International

Guidelines in

PracticePAM MITCHELL, DIP.N. PG DIP WHTR (WALES), M.N.

CLINICAL NURSE CONSULTANT (WOUND MANAGEMENT)

CDHB

NZWCS REP ON GUIDELINE GOVERNANCE GROUP

www.internationalguideline.com

Quick Reference Guide

and / or Flow Chart

Neonates who require Respiratory

Support

• Rec 1.19

Skin maturity, perfusion and oxygenation, medical devices (SoE B1, SoR ↑ ↑)

1.20

Illness severity and duration of stay in critical care (SoE B2, SoR ↑)

Medical Devices - Oxygen delivery

systems

8.1: To reduce the risk of medical device related pressure injuries, review and select medical devices withconsideration to:• The device’s ability to minimize tissue damage• Correct sizing/shape of the device for the individual• Ability to correctly apply the device according to manufacturer’s instructions• Ability to correctly secure the device.

(SoE, C; SoR, ↑↑)

Rec 8.6

If appropriate and safe, alternate the

oxygen delivery device between

correctly fitting mask and nasal prongs

to reduce the severity of nasal and

facial pressure injuries for neonates

receiving oxygen therapy.

SoE B1 SoR ↑

New Hospital Standard MattressesORGANISATION RESPONSIBILITY AND EDUCATION

Support surface Rec 7.4

Use a high specification single

layer foam mattress or overlay in

preference to a foam mattress

without high specification

qualities for people at risk

SoE B1 SoR

20.6

Engage all key stakeholders in oversight

Implementation of the quality improvement

program to reduce the incidence of pressure

injuries. (SoE B1; SoR ↑↑)

20.7

Include evidence-based policies, procedures and

protocols

Standardized documentation systems as part of a

quality improvement plan to reduce the incidence

of pressure injuries. (SoE B1; SoR ↑↑)

20.8

Provide clinical decision support tools as

part of a quality improvement plan to

reduce the incidence of pressure injuries. (SoE

B1; SoR ↑↑)

20.10 At a professional level

Provide education in pressure injury

prevention and treatment as part of a

quality improvement plan to reduce the

incidence of pressure injuries. (SoE A; SoR↑↑)

Patient Assessment for skin

tolerance

2.1: Conduct a comprehensive skin and tissue

assessment for all individuals at risk of pressure injuries:

● As soon as possible after admission/transfer to the healthcare service

● As a part of every risk assessment

● Periodically as indicated by the individual’s degree of pressure injury risk

● Prior to discharge from the care service.

(Good Practice Statement)

Assessing Different Skin tones

Rec 2.7

For darkly pigmented skin, consider skin temperature and sub-epidermal moisture

(SoE B2, SoR↑)

Rec 2.8

For darkly pigmented skin, consider skin tone assessment using color chart (SoE B2, SoR↔)

Assessing Different Skin tones Darkly Pigmented

pppia.org

Asian Skin tones

pppia.org

2.3 Differentiate Erythema

Differentiate blanchable

from non-blanchable

erythema using either

finger pressure or the

transparent disk method

and evaluate the extent

of erythema

SoE B1 SoR ↑↑

Erythema , Temperature,

Consistency, Oedema Rec 2.4

Assess the temperature of

skin and soft tissue (e.g.,

thermography) (SoE B1,

SoR↑↑)

2.5

Assess oedema and

assess for change in tissue

consistency in relation to

surrounding tissues

GPS

7.1 Select a support surface that meets the

individual’s need for pressure redistribution

based on the following factors:

• Level of immobility and inactivity

• Need to influence microclimate control and

shear reduction

• Size and weight of the individual

• Number, severity and location of existing

pressure injuries

• Risk for developing new pressure injuries.

GPS

Support Surfaces

Documentation of all these steps

and rationale to you

Consistent care

Monitor Progress or deterioration

Ongoing Risk assessment

Is the Programme Working?

20.11

Regularly monitor, analyze and evaluate

performance against quality indicators for pressure

injury prevention and treatment. B1 ↑↑

20.12

Use feedback and reminder systems to promote

the quality improvement program and its

outcomes to stakeholders. B2 ↑

In Summary

Improve your Practice by knowing the Guidelines

and use their content to expand and complement

your own knowledge

Improve your health system, organisation and facility

by Using The International Guideline – let evidence

supports your proposals for change

References

ACC, MOH and HQSC. Guiding Principles for Pressure Injury

Prevention Management in New Zealand. 2017.

European Pressure Ulcer Advisory Panel, National Pressure Injury

Advisory Panel, and Pan Pacific Pressure Injury Alliance. Prevention

and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline.

The International; Guideline. Emily Haesler (Ed.). EPUAP/NPIAP/PPPIA:

2019.

https://pppia.org