What nursing and physical therapy strategies can prevent pressure sores and complications in an 11-year-old patient with an explosive injury, resulting in a posterior flap from foot to thigh, fragile and raw buttocks area, bilateral femur fractures, and an external fixator on the right leg?

From the Guidelines

To prevent pressure sores and complications in this 11-year-old patient with extensive injuries, implement a comprehensive turning schedule of every 2-4 hours, as recommended by the French guidelines for the management of patients with spinal cord injury or at risk of spinal cord injury 1. This schedule should alternate between supine, left side-lying (30° angle), and prone positions as tolerated, avoiding pressure on the injured right leg. Use a pressure-redistributing mattress such as an air-fluidized or alternating pressure mattress, and elevate the heels completely off the bed surface with pillows placed under the calves. Perform meticulous wound care with gentle saline cleansing and appropriate dressings such as hydrocolloids or foam dressings for the posterior flap area, following the surgeon's specific protocol. Some key points to consider in wound care and pressure sore prevention include:

• Early mobilisation as soon as the spine is stabilised 1
• Visual and tactile checks of all areas at risk at least once a day 1
• Repositioning every 2-4 hours with pressure zone checks 1
• Use of tools for discharge (cushions, foam, pillows) to avoid interosseous contact (knees) 1
• Use of high-level prevention supports (air-loss mattress, dynamic mattress) 1 Maintain optimal nutrition with 1,500-2,000 calories daily including 1.5-2 g/kg of protein, supplemented with multivitamins and minerals, particularly zinc and vitamin C to support wound healing. Implement pain management with scheduled acetaminophen (15 mg/kg every 6 hours) and as-needed opioids like morphine (0.05-0.1 mg/kg IV every 2-4 hours), coordinating pain control before position changes or wound care. Monitor skin condition hourly, documenting any changes in color, temperature, or integrity, with particular attention to bony prominences and areas around the external fixator pins. Keep the skin clean and dry, using pH-balanced cleansers and applying moisturizers to intact skin. Maintain proper pin site care for the external fixator with daily cleaning using chlorhexidine solution and sterile technique. Early mobilization with physical therapy should begin as soon as medically cleared, starting with gentle range of motion exercises for unaffected joints and progressing to weight-bearing activities as permitted. These interventions work together to maintain skin integrity by reducing pressure, shear, and friction forces while supporting the body's healing processes through optimal nutrition and wound care. It is also important to consider the patient's overall condition and the presence of any underlying conditions that may affect wound healing, such as diabetes or vascular disease, and to involve a multidisciplinary team in the patient's care, including nurses, physical therapists, and surgeons, to ensure comprehensive management of the patient's condition 1.

From the Research

Nursing Strategies to Prevent Pressure Sores

• Identify patients at risk and implement specific prevention measures, such as following a patient repositioning schedule and using pressure-reducing surfaces 2
• Keep the head of the bed at the lowest safe elevation to prevent shear 2
• Assess nutrition and provide supplementation if needed 2
• Use dressings that keep the wound bed continuously moist and do not damage viable tissue, such as polyurethane film dressings for type 1 sores and hydrocolloid or alginate dressings for deeper ulcers 3, 4

Physical Therapy Strategies to Prevent Pressure Sores

• Regularly reposition the patient to reduce pressure on vulnerable areas 2
• Use physical therapy techniques to improve mobility and reduce immobility-related complications 2
• Consider using specialized equipment, such as airwave systems or polystyrene bead bed systems, to reduce pressure on vulnerable areas 3

Management of Established Pressure Sores

• Treat the underlying medical condition(s) and attend to hydration and nutrition 3
• Prevent further tissue trauma and use special dressings and procedures to facilitate the inflammatory repair response 3
• Consider using topical agents, such as insulin, to promote wound healing 5
• Debridement of necrotic tissue may be necessary, and can be performed autolytically, mechanically, enzymatically, or sharply 3, 6

Specific Considerations for the 11-Year-Old Patient

• The patient's age and explosive injury may increase the risk of pressure sores, and careful monitoring and prevention strategies are necessary 2
• The use of an external fixator on the right leg may also increase the risk of pressure sores, and regular repositioning and monitoring are necessary to prevent complications 2
• The patient's posterior flap from foot to thigh and buttocks area feeling raw and fragile may require specialized wound care and dressing to promote healing and prevent further tissue damage 3, 4