamble of developing PI's in uncommon areas such equally the: chest, iliac crest and face (tip of the nose, chin and forehead).

Literature suggests that PI'south 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 cess equally the patient continues their journey through surgery and during the postoperative period.

Risks for patients undergoing surgery should exist determined by:

• Length of the operation
  
• Increased hypotensive episodes intraoperatively
  
• Low cadre temperature during surgery
  
• Reduced mobility on day ane postoperatively
  
• Prolonged placement of complex equipment East chiliad: neuro surgery head frame
  

The RCH operating tables are all fitted with high density pressure-redistributing foam to reduce the risk of force per unit area injury development.

• Consider the utilize of Gel Pads and Perplex boxes for circuitous theatre cases.
  
• Patients should be positioned to reduce the gamble of pressure injury development during surgery.
  
• Heels should be completely elevated in such a way every bit 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 level redistribution prior to and later on 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 chance time.
  

Postoperative Direction

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

Operative consideration

Although doughnut gels are existence phased out in pressure area intendance, they are nevertheless used in RCH theatres mindfully in some cases. Special consideration needs to use to children who accept had these in identify as they may impact lymphatic drainage.

Patients in the Intensive Intendance Unit of measurement

Patients admitted to the Paediatric Intensive Care Unit of measurement (PICU) accept a higher incidence of PI'due south and commonly 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 take existing PI'south assessed every second hour. Even so, if the patient is too haemodynamically unstable with pressure area care and repositioning, an culling program should be discussed with the multidisciplinary squad.
Appendix seven - Pressure Relieving Devices and Techniques
Appendix eight - Preventing Pressure Injuries
Appendix 9 - What is the correct treatment?
Appendix x - 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 private factures.

Documentation

All pressure injuries need to be carefully documented. If a pressure injury is identified:

• Make up one's mind 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 accuse of shift about the pressure injury and inform the patient, family and/or carers about the pressure injury and direction plan.
  
• Document in EMR and handover a detailed description of what is observed and the action taken.
  
• Document assessment and handling programme for stages 2 and above pressure injury on LDA Avatar. This is updated in the LDA Cess flowsheets in the EMR.
  
• An prototype can exist captured on the 'ROVER' device and uploaded to the patients file.
  
• Notify incident on the hospital reporting system Victorian Health Incident Management Organization (VHIMS) and ostend the stage of the pressure injury is included.
  
• Follow the guide on how to document in Appendix x.

Patients with identified Pressure Injuries should be managed as high or very loftier run a 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 straight on an existing force per unit area injury or body surface that remains damaged or erythematous from a previous damage.

Activity should be increased equally soon every bit patient is able.

For patients with a stage 2 or greater pressure injury or those with a Glamorgan risk score of 10 or greater a Pressure Injury Prevention Programme should exist 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 volition be developed in collaboration with the child'due south parent or carer and will be specific to the patient's individual needs and gamble category. Ensure parents and carers receive adequate education of pressure level injury prevention through the force per unit area injury prevention parent factsheet.

The plan volition remain in use and visible on the EMR until the patients Glamorgan risk score changes. If the run a risk score increases a new plan volition be implemented as the patient'southward needs may take inverse.

Patient hazard should continue to exist assessed daily at the commencement of each shift. Once the patient's risk score is below x and the patient'due south adventure of developing a pressure injury is reduced, a management plan is no longer required, withal it is of import that unproblematic preventive measures are maintained.

Consult Orthotics Section 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 advisable measures and equipment are in identify 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 take 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'southward management program. Multiple risk factors and general poor health significantly increases the chance of pressure injuries. Palliative care may have a stronger focus on managing symptoms, comfort and quality of life.

Teaching: Educational activity of patients, parents and carers is essential in the prevention and direction of force per unit area injuries. Patients and their families should have a clear agreement of the potential affect 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 environs or being discharged from an inpatient area. Families and carers of patients discharged with take chances factors should receive a pressure level injury prevention parent factsheet and discuss suitable prevention strategies relevant to their kid prior to discharge.

Appendices

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

References

• Apold, J., Rydrych, D. (2012). Preventing device related force per unit area ulcers: using data to guide statewide modify. Journal of Nursing Intendance Quality, 27(1), 28-34
  
• Australian Commission on Prophylactic and Quality in Wellness Care. (2011) Preventing and Managing Pressure level Injuries, Standard 8.
  
• Australian Wound Management Association Inc, Clinical Practice Guidelines for the Prediction and Prevention of Pressure level Ulcers. 2001, West Leederville: Cambridge Publishing.
  
• Best Do Information Sheets – Joanna Briggs Constitute. (2008) Pressure ulcers – Prevention of Force per unit area related Damage. 12(ii) ane-4.
  
• Bernabe, K., (2012). Pressure ulcers in the pediatric patient. Current Opinion Pediatrics, 24 (three), 352-356
  
• Butler. C. T. (2006) Paediatric Skin intendance: Guidelines for Assessment, prevention and Treatment. Paediatric Nursing, 32(5), 443-450.
  
• Cassidy, Sharon., (2015). Preventing pressure injuries in children. Kai Tiaki Nursing New Zealand, 21(2), 25-26.
  
• Chaiken, N., (2012). Reduction of Sacral Pressure Ulcers in the Intensive Intendance Unit Using a Silicone Border Foam Dressing. Journal of Wound Ostomy Continence Nursing, 39(2), 143-145
  
• Coha, T., & Torres, Z., (2010), Mutual Peel Bug in Children with Special Healthcare Needs. Pediatric Register, 39(4), 206-215
  
• Gefen, A., (2015), Biomechanics of Pus in paediatric care settings. Journal of Wound Care, 24(3), 81
  
• Haesler, E., & Carville, K., (2015), Advancing pressure injury prevention around the world: from the Pan Pacific region to an international force per unit area injury guideline. Wound Practice and Research. 23 (2), 62 - 69
  
• Institute for Clinical Systems Improvement (ICSI), Pressure level ulcer prevention and treatment. Health care protocol. 2010, Bloomington (MN): ICSI.
  
• Kiss, East., Heiler, M. (2014). Pediatric Skin Integrity Practice Guideline for Institutional Use: A Quality Comeback Projection. Periodical of Pediatric Nursing, 29, 362-367
  
• Leonard, P., Colina, A., Moon, K., & Lima, Due south. (2013). Pediatric Pressure Injuries: Does modifying a tool alter the gamble assessment issue? Issues in Comprehensive Pediatric Nursing, 36(4), 279-290.
  
• Levy, A., Kopplin, K., & Gefen, A., (2015), Adjustability and adjustability are critical characteristics of Pediatric support surfaces. Advances in wound care, four(10), 615-621
  
• Maguina, P., & Kirkland-Walsh, H., (2014). Infirmary – Acquired Force per unit area Ulcer Prevention: A Burn Surgeon'due south Squad Approach. Journal of Burn Intendance. 35, 287-293
  
• Milbrath, C, D., Linroth, R., Wilhelmy, J., & Pate, April. (2014). A method of comparing effectiveness of mattresses for pressure management for pediatric patients. Journal Nursing Intendance Quality. 29(1), 66-73
  
• Murray, J.S., Noonan, C., Quigley, S., Curley, 1000.A.Q. (2013). Medical device-related hospital-caused pressure ulcers in children: an integrative review. Periodical of Pediatric Nursing, 28(6), 585-595.
  
• National Force per unit area Ulcer Informational Console (NPUAP) and European Pressure Ulcer Advisory Panel (EPUAP), Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. 2009, Washington DC: NPUAP.
  
• Neuhaus, M., Meuli, M., Koenigs, I., & Schiestl, C., (2013). Management of "Difficult" Wounds. European Journal of Peditric Surgery. 23, 365-374
  
• Parnham, A., (2012). Force per unit area ulcer gamble assessment and prevention in children.Nursing Children and Young People, 24(2), 24-29.
  
• Pan Pacific Clinical Practice Guideline for the Prevention and Management of Pressure Injury.
  
• Pressure Injury Prevention and Management, Policy and Process (2015), The Sydney Children's Infirmary, Sourced from: http://www0.wellness.nsw.gov.au/policies/pd/2014/pdf/PD2014_007.pdf
  
• Santamaria, N., Liu, Westward., Gerddtz, One thousand., Sage, S., McCann, J., Freeman, A., Vassiliou, T., DeVincentis, Southward., W Ng, Ai., Manias, E., Knott, J. & Liew, D (2013).  The cost-do good of using silicone multilayered cream dressings to prevent sacral and heel pressure ulcers in trauma and critically sick patients: a inside-trial analysis of the Border Trial. International Wound Journal ISSN 1742-4801, 344-350
  
• Schluer, A. B., Schols, J. M. A., & Halfens, R. J. Yard, (2013), Pressure Ulcer Treatment in Pediatric Patients. Advances in skin & wound  care, 26(11), 504 – 510
  
• Schindler, C.A., Mikhailov, T.A., Cashin, S.Due east., Malin, South., Christensen, Yard., & Winters, J.M. (2013). Under pressure level: preventing pressure ulcers in critically sick infants. Journal for specialists in Pediatric Nursing. 18, 329-341
  
• Schindler, C.A., Mikhailov, T.A., Fischer, Thousand., Lukasiewicz, G., Kuhn, Due east.M., Duncan, Fifty. (2007) Peel Integrity in Critically Sick and Injured Children. 16(half dozen), 568-574.
  
• Suddaby, E. C.,Barnett, South. D., Facteau, L. (2006) Peel breakup in Astute Paediatrics. Dermatology Nursing, 18(ii), 155- 166.

Prove table

Pressure level Injury Prevention Testify Table

Delight remember to read the disclaimer

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

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Source: https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Pressure_injury_prevention_and_management/

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