Download Preventing and Managing Pressure Injuries

Preventing and Managing
Pressure Injuries
Standard 8: Preventing and Managing Pressure
Injuries
The Victorian Department of Health is making this document freely available on the internet for health
services to use and adapt to meet the National Safety and Quality Health Service Standards of the
Australian Commission on Safety and Quality in Health Care. Each health service is responsible for all
decisions on how to use this document at its health service and for any changes to the document. Health
services need to review this document with respect to the local regulatory framework, processes and
training requirements.
The author disclaims any warranties, whether expressed or implied, including any warranty as to the
quality, accuracy, or suitability of this information for any particular purpose. The author and reviewers
cannot be held responsible for the continued currency of the information, for any errors or omissions, and
for any consequences arising there from.
Published by Sector Performance, Quality and Rural Health, Victorian Government, Department of Health
June 2014
Preventing and Managing Pressure Injuries
1
Acknowledgements
The Department of Health Victoria acknowledges the contribution of medical and health specialists,
Victorian health services, and members of the National Safety and Quality Health Service Standards:
Educational Resources Project project team, Steering Group and Advisory Committee.
For the Preventing and Managing Pressure Injuries module, Regional Wounds Victoria
http://www.grhc.org.au/vic-wound-man-cnc-project provided specialist advice.
The Education Resources Project Steering Group members comprised:
 Associate Professor Leanne Boyd, Steering Group Chair; Director of Education, Cabrini Education
and Research Precinct, Cabrini Health
 Ms Madeleine Cosgrave, Project Manager
 Ms Susan Biggar, Senior Manager, Consumer Partnerships, Health Issues Centre
 Mr. David Brown, Consumer representative
 Dr Jason Goh, Medical Administration Registrar - Cabrini Health
 Mr Matthew Johnson, Simulation Manager, Cabrini Education and Research Precinct, Cabrini
Health
 Ms Tanya Warren, Educator, Cabrini Education and Research Precinct, Cabrini Health
 Ms Marg Way, Director, Clinical Governance, Alfred Health
 Mr Ben Witham, Senior Policy Officer, Quality and Safety, Department of Health Victoria
The Education Resources Project Advisory Committee members comprised:
 Associate Professor Leanne Boyd, Advisory Committee Chair; Director of Education, Cabrini
Education and Research Precinct, Cabrini Health
 Ms Madeleine Cosgrave, Project Manager
 Ms Margaret Banks, Senior Program Director, Australian Commission on Safety and Quality in
Health Care
 Ms Marrianne Beaty, Oral Health National Standards Advisor, Dental Health Services Victoria)
 Ms Susan Biggar, Senior Manager, Consumer Partnerships, Health Issues Centre
 Mr David Brown, Consumer representative
 Dr Jason Goh, Medical Administration Registrar, Cabrini Health
 Ms Catherine Harmer, Manager, Consumer Partnerships and Quality Standards, Department of
Health, Victoria
 Ms Cindy Hawkins, Director, Monash Innovation and Quality, Monash Health
 Ms Karen James, Quality and Safety Manager, Hepburn Health Service
 Mr Matthew Johnson, Simulation Manager, Cabrini Health
 Ms Annette Penney, Director ,Quality and Risk, Goulburn Valley Health
 Ms Gayle Stone, Project Officer, Quality Programs, Commission for Hospital Improvement,
Department of Health Victoria
 Ms Deb Sudano, Senior Policy Officer, Quality and Safety, Department of Health Victoria
 Ms Tanya Warren, Educator, Cabrini Health
 Ms Marg Way, Director, Clinical Governance, Alfred Health
 Mr Ben Witham, Senior Policy Officer, Quality and Safety, Department of Health Victoria
Preventing and Managing Pressure Injuries
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Contents
Preventing and Managing Pressure Injuries
4
Learning outcomes
4
National Standards
4
Aim of Standard 8
4
Policies and procedures
4
Preventing Pressure Injuries
5
Background
5
Principles of pressure injury prevention
5
Risk screening and assessment
5
Risk Factors
6
Comprehensive skin assessment
7
Pressure injury prevention strategies
8
Documentation and monitoring
9
Engaging with patients and carers
9
Pressure Injury Assessment and Management
11
Pressure injury assessment
11
Pressure injury classification
11
Management of pressure injuries
12
Documentation and monitoring
13
Audit and evaluation
14
Engaging patients and carers
14
Reporting adverse events
14
Summary
15
Glossary of terms
16
Test Yourself
17
Answers
18
References and Resources
19
Preventing and Managing Pressure Injuries
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Preventing and Managing Pressure Injuries
This module relates to the National Safety and
Quality Health Service (NSQHS) Standard 8:
Preventing and Managing Pressure injuries
Aim of Standard 8
The intention of Standard 8: Preventing and
Managing Pressure Injuries is to prevent patients
from developing pressure injuries and effectively
manage them should they occur.
Standard 8 also relates to Standard 1: Governance
for Safety and Quality in Health Service
Organisations and Standard 2: Partnering with
Consumers. The principles in these Standards are
fundamental to all Standards and provide a
framework for their implementation.
ACSQHC, 2012
Learning outcomes
On completion of this module, clinicians will be
able to:
1. Outline the process for identifying risk of
pressure injuries including frequency of
assessment.
2. Describe preventative strategies to reduce
the risk of pressure injuries.
3. Describe the principles of pressure injury
management.
4. Describe the process for engaging patients
and carers in pressure injury prevention.
Criteria to Achieve Standard 8:
Governance and systems for prevention and
management of pressure injuries
Organisations have governance structures and systems
in place for the prevention and management of pressure
injuries.
Preventing pressure injuries
Patients are screened on presentation and pressure
injury prevention strategies are implemented when
clinically indicated.
Managing pressure injuries
Patients who have pressure injuries are managed
according to best practice guidelines.
Communicating with Patients and Carers
Patients and carers are informed of the risks, prevention
strategies and management of pressure injuries.
Table 1: Criteria to meet Standard 8 (ACSQHC, 2012)
National Standards
Policies and procedures
The Australian Commission on Safety and Quality
in Health Care (ACSQHC) developed the 10 NSQHS
Standards to reduce the risk of patient harm and
improve the quality of health service provision in
Australia. The Standards focus on governance,
consumer involvement and clinically related areas
and provide a nationally consistent statement of
the level of care consumers should be able to
expect from health services.
There are numerous policies, procedures and
resources within health care services to assist you
with prevention and management of pressure
injuries. It is important to access, read and adhere
to systems, policies and procedures within your
organisation.
Preventing and Managing Pressure Injuries
4
Preventing Pressure Injuries
o engaging patients in their own
pressure injury prevention program
Background
There is increased risk of in-hospital complications
in patients with a pressure injury and significant
health care costs to both patients and health care
services.
Pressure injuries are associated with:

increased morbidity and mortality

pain

reduced mobility and loss of independence
Immobility associated with hospital admissions
increases the risk of pressure injuries.
Older people in particular are at high risk due to
decreased mobility, and other associated risk
factors.
In most cases, pressure injuries are preventable.
ACSQHC, 2012;
Australian Wound Management Association (AWMA), 2012
Principles of pressure injury
prevention
The Pan Pacific Clinical Practice Guideline for
Prevention and Management of Pressure Injury
(AWMA, 2012) outlines the following key messages
in pressure injury prevention:

most pressure injuries can be prevented

they can occur in any patient, whether that
patient has only some or all risk factors

best practice in pressure injury prevention
includes:
o vigilant screening
o comprehensive assessment
o implementing pressure injury
prevention strategies
ACSQHC, 2012
Risk screening and assessment
A risk screening and assessment can be used to
identify patients who are at risk of developing a
pressure injury and require implementation of
pressure injury prevention strategies.
It is important to note that some documents refer
to risk assessment and others to risk screening
which can be confusing. However, the intent of
the risk screening and assessment process is to
identify risk factors and highlight the need for
comprehensive and ongoing skin assessment.
To minimise confusion, this document will refer to:

risk screening and assessment as the
process for identification of risk factors
using a validated tool

skin assessment as the process of
conducting a head to toe examination of
the skin
There a number of validated tools available that
assess a patient’s risk of developing a pressure
injury. These include the Braden, Waterlow and
Norton scales for adults and the Glamorgan,
Braden Q and StarKid scales for paediatric patients.
Organisational policy will determine the tools used
and frequency of screening in each health care
service. It is important that you make yourself
familiar with the specific tools you will be using.
Risk screening and assessment should occur on
presentation, as soon as possible after admission
(within 8 hours) and should also be repeated
whenever there is a change in condition.
AWMA, 2012; ACSQHC, 2012
o evaluating effectiveness of pressure
injury prevention strategies
Preventing and Managing Pressure Injuries
5
Risk Factors
Risk factors for pressure injuries can be grouped
into two broad categories:
 those that contribute to increased
exposure to pressure

those that reduce the tissue’s tolerance to
pressure
REDUCTION IN TISSUE TOLERANCE TO PRESSURE
The skin’s ability to tolerate the effects of pressure
is affected by several factors including:

friction and shear

moisture

effects of ageing such as reduced
vascularity, sensation or lymphatic
function

chronic illness, e.g. diabetes or
lymphoedema

diseases that reduce oxygen delivery, e.g.
cardiopulmonary and peripheral vascular
disease, anaemia

nutrition and hydration
AWMA, 2012
AWMA, 2012
The more risk factors a patient has, the higher the
risk of them developing a pressure injury. Some
key risk factors will be discussed in more detail
below.
Figure 1: Factors associated with increased risk or pressure
injury
AWMA, 2012
INCREASED EXPOSURE TO PRESSURE
Any reduction in a patient’s ability to change their
own body position will increase a patient’s risk of
developing pressure injuries. This can be a result
of impaired mobility, activity or sensory
perception. This may be caused by:

neurological conditions and spinal cord
injury

cognitive impairment

trauma and surgery

obesity

diabetes

medications such as sedatives and
hypnotics
Preventing and Managing Pressure Injuries
EFFECTS OF AGEING
The most significant risk factor for development of
a pressure injury is increasing age. This is caused
by a reduction in skin thickness, subcutaneous fat
and moisture content.
Older patients are more likely to experience
cognitive impairment which means that they may
not be able to communicate pain from pressure or
request assistance with changing position.
Older patients are also at risk of incontinence,
which can increase the likelihood of developing
pressure injuries due to increased exposure to
moisture.
AWMA, 2012
Improving Care of the Older Person, 2007
6
POOR NUTRITION AND HYDRATION
Poor nutrition and hydration can weaken the skin.
Decreased energy intake and dehydration:

reduce the skin’s tolerance to pressure
friction and shear
WHAT SHOULD BE INCLUDED?
A comprehensive skin assessment should include a
complete head to toe inspection of your patient’s
skin and hair observing:

skin integrity

increase the risk of skin breakdown

temperature

result in poor healing

colour

moisture and skin turgor

any areas of pain or discomfort

for pressure damage relating to devices
such as splints and anti-embolic stockings.
(Where possible these devices should be
removed at least once daily to complete a
comprehensive skin assessment).
Malnutrition is common and poorly recognised,
occurring in 25 – 30% of hospitalised older
patients.
Many older people are already at risk of undernutrition on admission to hospital due to ageing
and lifestyle. The impact of illness and
hospitalisation may further compromise their
nutritional status.
Hospitalisation can lead to an inability to access
and consume food due to:

inadequate supply of appetising food

inadequate staffing for meal set up and
assistance
AWMA, 2012; Hess, 2010
Particular attention should be paid to bony
prominences, especially the sacrum and heels,
observing for indications of pressure injury such as:

erythema

blanching response

interruptions to mealtimes

localised heat

lethargy and effects of illness

oedema

induration

skin breakdown
Improving Care of the Older Person, 2007
Comprehensive skin assessment
A comprehensive skin assessment is required for
patients who are at high risk of developing
pressure injuries. This should occur within 8 hours
of admission and daily thereafter.
ASQHC, 2013
Evaluation of other risk factors which contribute to
pressure injury risk is also recommended including
assessment of mobility and activity, continence,
cognitive function, psychosocial issues, nutrition
and extrinsic risk factors.
ACSQHC, 2012; AWMA, 2012
SCREENING FOR RISK OF MALNUTRITION
There are a number of validated risk screening
tools available. These tools usually include
Preventing and Managing Pressure Injuries
7
assessment of weight, height and BMI, as well as
recent weight changes and food intake.
It is also important to conduct an assessment to
check for any dental issues, medications or
swallowing difficulties. These may impact on the
patient’s ability to eat or drink. It is also important
to understand your patient’s dietary requirements
and preferences including cultural influences.
AWMA, 2012
Pressure injury prevention
strategies
The Pan Pacific Clinical Practice Guideline for
Prevention and Management of Pressure Injury
(2012) outline evidence based pressure injury
prevention strategies which should be included in
the development of a pressure injury prevention
plan.
AWMA, 2012; ACSQHC, 2012
SKIN PROTECTION
Skin protection is fundamental to the prevention
of pressure injury by protecting your patient’s skin
from exposure to moisture, friction and shear.
This can be achieved in a number of ways
including:

encouraging and assisting patients with
regular repositioning

utilising pressure relieving support
surfaces on beds, trolleys, operating tables
and seat cushions

promoting independent patient movement
using assistance devices such as overhead
bars

implementing a continence management
plan

ensuring patient’s skin is thoroughly dried

using pH balanced and water based skin
emollients daily or twice daily to clean and
moisturise skin
Preventing and Managing Pressure Injuries

avoid trauma to skin from devices such as
wheel chair footplates, wheelie frames,
bed rails and lifting machine parts
Tapes and adhesives should be avoided on fragile
skin but if required:

use tapes and dressings with a gentle
adhesive that won’t cause trauma on
removal (e.g. soft silicone dressings)

consider using light tubular bandages to
keep dressings in place

apply the tape or dressing using gentle
pressure to ensure it is firmly in place

use caution and consider the use of
adhesive removal wipes when removing
dressings or tapes from fragile skin
PATIENT POSITIONING
Patients who are unable to recognise pain from
pressure or who are unable to reposition
themselves require assistance with regular
repositioning.
The frequency of repositioning should be
determined by the patient’s risk of developing a
pressure injury and other factors such as comfort,
functional status and the support surface used.
When your patient is confined to bed, all bony
prominences are exposed to high pressures. To
relieve this pressure, you can position your patient
slightly on either side. A 30 degree tilt to either
side reduces pressure.
You can alternate your patient’s position from one
side, to their back, and then to the other side (also
known as ‘side to side’ nursing). Prone positioning
your patient (laying them on their front) can be
used as an alternative if medical reasons prevent
the previous options.
If the patient is required to sit at an angle greater
than 30 degrees in bed, they are at high risk of
experiencing shear on the sacrum and coccyx.
Patients should be supported to stop them slipping
down the bed to reduce exposure to shear.
8
Always check the positioning of heels and bony
prominences when repositioning and restrict time
spent in seated positions without pressure relief.
OPTIMISE NUTRITION AND HYDRATION
Patients identified with malnutrition, or those
found to be at risk, require referral to a dietician.
A dietician or assistant will undertake a full
nutritional assessment to ensure the nutritional
needs of the patient are being met and can
recommend supplements if required.
Nutrition can be optimised by ensuring:

accessibility to a range of food choices

the provision of assistance with meals as
required (patient positioned correctly,
packets opened, food cut up etc)

monitoring of weight and dietary intake

minimal interruptions and consideration of
protected meal times
AWMA, 2012
Crowe & Brockbank, 2009
Patients with poor oral intake can be monitored
using a food record chart, to enable an accurate
record of their daily dietary intake. They should be
weighed weekly.
PROVISION OF SUPPORT SURFACES
The use of support surfaces is recommended to
redistribute pressure on skin surfaces. Selection of
support surfaces should be based on individualised
patient assessment and requirements.
Recommendations include using a high
specification reactive (constant low pressure)
support foam mattress on beds and trolleys for
those patients at high risk. Active (alternating
pressure) support mattresses may be used as an
alternative.
Mattresses and support surfaces should always be
used in accordance with the manufacturer’s
instructions.
Medical grade sheepskins should only be used
when the mattress recommendations are not
tolerated by patients or for comfort and palliative
measures only. Sheepskins do not provide
adequate pressure redistribution and should not
be used on top of existing pressure relieving
devices.
Support cushions should be used for patients when
seated in a chair or wheelchair.
Devices used to prevent pressure injuries on heels
need to be fitted correctly. If not fitted correctly,
these devices will not only cease to provide
pressure relief but can also cause harm.
AWMA, 2012
Documentation and monitoring
Skin assessment should be documented as soon as
possible after admission, daily and whenever there
is a change in condition. It is important to note
that darker skin tones may be more difficult to
visually assess.
The results of risk screening and assessment and
the individual pressure injury prevention strategies
are to be used to inform the development of a
pressure injury prevention plan. This should be
developed in consultation with the patient and
their family or carer to ensure correct information,
education and collaboration in developing and
implementing prevention strategies
Pressure injury risk and prevention strategies
should be communicated during clinical handover
and on transfer or discharge. This ensures that all
clinicians, the patient and their families can
manage pressure injury risk. All clinicians should
monitor and evaluate the effectiveness of pressure
injury prevention strategies and document in the
clinical record.
ACSQHC, 2012
Engaging with patients and carers
Education should be provided to patients and
carers about pressure injury risks and prevention
Preventing and Managing Pressure Injuries
9
strategies. They should be engaged in the
development of a pressure injury prevention plan.
This collaboration enables an opportunity for
patients, carers and clinicians to share information
which may impact on the effectiveness of the
pressure injury prevention plan.
Health care professionals should consider the
following in order to encourage patients to
participate in pressure injury prevention:

provide relevant, easy to understand
information to allow patients and carers to
take part in discussions and decisions
about preventing pressure injuries

offer information in languages other than
English, where appropriate, and do not
assume literacy

ask the patient, family members or carers
to assist with pressure injury prevention
strategies

utilise pressure injury prevention posters
in ward areas commonly used by patients
and family members

ensure pressure injury prevention
strategies are included as part of patient
discharge information
ACSQHC, 2012
Preventing and Managing Pressure Injuries
10
Pressure Injury Assessment and Management
Stage 1 Pressure injury: non blanchable erythema
Pressure injury assessment
Ongoing assessment of any pressure injury is
required to develop a management plan.
Assessment should occur on admission (for
patients presenting with a pressure injury) or when
a pressure injury is noted. Ongoing assessment
should take place at least weekly, with each
dressing change, or if there is a change in healing
status.
AWMA, 2012
Assessment should include:
Intact skin with localised non blanchable redness
Area may be painful, firm, soft, warmer or cooler
than adjacent tissue
Stage 2 pressure injury: partial thickness loss
Shallow open wound with a red pink wound bed
(no slough)
Intact or ruptured serum filled blister
Shiny or dry shallow ulcer without sloughing or
bruising
NB: Bruising indicates suspected deep tissue injury
Stage 3 pressure injury: full thickness skin loss

location, size and depth of pressure injury

appearance of wound bed

condition of wound edges and surrounding
skin

odour, amount and type of exudate

level of pain and discomfort
It should be noted that assessment of pressure
injuries can be more difficult in patients with
darker skin tones.
Pressure injury classification
Pressure injury classification systems provide a
consistent method of assessing and documenting
pressure injuries.
The National Pressure Ulcer Advisory Panel
(NPUAP) and the European Pressure Ulcer Advisory
Panel (EPUAP) 2009 classification system is
recommended for use.
AWMA, 2012
Depth depends on location of pressure injury;
shallow on nose, ears and head but deeper in areas
with adipose tissue e.g. buttocks
Visible subcutaneous fat but no bone, tendon or
muscle exposure
Stage 4 pressure injury: full thickness tissue loss
Exposed bone, tendon or muscle
Slough or eschar present
Depth depends on location of pressure injury;
shallow on nose, ears and head but deeper in areas
with adipose tissue and can extend into muscle,
tendons and joint capsules
Unstageable pressure injury: depth unknown
Full thickness tissue loss with base covered by
slough and/or eschar
Depth and stage cannot be determined until slough
or eschar is removed (not advisable with stable
eschar as it actually protects the injury)
Visible subcutaneous fat but no bone, tendon or
muscle exposure
Suspected deep tissue injury: depth unknown
A description of the staging system is outlined in
the following table:
Preventing and Managing Pressure Injuries
Purple or maroon localised area or discoloured
intact skin or blood filled blister
Area may be preceded by painful, firm, mushy,
boggy tissue which is warmer or cooler than
adjacent skin
11
AWMA, 2012
Management of pressure injuries
The management of pressure injuries requires an
evidence based approach. Interventions will vary
dependent on the location, type and severity of
the pressure injury and may require a multi
disciplinary approach. You should access and use
your organisation’s wound and pressure injury
protocols.
ACSQHC, 2012
A wound management plan should be made by the
staff member making the initial assessment. The
assessment and plan may include photos of
pressure injuries to assist clinicians with accurate
classification.
If unsure, seek guidance from an experienced
colleague or contact the wound consultant (if
available in your health service).
The strategies used to prevent pressure injuries
are also important to:

manage pressure injuries

prevent further deterioration of any
pressure injury

prevent the development of further
pressure injuries
A patient with a pressure injury is at high risk of
developing further pressure injuries and must have
prevention strategies implemented as outlined in
the previous module. This should include:
The following issues should also be considered
when developing a pressure injury management
plan.
PAIN ASSESSMENT AND MANAGEMENT
A pain assessment should be conducted as part of
the initial and ongoing wound assessment using a
validated pain assessment tool.
Pain management should be regularly reviewed.
This includes evaluating the effectiveness of
analgesia and other pain management strategies.
Pre dressing analgesia should be administered with
enough time to take effect. Unnecessary handling
of the wound should be avoided.
AWMA, 2012
PATIENT POSITIONING
Patients should not be positioned in a way that
puts a pressure injury under any further pressure.
Activity should be encouraged.
The frequency of repositioning should be
determined by the patient’s general condition, risk
of developing further pressure injuries and factors
such as comfort, functional status and the support
surface used.
WOUND BED PREPARATION
Wound bed preparation is required for effective
healing. This can be done in a number of ways.
Debridement

skin protection including minimising
exposure to moisture, friction and shear
Debridement is the removal of infected or non
viable tissue which can increase inflammation and
bacteria and delay healing. Health professionals
should have suitable training and expertise to
debride pressure injuries.

optimising nutrition and hydration to assist
with wound healing
Skin and wound hygiene

provision of support surfaces to assist in
reducing and relieving pressure

regular patient repositioning
Skin and wound hygiene is important for wound
healing and to maintain overall skin integrity.
Regular cleaning of a pressure injury removes
exudate to prepare the wound bed.
Surrounding skin may be irritated by exudate and
moisture. Therapeutic healing products, topical
Preventing and Managing Pressure Injuries
12

cleaners and barriers should be used for
protection.

Treating infection
Not all pressure injuries will be infected, however,
all open or chronic wounds will be colonised.
Signs of local infection in a pressure injury include:

an increase in wound size or breakdown

erythema or oedema around the pressure
injury

increasing amount, viscosity or purulence
of exudate

increased or unexplained pain or
temperature

malodour
When infection is confirmed in a pressure injury, a
number of agents may be used to promote
healing. Systemic antibiotics should only be used
when there is evidence of spreading or systemic
infection.
AWMA, 2012
PRESSURE INJURY DRESSINGS
Pressure injury dressings are used to protect the
wound from trauma and contamination, absorb
exudate, reduce oedema and promote healing.
The selection of a dressing should:

promote a moist wound healing
environment unless contraindicated
cost, availability and patient preference
and tolerance
pressure injury stage
Stage 1 and 2 pressure injuries are often better
cared for without a dressing, to allow for frequent
skin care and inspection.
Negative pressure wound therapy involves the
application of suction to a wound using a vacuum
dressing. It can reduce oedema, remove exudate
and improve granulation. It may be considered
when treating stage 3 or stage 4 pressure injuries.
AWMA, 2012
SURGERY
Surgery may be considered to repair stage 3 and
stage 4 pressure injuries when other management
strategies have been ineffective. Surgical
techniques include debridement, direct wound
closure, flap reconstruction or skin grafting.
AWMA, 2012
Documentation and monitoring
The pressure injury assessment and management
plan must be documented in the clinical record
and communicated during clinical handover and
transfer of care.
It should comprise detailed information regarding:

type of wound

site of wound

treatment goals

maintain a constant wound temperature

daily assessment plan

prevent and manage infection

evaluation plan

minimise pain and further trauma
AWMA, 2011
Dressing selection should be based on
comprehensive ongoing assessment including:

wound size and location

management of pain, odour, infection and
exudates
Preventing and Managing Pressure Injuries
All clinicians should monitor and evaluate the
effectiveness of pressure injury prevention
strategies and document in the clinical record.
ACSQHC, 2012
13
Audit and evaluation
You may be required to participate in audit
activities which could include examination of:

patient clinical records

risk screening and assessment tools

pressure injury prevention plans
The purpose of audit is to measure compliance
with policies and protocols and to monitor the
frequency and severity of pressure injury. This
information can be used to improve practice.
Engaging with patients and carers
Patients and carers should be educated about
pressure injury risks and prevention strategies and
engaged in the development of pressure injury
prevention and management plans.
In order to prevent and manage pressure injuries,
patients and carers should be engaged in the
process immediately and involved in risk
assessment and development of a prevention plan.
You should consider the following when discussing
pressure injury prevention and management with
patients and carers:

maintaining the patient’s independence

providing relevant, easy to understand
information

offering information in languages other
than English and not assuming literacy

working with the patient and carer to
facilitate realistic goals

engaging family members to assist in
pressure injury prevention strategies

exploring and addressing barriers that
make it hard for patients to prevent
pressure injuries
Preventing and Managing Pressure Injuries

utilising pressure injury prevention posters
in ward areas

ensuring pressure injury prevention
strategies are included as part of patient
discharge information
ACSQHC, 2009; 2012
General strategies that assist in maintaining
patient’s skin integrity are outlined in Skin Care
and You (2012), a free booklet which may be
downloaded from the Connected Wound Care
website.
Reporting adverse events
All pressure injuries should be reported to the
nurse in charge, the attending medical officer and
be documented in the clinical record. They should
also be reported in your organisation’s risk or
incident management system. This includes
pressure injuries that the patient has on admission.
Patients and carers should be fully informed of any
pressure injuries and the organisation’s open
disclosure processes implemented.
Risk and incident information trends can then be
used to inform quality improvement activities such
as system, policy, protocol and equipment
improvements and education and training
activities.
ACSQHC, 2012
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Summary
Preventing and managing pressure injuries is the
focus of Standard 8 in the National Safety and
Quality Health Service Standards.
The key messages are:
1. Most pressure injuries can be prevented.
2. They can occur in any patient, whether
that patient has only some or all risk
factors.
3. Best practice in pressure injury prevention
includes:

vigilant screening

comprehensive assessment

implementing pressure injury
prevention strategies

evaluating effectiveness of pressure
injury prevention strategies

engaging patients in their own
pressure injury prevention program
4. All patients should be screened for risk of
pressure injury using a validated screening
tool.
5. Risk screening and assessment should
occur on presentation, as soon as possible
after admission (within 8 hours) and
should also be repeated whenever there is
a change in condition.
consultation with the patient and carer, to
enable sharing of information.
9. Pressure injury prevention and
management strategies include skin
protection, repositioning, optimising
nutrition and hydration and provision of
support surfaces.
10. Risk status and pressure injury prevention
plans should be documented and
communicated during clinical handover
and on transfer or discharge in order to
ensure awareness by all clinicians and the
patient and carer.
11. A comprehensive assessment of any
pressure injury is required to develop a
management plan to enable ongoing
monitoring and effective wound healing.
12. The management of pressure injuries
requires an evidence based approach
which may change dependent on the
location, type and severity of the pressure
injury.
13. All pressure injuries should be reported in
your organisation’s risk or incident
management system.
6. A comprehensive skin assessment is
required for patients who are at high risk
of developing pressure injuries. This
should occur on admission and daily
thereafter.
7. Any reduction in a patient’s ability to
change their own body position will
increase a patient’s risk of developing
pressure injuries.
8. The findings from risk screening and
comprehensive skin assessments should be
used to develop a pressure injury
prevention management plan in
Preventing and Managing Pressure Injuries
15
Glossary of terms
SKIN INTEGRITY
Skin that is whole, intact and undamaged is said to
have ‘integrity’. Skin integrity is vital to our well
being and is usually taken for granted until it is
damaged or shows signs of ageing.
ERYTHEMA
Redness of the skin caused by dilation and
congestion of capillaries which can often be a sign
of inflammation or infection.
AWMA, 2012
AWMA, 2012
PRESSURE INJURY
A localised injury to the skin and/or underlying
tissue, usually over a bony prominence, as a result
of pressure, or pressure in combination with shear
and friction.
AWMA, 2012
PRESSURE INJURY RISK ASSESSMENT
A detailed and systematic process used to identify
a person’s risk factors related to pressure injury. It
is used to help identify which interventions to
implement to reduce the likelihood of a pressure
injury occurring.
ACSQHC, 2009
SCREENING
A process that primarily aims to identify people at
increased risk.
ACSQHC, 2009
BLANCHING ERYTHEMA
Reddened skin that blanches white under light
pressure.
AWMA, 2012
Preventing and Managing Pressure Injuries
INDURATION
An abnormally hard spot or place.
AWMA, 2012
SHEAR
A mechanical force that causes the body to slide
against resistance between the skin and a contact
surface.
AWMA, 2012
FRICTION
A mechanical force that occurs when two surfaces
move across one another, creating resistance
between the skin and contact surface.
AWMA, 2012
MOISTURE
Moisture alters resilience of the epidermis to
external forces by causing maceration, particularly
when the skin is exposed for prolonged periods.
Moisture can occur due to spilt fluids,
incontinence, wound exudate and perspiration.
AWMA, 2012
16
Test Yourself
1. Refer to the summary of the National Pressure Ulcer Advisory Panel (NPUAP) and the European Pressure
Ulcer advisory Panel (EPUAP) classification and staging system for pressure injury:
a) Describe the features of a stage 2 pressure injury
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
b) Describe the features of an unstageable pressure injury
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
2. Fill in the gaps:
a) Risk screening and assessment should occur on presentation, as soon as possible after ___________
(within ___ hours) and should also be repeated whenever there is a change in ___________.
b) A comprehensive skin assessment should include a complete head to toe inspection of your patient’s
skin and hair observing: skin __________ , temperature, colour, __________ and skin turgor, any areas of
_____ or discomfort and for pressure damage relating to devices such as splints and anti embolic
_________.
c) Prevention and management of pressure injuries involves the clinician protecting the patient’s ______,
_____________ the patient regularly, optimising ____________ and hydration and providing __________
surfaces.
d) Signs of pressure injury development include: erythema, ___________ response, localised _______,
oedema, ____________ and skin breakdown.
Preventing and Managing Pressure Injuries
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Answers
1.
a) Stage 2: partial thickness skin loss of dermis. Shallow, open ulcer; red/pink wound bed; open or
ruptured blister.
b) Unstageable: full thickness tissue loss. Base of ulcer covered with slough or eschar. Unable to
determine depth or stage. Potential for deep injury
2.
a) admission, 8, condition
b) integrity, moisture, pain, stockings
c) skin, repositioning, nutrition, support
d) blanching, heat, induration
Preventing and Managing Pressure Injuries
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References
Australian Commission on Safety and Quality in Health Care (2012) Safety and Quality Improvement Guide:
Standard 8: Preventing and Managing Pressure Injuries Sydney: Commonwealth of Australia. Accessed
12.10.13 at http://www.safetyandquality.gov.au
Australian Commission on Safety and Quality in Health Care (2013) Preventing and Managing Pressure
Injuries Standard 8: Fact Sheet. Sydney: Commonwealth of Australia
Australian Wound Management Association.(2012) Pan Pacific Clinical Practice Guidelines for Prevention
and Management of Pressure Injury, Cambridge Media Osborne Park. WA 2012. Accessed at:
http://www.awma.com.au/publications/2012_AWMA_Pan_Pacific_Guidelines.pdf
Australian Wound Management Association. (2011) Standards for Wound Management. 2nd edition.
Accessed at: http://www.awma.com.au/publications/2011_standard_for_wound_management_v2.pdf
Crowe, T., and Brockbank, C. (2009). Nutrition therapy in the prevention and treatment of pressure ulcers.
Wound Practice and Research, 17(2)
Improving Care of the Older Person: Best Care for the Older Person everywhere – The toolkit (2007) Access
through www.health.vic.gov.au/older
Hess, C. T. (2010) Performing a Skin Assessment. Nursing 2013, 40(7)
Skin Care and You (revised 2012) Connected Wound Care Project Accessed on 5.1.2013 at:
ww.grhc.org.au/vic-wound-man-cnc-project/connected-wound-care-project
Resources
Regional Wounds Victoria
The Regional Wounds Victoria nurse consultants work collaboratively with staff in Home and Community
Care funded District Nursing Services and high level care Public Sector Residential Aged Care Services to
improve wound management practices and ultimately the outcomes for individuals in rural Victoria.
Regional Wounds Victoria is supported by funding from the Commonwealth and Victorian Governments
under the HACC program. http://www.grhc.org.au/vic-wound-man-cnc-project
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