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Course: Pediatric Nursing

Topic: Nursing Care of Child with Integumentary Disorders Part IV

The Nurses International Community

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Module Goals

Learners will be able to:

Define pressure injuries.
Identify common pressure areas in the body.
Discuss signs and symptoms of pressure injuries.
Describe classification of pressure injuries.
Explain nursing interventions for prevention of pressure injuries.

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Pressure Injuries (Pressure Sores/Bedsores)

“A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear.”

-The National Pressure Ulcer Advisory Panel (NPUAP), the European Pressure Ulcer Advisory Panel (EPUAP) and Pan Pacific Pressure Injury Alliance (PPPIA)

Garcia Monilla et. al., 2017

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Pressure Injuries: Locations

Commonly found at bony prominences of the body

Back of the head (especially in infants and toddlers) and ears
Sacrum/coccyx (tailbone), hips and buttocks
Heels and elbows
Spine and shoulder blades
Beneath plasters, casts, splints or braces
Around medical equipment (e.g. tubes, masks, drains etc).

Children’s Health Queensland Hospital and Health Service, 2020

The Royal Children’s Hospital Melbourne, 2018

Contact info: info@nursesinternational.org

Risk factors for pediatric and neonatal populations are similar to those for adults admitted to critical units
The main risk factors at neonatal age are the use of therapeutic and diagnostic devices (50–90% of the pressure ulcers (PU) in neonates)
Presence of endotracheal tube, use of noninvasive mechanical ventilation, hypotension and hypoxemia, prolonged stay in the neonatal intensive care unit (NICU), low birth weight (<2500 g) and prematurity (<37 weeks of GA)
The most frequent locations of PUs in neonates are:

the occipital region and ears as well as anatomical areas where therapeutic or diagnostic systems are at risk, such as fingers and feet (pulse oximetry sensor), skin support areas (vascular catheters), thorax (electrodes), ear lobe (capnaptic clamp sensor), nasal septum, back of the neck, nostrils and cheeks (continuous positive airway pressure interface, both binaural cannulae and face mask).

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Pressure Injuries: Sign and Symptoms

Erythema (redness of the skin)
Blue or purple areas (in darker skin)
Blistering
Broken skin
Pain

The The Royal Children’s Hospital Melbourne, 2018

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Pressure Injuries: Classification

Stage 1: A non-blanching erythema is produced on intact skin
Stage 2: A partial loss of skin thickness or blisters may appear
Stage 3: A total loss of skin thickness
Stage 4: A total loss of tissue thickness with exposed muscle or bone

Garcia et al.,2017

The Joint Commission, 2016

Grada & Phillips, 2021

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Pressure Injuries: Classification

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Pressure Injuries: Classification (Continued)

Unstageable:

Full-thickness skin and tissue loss in which the extent of tissue damage cannot be determined because it is obscured by debris, slough, or eschar.

Deep-tissue pressure injury:

Intact or non intact skin with a localized area or persistent, nonblanchable, purple to maroon discoloration and blood-filled vesicles
May feel firm, ‘boggy’ (soft), warm, or cool compared with surrounding tissue

Garcia et al.,2017

The Joint Commission, 2016

Grada & Phillips, 2021

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Pressure Injuries: Classification (Continued)

Medical device–related pressure injury:

Prolonged use of poorly placed or ill-fitted medical devices.

Mucosal membrane pressure injury:

Appears on mucous membranes where medical devices have been used (i.e. misfitting dentures or endotracheal tubes).

Garcia et al.,2017

The Joint Commission, 2016

Grada & Phillips, 2021

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Case Study/ Critical Thinking Question/ What Would the Nurse Do?

A nurse is caring a child who is bedridden for multiple fractures secondary to motor vehicle accidents.

On skin assessment, the nurse notices tiny blisters on hip area. �

What degree of the ulcer has the child developed?

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Pressure Injuries: Prevention

Risk assessment
Skin care
Nutrition
Positioning and mobilization
Support surfaces

Garcia et al.,2017

The Joint Commission, 2016

Delmore, et al., 2019

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Prevention: Risk Assessment

Requires an ongoing risk assessment
Use a structured risk assessment tool to identify risk as early as possible
Repeat the assessment on a regular basis and address changes as needed
Develop a plan of care based on the risk assessment
Prioritize and address identified issues

Garcia et al., 2017

The Joint Commission, 2016

The Royal Children Hospital Melbourne, 2022

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Prevention: Risk Assessment (Continued)

Glamorgan Scale, The Royal Children Hospital

Melbourne, 2022

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Prevention: Risk Assessment (Continued)

Glamorgan Scale, The Royal Children Hospital

Melbourne, 2022

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Prevention: Risk Assessment (Continued)

Head to toe assessment on admission and every 12 to 24 hours (in high risk areas)

Assess and document high risk factors:

Limited mobility (with a spinal cord injury)
Previous or current pressure injury (PI)
Nutritional deficiency
Cognitive impairment

Garcia et al., 2017

The Joint Commission, 2016

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Case Study/ Critical Thinking Question/ What Would the Nurse Do?

A nurse identifies a bedridden child is at the higher risk of developing pressure ulcer. What kind of electronic device would the nurse consider for the child?

SCD pumps
Air Mattress
Foot drop splint
DVT stockings

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Prevention: Optimal Skin Care

Maintain skin integrity
Avoid excess moisture

Use of products that prevent, absorb, or diminish further damage may decrease risk of pressure injury
Routine use of petroleum-based products or products with zinc oxide is recommended for dermatitis and ‘crusting’

Garcia et al., 2017

The Joint Commission, 2016

Delmore, et al., 2019

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Prevention: Optimal Skin Care

A percutaneous gastrostomy tube may require the use of a foam dressing for protection and absorption

Most common dressings in pediatric PI management include hydrocolloids, hydrogels, polyurethane foams, and transparent films
Gentle dressings or adhesives (i.e. tape) with silicone are generally recommended

Delmore, et al., 2019

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Prevention: Optimal Skin Care

Avoid massaging red or bony areas of the body, since pulling or stretching the skin may cause more damage
If the child is wearing diapers or continence aids, change them as soon as they become soiled
Change positions regularly if unable to move independently (every two hours during the day, and every four hours at night)

Garcia et al.,2017

Child Health Queensland Hospital and Health Service,2020

Delmore, et al.,2019

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Prevention: Nutrition

Evaluate the nutritional status in children with high risk of pressure injuries using parameters (height/weight, cranial perimeter, body mass index).
Initiate parenteral or enteral nutrition when malnutrition risk is identified.
Encourage breastfeeding or bottle feeding.
Refer at-risk children to a registered dietitian or nutritionist.

Garcia et al.,2017

The Joint Commission, 2016

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Prevention: Support Surfaces

Provide a low-friction interface to reduce shear
Air cell mattresses

Provide superior protection against increased soft tissue deformation around a misplaced tube in NICU and PICU populations compared with foam mattresses.

Delmore, et al., 2019

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Prevention: Positioning and Mobilization

Turn and reposition high risk children (if no contraindications) at scheduled frequencies
Consider the use of pressure-relieving devices

Child Health Queensland Hospital and Health Service,2020

The Joint Commission, 2016

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Nurse’s Role

Perform pressure injury risk assessment
Provide adequate nutrition and hydration
Provide education to client and family
Ensure moisture control and skin care
Maintain mobility and positioning
Prevent medical device-related injuries

The Royal Children’s Hospital Melbourne, 2022

Contact info: info@nursesinternational.org

Assessment:

Complete a general visual check of the skin including analysis of the entire skin surface to assess its integrity and identify any characteristics indicative of pressure damage.
Monitor and check the skin beneath dressings, prosthesis and devices when clinically appropriate.
Check for areas of localised heat, skin breakdown, edema, areas of redness that do not blanch and induration of the wound.

Nutrition and Hydration:

Malnourished children are at increased risk of pressure injury development due to their compromised ability to maintain healthy skin and mucosa. Hydration and nutritional support should be aimed at preventing and correcting these deficits
Children at risk should be offered frequent fluids and diet to maintain adequate nutrition and hydration
Children considered high risk or very high risk should follow the advice of the Paediatric Nutritional Screening Tool and be referred to a dietician for assessment.

Moisture control and skin care:

Keep the skin clean and dry

Clean skin daily to remove unwanted substances and allow to dry
Do not vigorously rub or massage the client’s skin
Use a pH neutral or slightly acidic skin cleanser (pH 4-7) ~ Alkaline products (pH >7) should be avoided.

Preventing Medical devices pressure injuries:

Regular repositioning and inspection of the child to ensure that they are not unintentionally lying on devices
Conduct more frequent assessments at the skin-device interface in children vulnerable to fluid shifts and exhibiting localised or generalised edema
Use the correct size equipment suitable to the client’s anatomical size
When equipment is secured using tapes, ensure that they are not applied too tightly and that where possible they have some elasticity and stretch
Use the minimal amount of strapping or tape to safely secure the device to allow for maximal visualization of the client’s skin
Devices that are unable to be easily repositioned should be managed with appropriate dressing and skin care

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Case Study

A adolescent who has fractured his both leg and is bed ridden asks the nurse how nutrition and skin integrity are related. Which response should the nurse make that explains the relationship?

“More intake of carbohydrates and minerals can cause pressure injuries."
"Increased intake of protein and carbohydrates can cause pressure injuries."
"Poor intake of kilocalories, protein, and iron increase the risk of pressure injuries."
"Poor intake of green vegetables and fruits can increase the risk of pressure injuries."

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Red Flags

Skin assessment findings

Erythema
Blue or purple areas (in darker skin)
Blistering
Broken skin
Unexplained bruising or injuries at various stages of healing

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Cultural Considerations

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Health beliefs: In some cultures talking about a possible poor health outcome will cause that outcome to occur.
Health customs: In some cultures family members play a large role in health care decision-making*.
Ethnic customs: Differing gender roles may determine who makes decisions about accepting & following treatment recommendations.

AHRQ, 2020

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Cultural Considerations (Continued)

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Religious beliefs: Faith and spiritual beliefs may affect health seeking behavior and willingness to accept treatment.
Dietary customs: Dietary advice may be difficult to follow if it does not fit the foods or cooking methods of the family.
Interpersonal customs: Eye contact or physical touch may be ok in some cultures but inappropriate or offensive in others.

AHRQ, 2020

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References:

Delmore, B. et al. (2019).Pressure Injuries in the Pediatric Population: A National Pressure Ulcer Advisory Panel White Paper. Advances in Skin & Wound Care: September, Volume 32 - Issue 9 - p 394-408. https://journals.lww.com/aswcjournal/Fulltext/2019/09000/Pressure_Injuries_in_the_Pediatric_Population__A.5.aspx

Children’s Health Queensland Hospital and Health Service.(2020). Pressure injuries. https://www.childrens.health.qld.gov.au/fact-sheet-preventing-pressure-injuries/

Garcia Molina, P. et al. (2017). Neonatal pressure ulcers: prevention and treatment. Dove Press. 7. https://www.dovepress.com/neonatal-pressure-ulcers-prevention-and-treatment-peer-reviewed-fulltext-article-RRN

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References:

Grada, A. & Phillips, T. J. ( 2021). Pressure Injuries. MSD Manual. https://www.msdmanuals.com/professional/dermatologic-disorders/pressure-injury/pressure-injuries

The Joint Commission. (2016). Preventing Pressure Injuries. https://www.jointcommission.org/-/media/tjc/documents/newsletters/quick-safety-issue-25-july-2016-final-w-addendumrev.pdf?db=web&hash=1F752D2EE443567784ABE6E024792BB3&hash=1F752D2EE443567784ABE6E024792BB3

The Royal Children’s Hospital Melbourne. (2022). Pressure injury prevention and management.https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Pressure_injury_prevention_and_management/

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