Which Is The Most Effective Intervention For Compromised Skin Integrity?

Annotation: This guideline is currently under review.

Introduction

Aim

Definition of Terms

Force per unit area Injury Evolution

Prevention

Management

Patients in the Operating Room

Patients in Intensive Care Unit of measurement

The Orthopaedic Patient

Documentation of pressure level injuries

Discharge

Appendices

References

Evidence Tabular array

Introduction

Fantabulous peel care is an aspect 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'southward recognised as a patient safety trouble as they tin can increment 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 amidst health care professionals at the Royal Children'southward Hospital (RCH). The principal objectives are to provide the finest intendance to patients at risk of or with PI'south and optimally to promote their prevention.
The guideline ensures health care professionals:

• Improve their knowledge of the underlying physiology of PI germination.
  
• Recognise factors which contribute to PI's.
  
• Identify high risk patients.
  
• Implement and document intervention and prevention strategies.
  
• Prevent complications equally a consequent to PI's.
  
• Raise force per unit area injury direction.
  
• Provide adequate parent and carer instruction.
  

Definition of Terms

• Blanching Erythema - Reddened peel that becomes white or stake in appearance when low-cal pressure level 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 0-14, with being neutral.
  
• Pressure Injury - Is a localised area of tissue devastation 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 course used to help ascertain the degree of pressure level injury risk. At the Royal Children's Hospital the 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 later a period of ischemia or lack of oxygen.
  
• Induration – A hardened mass or germination of the skin tissue due to increment in gristly elements commonly associated with inflammation and marked loss of elasticity and pliability of the skin.
  

Pressure Injury Development

PI's are any alienation of pare integrity caused by unrelieved pressure level on soft tissue that has been compressed between any external surface and bony prominences for a prolonged period of fourth dimension. In addition to this, poor blood period, 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 take prolonged pressure level cause the apoplexy of blood catamenia, 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.

Delight see the Force per unit area Injury Staging Guide for stages of force per unit area expanse development found in Appendix ane.

Factors associated with increased hazard of force per unit area injury

In the prevention of PI'due south, information technology is essential that patients at take a chance are identified and an individualised prevention plan is implemented. A risk factor is whatsoever 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 Practise Guideline for the Prevention and Direction of Force per unit area Injury.)

Intrinsic Factors

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, awareness, tissue perfusion, lymphatic office are identified as increasing PI hazard and include, but are not limited to:

• Smoking
  
• Anaemia
  
• Low Claret Pressure
  
• Diabetes mellitus
  
• Lymphodema
  
• Elevated skin temperature
  
• Dehydration
  
• Impaired diet status
  
• Renal failure or impairment
  
• Circulatory abnormalities
  
• Carcinoma
  
• Peripheral arterial affliction
  
• Cardiopulmonary disease
  
• Depressed Allowed System
  

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

Increased exposure to pressure

Gamble factors that increase exposure of the pare to PI's are related to sensory perception, action, the patient'due south ability to change their body position and impaired mobility. Specific circumstances that fall into these categories include:

• Obesity
  
• Cognitive impairment
  
• Medication Use (Hyponotics, analgesics, sedatives, muscle relaxants)
  
• Diabetes
  
• Spinal String Injury (SCI)
  
• Stroke
  
• Multiple Sclerosis
  
• Trauma
  
• Post-op surgical
  
• Patients sitting in wet clothing, moisture nappy, and wet bed for long periods.
  
• Reduced pare sensation (paralysis, epidural, nervus blocks)
  
• Patients lying/sitting in one identify for too long.
  

Reduction in tissue tolerance

This is the ability of the supporting structures and its skin to tolerate the furnishings of pressure. The skins surface acts equally a cushion to protect the skeleton during transferring pressure loads. Factors that touch on tissue tolerance include both intrinsic and extrinsic factors.

Factors contributing to reduced tissue (skin) tolerance:

• Pre-access history of prolonged unchanging force per unit area on trunk function(s)
  
• 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.
  
• Disproportionate weight distribution for prolonged periods of inactivity/immobility including:
  
• Functioning time/Position in operating theatre
  
• Length of stay in NNU/PICU
  
• Prolonged mechanical ventilation OR Non Invasive Ventilation
  
• Decreased sensory perception due to chemical paralysis or neurological disturbances
  
• Altered skin integrity due to fluid resuscitation, wet, 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 use of therapeutic hypothermia
  
• Oxygen saturations <95%
  
• Capillary refill > 2 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 casual factors, implementation of prevention strategies and the selection of an advisable apply of pressure relieving devices. When an cess identifies a patient at take chances of force per unit area injury, interventions should exist implemented immediately.

Education of patients and families

Carers and parents are a primal part of the child's intendance and tin prevent and manage PI'southward past working with the multidisciplinary squad. Carers and parents should be informed of the risk of developing PI's whilst in infirmary and subsequently should exist provided with literature that will help them to understand and contribute in the development of constructive and suitable strategies to forestall PI's.

Factsheets should be fabricated available to carers and parents who take a kid that has been identified at risk of developing a force per unit area surface area. The carer/parent factsheet for Pressure Injury Prevention can exist found on the intranet.

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

Skin Integrity Assessment

Children who are at risk of developing force per unit area injuries need to be identified so that preventative measures tin can exist 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 co-ordinate to a series of parameters considered to exist risk factors for PI's. Certified risk cess tools for children are effective for identifying those at take chances and increasing awareness of potential pressure related injuries, even so they cannot embody every possible circumstance. Therefore, clinicians demand to utilise 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 full general condition in relation to factors which puts them at increased chance for PI development. This should be done:

1. On access or every bit soon as applied afterwards the access (within six 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 one ward/section to another.
   
4. Prior to belch.

All patients have a screening tool cess 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 consummate a comprehensive Integumentary Organisation Inspection:

The status of the patient's skin is the most of import early indicator of the skin's reaction to pressure exposure and the standing chance of force per unit area injury.

• Complete a full general visual check of the integumentary, which includes analysis of the entire skin surface to assess its integrity and place whatever characteristics indicative of pressure damage.
  
• Monitor and check the peel below dressings, prosthesis and devices when clinically appropriate.
  
• Check for areas of localised heat, pare breakdown, oedema, areas of redness that practice not blanch and induration of the wound.

Particular attention should exist paid to areas of bony prominence, which are at an increased risk for force per unit area injury due to pressure, friction and shearing forces. Regular inspection of the following areas is required:

• Sacrum
  
• Heels
  
• Elbows
  
• Wrists
  
• Temporal region of Skull
  
• Ears
  
• Shoulders
  
• Back of Head specially in infants less than 36 months of historic period
  
• Knees
  
• Toes
  

Glamorgan Force per unit area Injury Risk Assessment Tool

Document the appropriate score in the EMR

Version (final) pressure injury medico 15-ane-2010 Adapted from the Glamorgan Risk Assessment Calibration from the Great britain

Direction

Skin Care

• Keep the skin make clean and dry
  
• Investigate and manage incontinence (Consider alternatives if incontinence is excessive for historic period)
  
• Do not vigorously rub or massage the patients' skin
  
• Use a pH advisable peel cleanser and dry thoroughly to protect the skin from excess moisture
  
• Use water based skin emollients to maintain skin hydration where possible
  
• Use barrier cream
  
  • RCH Nappy goo for prophylactic nappy care to healthy skin
    
  • Sudocream for good for you skin/nappy rash
    
  • Orabase Protective Paste for cleaved downwards skin in nappy region
    
• Utilise chlorhexidine wipes daily Merely effectually CVC sites and open up wounds/open sternotomies
  

Redistributing pressure

Prevention strategies should involve the use of pressure relieving devices appropriately called for the patient, regular pare inspection and often redistributing the pressure by repositioning the patients frequently and safely.

• Employ appropriate transmission handling techniques in line with Occupational Health and Safety guidelines when transferring and repositioning patients. Please adhere to Smart Move/Smart Lift guidelines.
  
• Provide transfer assistance devices. Instance: Hoist to reduce friction and shear forces.
  
• Provide the right positioning aids and employ of appropriate support surfaces to help reduce friction and shear.
  

Positioning and repositioning the patient

Patients at risk of pressure injury should exist suitably positioned to redistribute force per unit area, repositioned regularly by minimising shear and friction forces on the pare.

Recommendations:

• For the patient to practise so independently if able
  
• Equipment tin can be used to promote independent mobility. E.g. overhead bed pole, side rails, walking frame.
  
• Patient and/or carers may demand reminders to reposition
  
• For patients who are unable to assist moving themselves, it is recommended that they be repositioned every ii hours
  
• Patients in pain are at an increased run a risk of pressure injury. If pain is managed appropriately they are able to move or be moved at frequent intervals. Monitor the patient'southward level of hurting and ensure appropriate hurting relief is provided. Refer to The principles of pain management for children guide. Give analgesia v to xxx minutes prior to attending to pressure surface area intendance to reduce the patient's hurting on moving
  
• Heels should be suspended off the bed using pillows or gel pads
  
• Reposition tubes and face up masks every two hours for pressure expanse care. Use bulwark dressings such every bit:
  
  • Comfeel for nasogastric tubes/ LFNP/HFNP. (DO Not remove comfeel that is placed within twenty-four hours as it volition 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, to reduce the chance of a pressure injury developing.
    
• For high risk patients, limit time spent sitting in bed with head elevated > thirty degrees to no more than than two hours due to the increased pressure on the sacrum.
  
• Positions may include: prone, seated in bed, seated in chair, left side lying, correct side lying and supine.
  
• Monitor the patient's level of discomfort or pain and ensure appropriate pain relief is provided to back up and encourage mobility
  
• Consider smaller more frequent shifts in position of patients who cannot tolerate major changes in trunk position to redistribute pressure level. E.g. Patients with Pulmonary hypertension, On ECMO Back up
  
• The patient should be 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 prevent shear forces on the sacrum, the caput of the bed should be raised in conjunction with a articulatio genus block or pillows under the knee joint
  
• Always cheque the positioning of the bony prominences and heels when repositioning the patient into any position
  
• Lower the bed caput before repositioning
  
• Employ slide sheets with every reposition
  
• Consider Physiotherapy consultation for assistance/communication on transferring patients and repositioning
  

These techniques are to exist used in conjunction with transmission handling procedure.A list of infirmary available pressure relieving devices and their location are bachelor in Appendix 2 – Types of Pressure Relieving Devices. A guide of how to rent pressure relieving devices is bachelor in Appendix three – Hiring Process. For more information on obtaining a detail 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 yous are having trouble selecting a device for your patient, additional advantages and disadvantages of pressure relieving devices can exist constitute nether Appendix vi - Constant Reactive Support Devices.

Prevention Strategies for device related

There is a variety of different equipment or medical devices that may be required equally a part of a patient's treatment. It is significant to recognise that any foreign object that comes into direct contact with the patient'south integumentary system has the potential to cause PI. Therefore, healthcare workers must be vigilant with their inspection and monitoring of the patients skin, in gild to prevent PI's that are device related. The following devices can contribute to the germination of PI'southward:

• Cervical collars
  
• Casts and orthotics
  
• Pressure stockings
  
• Intermittent dogie compressors
  
• Four 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 forestall device related pressure level injuries include

• Repositioning devices as appropriate due east.thousand. oxygen delivery, saturation probes (min 2 hourly), monitoring electrodes
  
• Protective barriers between the device and the patients skin eastward.g. hydrocolloid under NGT/oxygen tubing, foam pad nether cables.
  
• Regular repositioning and inspection of the patient to ensure that they are non unintentionally lying on devices
  
• Use the correct size equipment suitable to the patient'southward anatomical size. E.k. nasal cannula, IDC.
  
• Utilize padding to soften hard surfaces. East.g. Foam padding nether Iv boards/electrical cords, cast padding under splints.
  
• When equipment is secured to the patient using tapes, ensure that they are non applied likewise tightly and that the applicable tapes are utilised. Ensure where possible that they have some elasticity and stretch.
  
• Use the minimal corporeality of strapping or tape to safely secure the device but allow for maximal visualisation of the patient's peel.
  

Diet

• Offer frequent fluids and nutrition to at risk patients to maintain adequate nutrition and hydration
  
• High or very loftier-risk patients should exist referred to a dietician following the Paediatric Nutritional Screening Tool Assessment.
  
• Nutritional support should exist designed to foreclose or right nutritional deficits, maintain or achieve positive nitrogen residue, and restore or maintain serum albumin levels. Nutrients that have received primary interest in the prevention and treatment of
• pressure injuries include poly peptide, arginine, vitamin C, vitamin A, and zinc.
  

Moisture

Moisture on the peel increases the risk of pressure injury evolution. This is also true if the skin is besides dry, every bit information technology may cause skin to breakdown
Patients who are incontinent of urine and/or faeces should have an adequate evaluation to identify whether a reversible causes exist. Reversible causes include:

• polyuria due to glycosuria/ hypercalcemia
  
• urinary tract infection
  
• medications
  
• modify in mental status
  
• restricted mobility
  
• faecal impaction
  

A bowel training program must be instituted for spinal cord injury patients. Refer to Spinal String injury Clinical Guideline (Acute management)

Pressure redistributing equipment:

Redistributing equipment are back up surfaces that offering redistribution of pressure level on which patients are placed to manage pressure load to their integumentary system. They are designed to alternate the area of the torso in contact with the support surface and to reduce interface pressure through increasing the body expanse.
It is significant that weight be considered when selecting the right force per unit area mattress. Patients at high risk of PI, should exist nursed on a high grade pressure redistributing mattress. Some options may demand to be hired.
For these devices to be effective, in that location must exist minimal layering in betwixt the device and the person. For patients that are very high risk, these devices may allow a decrease in turning frequency overnight to 3-iv hourly to encourage rest patterns, however, this should be assessed on a lonely basis at RCH.
The following should NOT exist used as pressure relieving devices:

• Sheepskins
  
• Doughnut shaped gels – this blazon of device may impair lymphatic drainage and circulation.
  
• Water filled gloves under heels – these are not constructive every bit the water filled glove is unable to redistribute pressure and it only supports a pocket-sized surface of the heel.

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 inside the bed, his/her condolement and the need for microclimate command.

Please consider the Sudden Infant Expiry Syndrome (SIDS) risk reduction recommendations when using pressure redistribution devices for infants. Monitoring is required for infants nursed exterior of these recommendations. Consider Occupational Therapist consultation for assistance with assessment of causal factors and advice on appropriate pressure level relieving devices.

Important Note
It is important to note that the use of sheets, overlay sheets, pillows and towels potentially change 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 canvass that tin can be kept dry out and pucker free is optimal.

Patients in the Operating Room

In order to provide optimal patient care in the operating theatre, the multidisciplinary team needs to be enlightened of potential bug. In club to prevent PI's a strategic program of adequate implementation and appropriate 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 2 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 college chance 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 i to four days post operatively. This highlights the significance of prevention and the importance of a thorough integumentary assessment every bit the patient continues their journeying through surgery and during the postoperative period.

Risks for patients undergoing surgery should be determined by:

• Length of the operation
  
• Increased hypotensive episodes intraoperatively
  
• Low core temperature during surgery
  
• Reduced mobility on 24-hour interval ane postoperatively
  
• Prolonged placement of circuitous equipment E chiliad: neuro surgery head frame
  

The RCH operating tables are all fitted with high density pressure-redistributing foam to reduce the risk of pressure level injury evolution.

• Consider the employ of Gel Pads and Perplex boxes for circuitous theatre cases.
  
• Patients should exist positioned to reduce the adventure of force per unit area injury evolution during surgery.
  
• Heels should be completely elevated in such a way as to distribute the weight of the leg along the calf without putting all the pressure on the achilles tendon. The articulatio genus should exist in slight flexion.
  
• Hyperextension of the human knee may cause obstruction of the popliteal vein, and this could predispose the individual to deep vein thrombosis.
  
• Pay attention to pressure redistribution prior to and later 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 force per unit area intendance devices are utilized at this high gamble fourth dimension.
  

Postoperative Management

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

Operative consideration

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 in the Intensive Care Unit of measurement

Patients admitted to the Paediatric Intensive Care Unit (PICU) accept a higher incidence of PI's and unremarkably they are more severe. Effective prevention for these patients should be based on correctly identifying them at take chances.
The ICU environment includes several master contributing factors:

• Depression cardiac output state
  
• Inotrope and vasoconstrictor use
  
• Impaired level of consciousness
  
• Immobility
  
• Poor peripheral blood flow
  
• Decreased nutrition
  

Patients should exist repositioned fourth hourly and accept existing PI's assessed every second hour. Nonetheless, if the patient is too haemodynamically unstable with pressure expanse care and repositioning, an culling program should be discussed with the multidisciplinary team.
Appendix 7 - Pressure Relieving Devices and Techniques
Appendix viii - Preventing Force per unit area Injuries
Appendix ix - What is the right treatment?
Appendix 10 - How to document

The Orthopaedic Patient

Patients that accept had orthopaedic surgery are considered to be high risk of PI's due to the presence of stock-still 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.

Documentation

All force per unit area injuries need to exist carefully documented. If a pressure injury is identified:

• Determine and certificate likely causal factors.
  
• Document Pressure Injury appearance, measurement of the wound size and depth, exudate, odour and stage.
  
• Notify medical staff and nurse in charge of shift about the pressure injury and inform the patient, family unit and/or carers about the pressure injury and management plan.
  
• Document in EMR and handover a detailed description of what is observed and the activity taken.
  
• Document cess and treatment plan for stages 2 and in a higher place force per unit area injury on LDA Avatar. This is updated in the LDA Assessment flowsheets in the EMR.
  
• An image can be captured on the 'ROVER' device and uploaded to the patients file.
  
• Notify incident on the hospital reporting organization 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 ten.

Patients with identified Pressure level Injuries should exist managed every bit high or very high risk regardless of their identified Glamorgan Risk Cess Score. This assessment should be documented in the EMR under the pressure prevention program.

Patients should non be positioned directly on an existing pressure injury or body surface that remains damaged or erythematous from a previous damage.

Activity should be increased equally before long every bit patient is able.

For patients with a stage 2 or greater pressure injury or those with a Glamorgan gamble score of x or greater a Pressure Injury Prevention Programme 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 cess and management of the wound if clinically indicated.

The plan will exist developed in collaboration with the kid'southward parent or carer and will be specific to the patient'south individual needs and adventure category. Ensure parents and carers receive acceptable pedagogy of pressure injury prevention through the pressure injury prevention parent factsheet.

The program will remain in use and visible on the EMR until the patients Glamorgan adventure 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 first of each shift. Once the patient'south risk score is below ten and the patient's run a risk of developing a pressure injury is reduced, a management programme is no longer required, however information technology is important that uncomplicated preventive measures are maintained.

Consult Orthotics Department for the correct fitting of braces/splints/collars where appropriate.

Consider referring patients with a pressure level injury to a dietician, allied health, plastics department for assessment, handling and ongoing monitoring.

Belch

Ensure the appropriate measures and equipment are in identify in the home prior to belch 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, advisable goals should be established and included in the patient'south management programme. Multiple chance factors and general poor health significantly increases the take chances 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 direction of pressure injuries. Patients and their families should have a clear understanding of the potential bear on of a pressure level injury and the importance of its prevention, contributing take a chance factors and strategies that assistance in reducing the take a chance. This is especially 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.

Appendices

1. Appendix i - Pressure Injury Staging Guide
   
2. Appendix 2 - Types of Pressure Relieving Devices
   
3. Appendix 3 - Hiring Processes
   
4. Appendix iv - Discard Process
   
5. Appendix 5 - Obtaining Force per unit area Relieving devices
   
6. Appendix 6 - Abiding Reactive Back up Devices
   
7. Appendix 7 - Pressure level relieving devices and techniques
   
8. Appendix 8 - Preventing pressure injuries
   
9. Appendix 9 - What is the right treatment
   
10. Appendix 10 - How to document

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• Australian Commission on Safe and Quality in Wellness Care. (2011) Preventing and Managing Pressure Injuries, Standard 8.
  
• Australian Wound Management Association Inc, Clinical Exercise Guidelines for the Prediction and Prevention of Pressure Ulcers. 2001, West Leederville: Cambridge Publishing.
  
• Best Exercise Information Sheets – Joanna Briggs Institute. (2008) Pressure ulcers – Prevention of Pressure related Impairment. 12(ii) 1-4.
  
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• Cassidy, Sharon., (2015). Preventing pressure injuries in children. Kai Tiaki Nursing New Zealand, 21(two), 25-26.
  
• Chaiken, Due north., (2012). Reduction of Sacral Pressure Ulcers in the Intensive Intendance Unit Using a Silicone Edge Cream Dressing. Journal of Wound Ostomy Continence Nursing, 39(ii), 143-145
  
• Coha, T., & Torres, Z., (2010), Common Skin Issues in Children with Special Healthcare Needs. Pediatric Annals, 39(4), 206-215
  
• Gefen, A., (2015), Biomechanics of Pus in paediatric care settings. Journal of Wound Care, 24(3), 81
  
• Haesler, East., & Carville, K., (2015), Advancing pressure injury prevention around the globe: from the Pan Pacific region to an international force per unit area injury guideline. Wound Do and Research. 23 (2), 62 - 69
  
• Institute for Clinical Systems Comeback (ICSI), Force per unit area ulcer prevention and treatment. Health care protocol. 2010, Bloomington (MN): ICSI.
  
• Kiss, E., Heiler, Yard. (2014). Pediatric Skin Integrity Practice Guideline for Institutional Use: A Quality Improvement Project. Journal of Pediatric Nursing, 29, 362-367
  
• Leonard, P., Loma, A., Moon, K., & Lima, S. (2013). Pediatric Pressure level Injuries: Does modifying a tool alter the risk assessment outcome? Bug in Comprehensive Pediatric Nursing, 36(iv), 279-290.
  
• Levy, A., Kopplin, K., & Gefen, A., (2015), Adjustability and adaptability are critical characteristics of Pediatric support surfaces. Advances in wound care, 4(10), 615-621
  
• Maguina, P., & Kirkland-Walsh, H., (2014). Hospital – Acquired Pressure Ulcer Prevention: A Burn down Surgeon'southward Team Approach. Journal of Burn Intendance. 35, 287-293
  
• Milbrath, C, D., Linroth, R., Wilhelmy, J., & Pate, Apr. (2014). A method of comparing effectiveness of mattresses for pressure management for pediatric patients. Journal Nursing Intendance Quality. 29(1), 66-73
  
• Murray, J.Southward., Noonan, C., Quigley, S., Curley, Thou.A.Q. (2013). Medical device-related hospital-acquired pressure ulcers in children: an integrative review. Journal of Pediatric Nursing, 28(6), 585-595.
  
• National Pressure Ulcer Informational Panel (NPUAP) and European Pressure level Ulcer Advisory Panel (EPUAP), Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. 2009, Washington DC: NPUAP.
  
• Neuhaus, K., Meuli, M., Koenigs, I., & Schiestl, C., (2013). Management of "Difficult" Wounds. European Journal of Peditric Surgery. 23, 365-374
  
• Parnham, A., (2012). Pressure ulcer risk assessment and prevention in children.Nursing Children and Young People, 24(2), 24-29.
  
• Pan Pacific Clinical Do Guideline for the Prevention and Management of Pressure Injury.
  
• Pressure level Injury Prevention and Direction, Policy and Procedure (2015), The Sydney Children's Hospital, Sourced from: http://www0.wellness.nsw.gov.au/policies/pd/2014/pdf/PD2014_007.pdf
  
• Santamaria, North., Liu, W., Gerddtz, M., Sage, S., McCann, J., Freeman, A., Vassiliou, T., DeVincentis, S., W Ng, Ai., Manias, E., Knott, J. & Liew, D (2013).  The cost-benefit of using silicone multilayered cream dressings to forestall sacral and heel pressure ulcers in trauma and critically ill patients: a within-trial analysis of the Border Trial. International Wound Journal ISSN 1742-4801, 344-350
  
• Schluer, A. B., Schols, J. Grand. A., & Halfens, R. J. G, (2013), Pressure Ulcer Treatment in Pediatric Patients. Advances in skin & wound  care, 26(11), 504 – 510
  
• Schindler, C.A., Mikhailov, T.A., Cashin, South.E., Malin, S., Christensen, Grand., & Winters, J.Yard. (2013). Under force per unit area: preventing pressure ulcers in critically ill infants. Journal for specialists in Pediatric Nursing. 18, 329-341
  
• Schindler, C.A., Mikhailov, T.A., Fischer, M., Lukasiewicz, G., Kuhn, E.M., Duncan, L. (2007) Skin Integrity in Critically Sick and Injured Children. 16(half-dozen), 568-574.
  
• Suddaby, E. C.,Barnett, Due south. D., Facteau, L. (2006) Skin breakdown in Acute Paediatrics. Dermatology Nursing, 18(2), 155- 166.

Show table

Pressure Injury Prevention Evidence Table

Please remember to read the disclaimer

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

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

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