Pediatric Skin Care: Guidelines for Assessment, Prevention, and TreatmentColleen T. Butler  Pediatr Nurs.  2006;32(5):443-450.  ©2006 Jannetti Publications, Inc.Posted 12/19/2006

Abstract and Introduction

Abstract

The review of literature suggests the pediatric population is at risk for skin breakdown and therefore pressure ulcer development. The literature reveals limited information on pediatric skin care issues in comparison to the adult population. The prevention and treatment of pressure ulcers and maintenance of skin integrity in the pediatric population often is not a high priority especially in the critically ill child. Research has demonstrated that children differ from adults in the anatomical sites of skin breakdown; however, treatment remains the same. It is important to have an understanding of the underlying physiology of ulcer formation, the factors responsible for ulcer development, and the factors that put infants and children at risk for developing pressure ulcers. Accurate assessment, documentation, prevention, and treatment are all key factors.

Introduction

The prevention and treatment of pressure ulcers and maintenance of skin integrity in the pediatric population often is not a high priority, especially when caring for the critically ill child. Pressure ulcers are often considered a problem in the adult population; however, research shows that pressure ulcers do occur in the pediatric population. An abundance of nursing research exists on the incidence, prevalence, and cost of pressure ulcer prevention and management in adults (Quigley & Curley, 1996). The available pediatric skin care literature has been based on the adult research in the attempt to meet the special needs of the pediatric population.

Prevention and management of pressure ulcers is multifaceted. One must understand the underlying physiology of ulcer formation, the factors responsible for ulcer development, and the factors that put infants and children at risk for developing pressure ulcers. Accurate assessment, documentation, prevention, and treatment are all important factors.

The skin is an organ that forms a protective barrier against bacteria, chemicals, and physical action, while maintaining a homeostatic internal environment (Bryant, 2000). The largest organ of the body, the skin receives one third of the body's circulating blood. The skin serves many functions: protection, immunity, thermoregulation, metabolism, communication and identification, and sensation. The skin consists of four layers: the epidermis, dermis, subcutaneous fat, and muscle (see Figure 1). In the outermost layer, the epidermis, dead skin cells are constantly being shed and replaced. The dermis, or second layer, has sweat glands, blood vessels, nerve endings, and capillaries, which are all woven together to provide nourishment and support. Destruction to either the epidermis or the dermis can cause systemic infection (Pallija, Mondozzi, & Webb, 1999).

Figure 1. 

The Four Layers of the SkinSource: KCI's Pressure Ulcer Assessment Tool, 2002. Used with permission.

     

Pressure Ulcer Development

According to the National Pressure Ulcer Advisory Panel (NPUAP), a pressure ulcer is defined as a localized area of tissue destruction that develops when soft tissue (muscle, fat, fibrous tissue, blood vessels, or other supporting tissue of the body) is compressed between a bony prominence and an external surface, for a prolonged period of time (Quigley & Curley, 1996). An ulcer forms when arterioles and capillaries collapse under this external pressure (Bryant, 2000). With the compression of these vessels, the blood that nourishes the cells is cut off, resulting in a limited oxygen supply and a decrease in the transportation of vital nutrients to the cells. These two factors result in tissue hypoxia, causing cellular death, injury to the surrounding area, and ultimately, a pressure ulcer (Pallija et al., 1999). Factors that have been identified as responsible for ulcer development include intensity and duration of pressure, and the tolerance of the skin and supporting surfaces (including soft tissue) to endure the effects of pressure without incidence. De creased mobility, activity, and sensory perception contribute to the intensity and duration of pressure (Quigley & Curley, 1996). Supracappilary pressures cause occlusion of the capillary bed. This pressure leads to the development of localized tissue ischemia, leading to cellular death and tissue necrosis. Increased pressure, over short periods of time and slight pressure for long periods of time, has been shown to cause equal damage (Neidig, Kleiber, & Oppliger, 1989).

Tissue tolerance includes both intrinsic and extrinsic factors. Intrinsic factors include nutrition, tissue perfusion, and oxygenation. Tissue ischemia and damage occur when cells are deprived of oxygen and nutrients, combined with an accumulation of metabolic waste products for a specific period of time. Inadequate nutrition is one of the major risk factors associated with the development of pressure ulcers. Children must be given adequate nutrients to reduce the risk of developing pressure ulcers and to support healing. To achieve this, nutritional support should be designed to prevent or correct nutritional deficits, maintain or achieve positive nitrogen balance, and restore or maintain serum albumin levels. Nutrients that have received primary attention in the prevention and treatment of pressure ulcers include protein, arginine, vitamin C, vitamin A, and zinc (Novartis Nutrition Corporation, 2006).

Extrinsic factors that support healing and reduce the risk of pressure ulcers include: moisture, friction, and shear. Skin injured by friction, two surfaces rubbing together, has the appearance of an abrasion. Typically this type of superficial injury is seen on heels and elbows, resulting from repositioning. Shearing force, such as movement on a bed sheet,

creates occlusion by laterally displacing the tissue. Bones move against the subcutaneous tissue, while the epidermis and dermis remain, essentially, in the same position against the supporting surface. This causes a decrease in blood flow to the skin, eventually leading to breakdown (Neidig et al., 1989). Moisture macerates the surrounding skin, causing superficial erosion of the epidermis. Primary sources of skin moisture include perspiration, urine, feces, and drainage from wounds or fistulas.

Risk Factors

Limited information exists regarding the identification of risk factors associated with skin breakdown in the pediatric patient in comparison to those found in the adult literature. However, risk factors that have been identified in the adult population include:

immobility neurological impairment impaired perfusion decreased oxygenation poor nutritional status presence of infection moisture acidemia vasopressin therapy surgery hypovolemia

weight It can be assumed that many of these factors would affect the pediatric population, similarly; however, limited research exists at this time.

Review of Literature

A study conducted with postoperative cardiac patients identifies three risk factors for skin breakdown in the critically ill child. These factors include age, length of intubation, and length of stay in the intensive care unit (Neidig et al., 1989). The relationship between age and pressure ulcer formation is due, primarily, to the disproportionately large head, in comparison to body size, in infants and children. In children younger than 36 months, the head constitutes a greater portion of the total body weight and surface area. When children are positioned supine, the occipital region becomes the primary pressure point. Limited hair growth and less subcutaneous tissue contribute to increased susceptibility to the effect of pressure and shearing forces, often leading to pressure-induced alopecia. Vigorous side-to-side movement of the head, as a result of agitation, also increases the shearing force and friction being applied to the head.

Length of intubation plays a significant role in the development of pressure ulcers for several reasons. First, the primary goal is to protect the child's airway. This sometimes means restricting movement and immobilizing the child's head. The use of sedation and paralyzing agents also plays a role in reducing spontaneous body movements. Unless the child's position is changed regularly, the head experiences periods of prolonged pressure. Changing positions can be difficult for the child on extracorporeal membrane oxygenation (ECMO) or oscillatory ventilation. Finally, length of intubation becomes a factor when sedation and ventilator settings are being weaned, contributing to weaning agitation. Again, frequent vigorous side-to-side movement of the head, as a result of agitation, causes friction and shear (Neidig et al., 1989).

A retrospective cohort study of 32 patients, supported with high frequency oscillatory ventilation (HFOV), paired with 32 patient on conventional ventilation in a pediatric intensive

care unit (PICU), conducted by Schmidt, Berens, Zollo, Weisner, and Weigle (1998), investigated the relationship of HFOV to skin breakdown on the scalp and ears in mechanically ventilated children. Results indicate a higher incidence of skin breakdown in children ventilated with HFOV than those ventilated with a conventional ventilator (53% versus 12.5%). However, after the data analysis, it was determined that PICU time at risk was the most important risk factor for the development of skin breakdown in this population.

Zollo, Gostisha, Berens, Schmidt, and Weigle (1996) conducted a prospective, matched-case study in a 14- bed PICU in a tertiary care children's hospital. Subjects were assessed, daily, for a change in skin integrity. Data were collected on 76% of all admissions to the PICU. Zollo and colleagues concluded that skin breakdown was affected by many factors; however, the strongest predictors of pressure ulcers were the Pediatric Risk of Mortality Score (PRISM) completed on admission to the PICU, and White race. The Pediatric Risk of Mortality score is used to calculate the risk of mortality for patients admitted to pediatric intensive care units. It consists of 14 routinely measured, physiologic variables, and 23 variable ranges. These variables include systolic blood pressure, diastolic blood pressure, heart rate, respiratory rate, PaO2/ FI O2, PaCO2, PT/PTT, total bilirubin, calcium level, potassium level, glucose, HCO3, pupillary reactions, and Glasgow coma score (Pollack, Ruttimann, & Getson, 1988).

Children with spina bifida and spinal cord injuries were tracked over four years at Children's Hospital Medical Center of Akron. Pallija and colleagues (1999) identified 11 risk factors associated with skin breakdown in children with spina bifida and spinal cord injuries: (a) urticaria, (b) obesity, (c) edema, (d) trauma, (e) surgical incision, (f) paralysis, (g) insensate areas, (h) immobility, (I) poor nutrition, (j) incontinence, and (k) impaired cognition.

Samaniego (2003) conducted a retrospective exploratory study at an outpatient wound clinic. The principal diagnoses, identified in the sample, were myelodysplasia (60%), cerebral palsy (16%), and clubfeet (6%); also included were scoliosis, constricted band syndrome, and femoral deficiency. Four primary risk factors were identified: paralysis, insensate areas, high activity, and immobility.

Research has demonstrated that children differ from adults in the anatomical sites of skin breakdown. Six prominent pressure points have been identified in the adult population: the sacrum/ coccyx, heels, elbows, lateral malleolus, the greater trochanter of the femur, and the ischial tuberosities (Meehan, 1994). In infants and children the areas that are affected are the occipital region (primary in infants), sacral region (primary in children), ear lobes, and calcaneous region (the heel of the foot) (Neidig et al., 1989). Baldwin (2002) conducted a national survey of children's health care institutions to determine the incidence and prevalence of pressure ulcers in children. In her study, the sacrum/coccyx was the most frequent site for pressure ulcers, heels the second and the occiput region.

Intervention and Prevention

Early intervention can be an effective preventative measure if patients at increased risk for pressure ulcer development are identified. The principal components for early intervention are (a) identification of at risk individuals, (b) maintenance and improvement of tissue tolerance to injury, (c) protection against the adverse effects of pressure, friction, and shear, and (d) reduction of the incidence of pressure ulcers through an educational program.

Prevention is a multifaceted process. Again, much of the research has been conducted on the adult population, but it can easily be applied to pediatrics. Pressure ulcer prevention begins with accurate assessment to identify an at-risk patient. Various tools exist for assessing adults, and recently the Braden scale, frequently used in adults, has been adapted into the Braden Q scale for pediatrics. Sandra Quigley and Martha Curley developed this scale in 1996. Changes from the original Braden scale reflect the unique developmental needs of the pediatric patient, the prevalence of gastric/transpyloric tube feedings, and the availability of blood studies and noninvasive technology in the acute-care pediatric setting

(Curley, Razmus, Roberts, & Wypij, 2003).

The Braden Q scale consists of seven subscales: mobility, activity, sensory perception, moisture, friction/shear, nutrition, and tissue perfusion/oxygenation. The first six originate directly from the Braden scale. Each subscale is rated one through four, with the lowest number representing the highest risk. Total scores range from 7-28 with seven putting a child at the highest risk for breakdown and 28 with no risk (see Table 1 ). In a multi-site prospective cohort descriptive study, Curley and colleagues (2003) studied 322 PICU patients on bedrest for at least 24 hours, without preexisting pressure ulcers or congenital heart defects. They found that acutely ill pediatric patients with a Braden Q score of 16 are considered at risk for Stage II pressure ulcers. The lower relative Braden Q scores that identify patients at risk for Stage II pressures may reflect a unique characteristic of pediatric skin. Younger skin, which has sufficient collagen and elastin, may be more resilient to normal and shearing pressures (Curley et al., 2003).

Early assessment of the risk factors associated with the development of pressure ulcers is essential in their prevention. When an assessment identifies this risk as high, interventions should be implemented to reduce the risk. Preventing mechanical injury to the skin from friction and shearing forces during repositioning and transfer activity is important. The key is to have a sufficient number of personnel available to move a patient. In pediatrics, most patients under 8 years of age can be lifted easily enough to prevent friction and shear. Assistive devices such as lifts, trapezes, transfer boards, or mechanical lifts may be useful adjunctive devices to minimize tissue injury. Remembering to lower the head of the bed, as much as tolerated before repositioning, also will help minimize friction and shear. Mechanical injury from friction can be reduced with application of a barrier dressing, such as transparent films or hydrocolloids, over at risk areas.

Interventions to reduce pressure over bony prominences are of primary importance. A turning schedule must be instituted for patients on strict bedrest. In a study of postoperative cardiac patients, a significant decrease in the incidence of occipital pressure ulcers was observed (16.9% to 4.8%) by instituting a prevention protocol of repositioning the head at least every two hours (Neidig et al., 1989). In addition to turning, heels should be suspended off the bed using pillows or heel lift devices, and the head of the bed should not be elevated for more than two hours to avoid shearing injury to the sacral area. A rolled up blanket is always useful under the patient's upper thighs, or the bottom of the bed can be elevated to reduce the chances of a patient sliding down in the bed. Of course, repositioning is not always an option before hemodynamic and respiratory stability is achieved. Other factors influencing the ability to reposition a patient include line placement, edema of the head and neck, or a positional air leak around the endotracheal tube.

Even with correct positioning methods, a therapeutic surface may need to be used (Bryant, 2000). Although a principal goal in nursing care is to reduce external forces of pressure, shear, friction, and moisture, to prevent or treat tissue injury, frequent turning may be contraindicated in unstable, critically ill children. Examples of such patients include a patient who is hemodynamically unstable, a patient with acute respiratory distress syndrome (ARDS) whose oxygen saturations may decrease with position change, or a patient on ECMO or high frequency oscillatory ventilation.

Another important factor that can reduce the risk of the development of pressure ulcers is the type of surface supporting the patient. The therapeutic benefit of a product and its ability to maintain skin integrity determines which type of surface will offer the best outcome. Airflow through the surface of a mattress will reduce moisture. The material used on the surface of a mattress or overlay will determine the product's ability to reduce friction and shearing. A therapeutic surface should reduce or relieve pressure, promote blood flow to the tissues, and enable proper positioning. The ability of a product to reduce or relieve pressure is determined by its interface and capillary-closing pressure measurements (Bryant, 2000). Capillary-closing pressure is the amount of pressure required to impede the flow of oxygen and blood to the tissues. In a study by Landis, where the microinjection method was used to determine blood

pressure in capillaries, 32 mmHg was found to be the average pressure in the arteriolar limb (Quigley & Curley, 1996). Interface pressure is the amount of pressure the resting surface places on the skin over a bony prominence. A pressure reduction mattress reduces pressure, although only to the standard of 32 mmHg, and should be used in patients with more than one turning surface, keeping in mind that the mattress will not provide consistent relief (Quigley & Curley, 1996). These mattresses/overlays lower pressure, compared to a standard hospital mattress; examples include: an eggcrate overlay, air-filled bed, or action bed overlay (also beneficial in reducing shear). A gel pillow is also beneficial under the occiput as a means to relieve pressure.

A pressure-relieving surface is one where pressures are consistently lower than 25mmHg. These surfaces are ideal for children with one turning surface and in need of consistent relief; an example of this is the use of a low air-loss bed, such as the PediaDyne and TriaDyne II beds (Kinetic Concepts, Inc., San Antonio, Texas). A low air-loss bed consists of a bed frame with a series of connected air-filled pillows. The amount of pressure in each pillow is controlled, and can be calibrated to provide maximum pressure reduction for an individual child (Bryant, 2000). The PediaDyne and TriaDyne II beds also offer percussion therapy and rotation. It is also important to note that when a child is on a specialty surface, turning every two hours, as tolerated, is still required for the best outcome.

Assessment and Documentation

Even in the best of circumstances, and with preventative measures in place, skin breakdown can still occur. Accurate assessment and documentation is an essential part of determining the course of treatment. According to Quigley and Curley (1996), "Assessment includes (a) anatomic location, (b) accurate staging, as defined by the NPUAP (1989), (c) size in centimeters (length up and down head to toe, width across and depth), (d) type of tissue at the wound base (including color red, yellow or black), (e) presence of exudate or odor, (f) presence and location of undermining or tunneling, (g) character of the wound margins, (h) condition of the periwound skin, and (I) dressing type" (pg.15).

Undermining is defined as tissue destruction beneath intact skin along wound margins. Tunneling can extend in any direction from the wound surface, resulting in "dead space," creating the potential for abscess formation if the area is not cleansed and packed correctly (Bryant, 2000). Quigley and Curley (1996) found that an optimal wound environment, according to Braden and Bryant, is free of nonviable tissue, clinical infection, dead space, excessive exudate, has a moist wound surface, is protected from bacterial contamination and reinjury, and provides pain relief.

Pressure ulcers are staged according to the NPUAP (1992). A stage I pressure ulcer is defined as an area of nonblanchable erythema of intact skin that does not resolve after 30 minutes of pressure relief and the epidermis is intact. In individuals with dark skin, discoloration of the skin, warmth, edema, and induration may also be indicators. Partial thickness skin loss involving the epidermis, dermis, or both is considered a stage II pressure ulcer. The ulcer is superficial and presents as an abrasion, blister, or shallow crater. A stage III ulcer is full thickness skin loss, involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, the underlying fascia. The ulcer presents as a deep crater, with or without undermining of adjacent tissue. Stage IV pressure ulcers are those with full thickness skin loss and involve extensive destruction, tissue necrosis, or damage to muscle, bone, or the supporting structure. Undermining or tunneling may also be present in a stage IV ulcer (see Figures 2-5).

Figure 2. 

Stage I Pressure UlcerSource: KCI's Pressure Ulcer Assessment Tool, 2002. Used with permission.

     

Figure 3. 

Stage II Pressure UlcerSource: KCI's Pressure Ulcer Assessment Tool, 2002. Used with permission.

     

Figure 4. 

Stage III Pressure UlcerSource: KCI's Pressure Ulcer Assessment Tool, 2002. Used with permission.

     

Figure 5. 

Stage IV Pressure UlcerSource: KCI's Pressure Ulcer Assessment Tool, 2002. Used with permission.

     

According to the NPUAP, it is also important to never reverse stage a wound. Pressure ulcers heal to a progressively more shallow depth; they do not replace lost muscle, subcutaneous fat, or dermis. A Stage IV ulcer cannot become a Stage III, Stage II or Stage I. When a Stage

IV ulcer has healed, it should be classified as a healed Stage IV pressure ulcer (NPUAP, 2000). It should be noted that an ulcer should never be staged if uncertainty exists about the stage. Instead, it is recommended that the wound be described. In describing a wound, it is important to refrain from sizing a wound using dime or quarter sizing; the wound should always be measured. Further, wounds not related to pressure, including partial or full thickness skin loss and burns, are never staged.

Superficial skin damage can also occur when adhesive products are used with any pediatric patient (although the chronically ill and critically ill are at an even higher risk). A skin tear or epidermal stripping is a partial thickness wound, involving tissue loss of the epidermis and possibly the dermis (Bryant, 2000). It is the inadvertent removal of these layers by mechanical means, such as tape removal. A skin tear may present as a broad wound, similar to an abrasion or as a narrow tear in the epidermis. It may be dry with little or no drainage, or have moderate drainage, depending on the location and the extent of epidermal involvement. Some skin tears also will have a viable skin flap; the treatment goal should be to avoid dislodging the flap. The flap should be positioned in an area that optimizes its chances of re-adhering to the wound bed. Dressing choice is important; a dressing should be used that will not stick to the area, such as a hydrogel. If the surrounding skin also is fragile, a dressing without an adhesive border should be considered and secured with a gauze roll. In patients where there is good surrounding skin integrity, a transparent film can be used if little or no drainage is present.

Skin tears or epidermal stripping, as well as tension blisters, can easily be avoided by proper skin preparation, choice of tape, and proper application and removal of tape. Stripping can occur when the adhesive bond between tape and skin is greater than between epidermis and dermis. As tape is removed, the epidermis remains attached to the tape, resulting in painful damage. Tension blisters are the result of tightly strapping the tape during application and distention of the skin underneath. Strapping is mistakenly thought to increase adhesion; however, as the tape resists stretching, the epidermis begins to lift, resulting in a blister at the end of the tape.

A key component to the prevention of skin tears/stripping is to recognize fragile, thin, vulnerable skin (Bryant, 2000). Careful and gentle care is important in routine patient care because most skin tears occur during this time. In addition, the current focus of prevention is on the application of products to serve as a barrier. Skin tears resulting from adhesion can be prevented by appropriate application and removal of tape, use of solid wafer skin barriers, thin hydrocolloids, low-adhesion foam dressings or skin sealant under adhesives, use of porous tapes, and avoidance of unnecessary tapes.

Wound Treatment

The key to properly treating a wound is having a basic sense of the wound healing process and understanding the various products available. For example, moist wounds heal faster than dry wounds. It is easier for a wound in a moist environment to granulate and for the cells to migrate across the wound bed. A moist environment also increases the effectiveness of white blood cells in fighting infection and removing cellular debris (Bryant, 2000). However, if a wound is draining heavily, an appropriate dressing should be used to contain the drainage.

Dressings can be categorized into four types: primary, secondary, occlusive, and semi-occlusive. A primary dressing is one that comes directly in contact with the wound bed. A secondary dressing is used to cover a primary dressing when the primary dressing does not protect the wound from contamination. Occlusive dressings cover a wound from the outside environment and keep nearly all moisture vapors at the wound site. And finally, a semi-occlusive dressing allows some oxygen and moisture vapor to evaporate through the dressing. For a sampling of dressings and their characteristics, see Table 2 .

Nursing Implications

According to clinical practice guideline number 15, set forth by the U.S. Department of Health and Human Services (1994), institutions should design, develop, and implement educational programs to address prevention and treatment of pressure ulcers for patients, caregivers, and healthcare providers; these programs should reflect a continuum of care. Adequate involvement of the patient and caregiver, when possible in treatment and prevention strategies, is highly recommended. In the pediatric population, depending on age, it is not always possible to involve the patient; however, the parents should be involved. In particular, in the critical care environment, involving parents and caregivers can provide a sense of involvement in the care of the child, reducing the sense of powerlessness sometimes experienced by parents of critically ill children. Further educational programs should identify those responsible for pressure ulcer treatment, providing a clear description of each person's role in the treatment process.

An educational program should emphasize the need for accurate, consistent, and uniform assessment, and documentation of the extent of tissue damage. The clinical practice guidelines on the treatment of pressure ulcers suggest a comprehensive educational program. Information in a educational program on the treatment of pressure ulcers should include (a) etiology and pathology, (b) risk factors, (c) uniform terminology for stages of tissue damage based on specific classifications, (d) principles of wound healing, (e) principles of nutritional support, (f) individualized programs of skin care, (g) principles of cleansing and infection control, (h) principles of postoperative care, including positioning and support surfaces, (I) principles of prevention to reduce recurrence, (j) product selection, (k) effects of the physical and mechanical environment on the pressure ulcer, (l) strategies for management, and (m) mechanisms for accurate documentation and monitoring of pertinent data, including treatment interventions and healing progress (Bergstrom et al., 1994).

Summary

A comprehensive pediatric skin care program should emphasize the need for accurate, consistent assessment, including description and documentation of the extent of tissue damage. Nurses should familiarize themselves with risk assessment tools, such as the Braden Q Scale, and use it in their daily practice. A skin care algorithm, such as the one used at the PICU at Advocate Hope Children's Hospital (see Figure 6) can also be a valuable tool to guide nurses in prevention and treatment strategies for children who are at risk for pressure ulcers.

Figure 6. 

Skin Care Algorithm, Advocate Hope Children's Hospital

     

Although the research on pressure ulcers in the pediatric population is limited when compared to that of the adult population, pressure ulcers are not age discriminate. The risk factors for pressure ulcer development such as immobility, neurologic impairment, impaired perfusion, and decreased oxygenation are primarily defined in the adult research. It can be assumed that these risk factors also apply to the pediatric population. The anatomical sites of skin breakdown differ between the adult and pediatric population. The occipital region in

children less than 36 months, the sacral region in children, and the calcaneous are the primary sites identified in the research.

The development of pressure ulcers has major implications for both patients and nursing staff. Pediatric nurses, especially those in a critical care setting, need to be aware that pressure ulcers do exist in this population. The research in pediatrics is emerging drawing increased awareness to this problem. As with adults, early recognition of an at-risk infant or child is critical.

CE Information

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Table 1. The Braden Q Scale

Intensity and Duration of Pressure

MobilityThe ability to change and control body position

1. Completely immobile:Does not make even slight changes in body or extremity position without assistance.

2. Very Limited:Makes occasional slight changes in body or extremity position but unable to completely turn self independently.

3. Slightly Limited:Makes frequent though slight changes in body or extremity position independently.

4. No Limitations:Makes major and frequent changes in position without assistance.

Activity:The degree of current physical activity

1. Bedfast:Confined to bed

2. Chairfast:Ability to walk severely limited or nonexistent. Cannot bear own weight and/or must be assisted into chair or wheelchair.

3. Walks Occasionally:Walks occasionally during day, but for very short distances, with or without assistance. Spends majority of each shift in bed or chair.

4. If ambulatory, all patients too young to ambulate OR walks frequently:Walks outside the room at least twice a day and inside room at least once every 2 hours during waking hours.

Sensory Perception:The ability to respond in a developmentally appropriate way to pressure-related discomfort

1. Completely Limited:Unresponsive (does not moan, flinch, or grasp) to painful stimuli, due to diminished level of consciousness or sedation. OR limited ability to feel

2. Very Limited:Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness OR has sensory impairment which

3. Slightly Limited:Responds to verbal commands, but cannot always communicate discomfort or need to be turned OR has

4. No Impairment:Responds to verbal commands. Has no sensory deficit that would limit ability to feel or communicate pain or discomfort.

pain over most of body surface.

limits the ability to feel pain or discomfort over 1/2 of body.

some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities.

Tolerance of the Skin and Supporting Structure

MoistureDegree to which skin is exposed to moisture

1. Constantly Moist:Skin is kept moist almost constantly by perspiration, urine, drainage, etc. Dampness is detected every time patient is moved or turned.

2. Very Moist:Skin is often, but not always moist. Linen must be changed at least every 8 hours.

3. Occasionally Moist:Skin is occasionally moist, requiring linen change every 12 hours.

4. Rarely Moist:Skin is usually dry, routine diaper changes, linen only requires changing every 24 hours.

Friction - ShearFriction: occurs when skin moves against support surfacesShear: occurs when skin and adjacent bony surface slide across one another

1. Significant Problem:Spasticity, contracture, itching or agitation leads to almost constant thrashing and friction

2. Problem:Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance.

3. Potential Problem:Moves feebly or requires minimum assistance. During a move skin probably slides to some extent against sheets, chair, restraints, or other devices. Maintains relative good position in chair or bed most of the time but occasionally slides down.

4. No Apparent Problem:Able to completely lift patient during a position change; Moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair at all times.

NutritionUsual food intake pattern

1. Very Poor:NPO and/or maintained on clear liquids, or IVs for more than 5 days OR Albumin < 2.5 mg/dl OR Never eats a complete meal. Rarely eats more than ____ of any food offered. Protein intake includes only 2 servings of meat or dairy products per day. Takes fluids poorly. Does not take a liquid dietary supplement.

2. Inadequate:Is on liquid diet or tube feedings/TPN that provide inadequate calories and minerals for age OR Albumin < 3 mg/dl OR rarely eats a complete meal and generally eats only about 1/2 of any food offered. Protein intake includes only 3 servings of meat or dairy products

3. Adequate:Is on tube feedings or TPN which provide adequate calories and minerals for age OR eats over half of most meals. Eats a total of 4 servings of protein (meat, dairy products) each day. Occasionally will refuse a meal, but will

4. Excellent:Is on a normal diet providing adequate calories for age. For example: eats most of every meal. Never refuses a meal. Usually eats a total of 4 or more servings of meat and diary products. Occasionally eats between meals. Does not require supplementation.

per day. Occasionally will take a dietary supplement.

usually take a supplement if offered.

Tissue Perfusion and Oxygenation

1. Extremely Compromised:Hypotensive(MAP < 50mmHg; < 40 in a newborn) or the patient does not physiologically tolerate position changes

2. Compromised:Normotensive; Serum pH is < 7.40; Oxygen saturation may be < 95 %; Hemoglobin maybe < 10 mg/dl; Capillary refill may be > 2 seconds.

3. Adequate:Normotensive; Serum pH is normal; Oxygen saturation may be < 95 %; Hemoglobin maybe < 10 mg/dl; Capillary refill may be > 2 seconds.

4. Excellent:Normotensive, Serum pH is normal; Oxygen saturation >95%; Normal Hgb; Capillary refill < 2 seconds.

Total: If < 23, refer to Skin Care Algorithm.

Source: Quigley & Curley, 1996.

Table 2. A Sampling of Dressings and Their Characteristics

Dressing Type Properties Brand Names

Comments

Calcium Alginates

Primary, Semi-Occlusive

Alginate fibers absorb exudate and convert into a gel providing moisture for healing.

Absorbs moderate to heavy drainage.

Controls minor bleeding.

Provides a moist healing environment.

Kaltostat Choose secondary dressings according to manufacturers´ recommendations (usually a combined dressing [ABD pad], gauze dressing, or transparent film to take away excess fluid and secure the dressing in place).

Film Dressing

Primary or Secondary (depending on use), Occlusive

Use on skin tears.

Use on wounds with little or no drainage.>

Bio OcclusiveTegaderm

Overlay the wound margins by about 3 cm.

Foam Dressing

Primary, Semi-Occlusive

Absorbs moderate to

Polymem Allevyn

Do NOT use on dry wounds. Extend dressing to 1 inch or

heavy exudates.

Is nonadherent.

more beyond the edges and tape.

Hydrocolloid dressing

Primary, Occlusive

Combines colloids, elastomeres and adhesives.

Promotes autolytic debridement.

Use with low to moderate exudates.

DuodermReplicareTegasorb

Use cautiously in infected wounds. Cover at least 1 inch margin around intact skin around the wound.

Hydrogel Primary,Semi-Occlusive

Use with minimal to moderate exudates.

Provides autolytic debridement.

Maintains a moist environment.

VigilonDuoderm GelSolositeAquaflo Discs

Cover at least 1 inch of intact skin around the wound.

Skin Barrier N/A Protects area around wound/dressing.

Use under tape to protect skin.

Skin Prep Allow to dry thoroughly prior to dressing application.

Source: Adapted from Kendall Healthcare Products Company, 1999.

References

1. Baldwin, K.M. (2002). Incidence and prevalence of pressure ulcers in children. 2. Bergstrom N., Alma, R., Alvarez, D., Bennett, M.A., Carlson, C.E., & Frantz, R. (1994).

Treatment of Pressure Ulcers. Clinical Practice Guideline Number 15. 3. Bryant. (2000). Acute and chronic wounds: Nursing management. 4. Curley, M.A., Razmus, I.S., Roberts, K.E., & Wypij, D. (2003). Predicting pressure ulcer risk in

pediatric patients. 5. Kendall Healthcare Products Company. (1999). Understanding wound care products 6. KCI's Pressure Ulcer Assessment Tool. 7. Meehan, M. (1994). National pressure ulcer prevalence survey. 8. National Pressure Ulcer Advisory Panel (NPUAP). (1992). Statement on pressure ulcer

prevention.

9. National Pressure Ulcer Advisory Panel (NPUAP). (2000). The facts about reverse staging in 2000: The NPUAP position statement.

10. Neidig, J., Kleiber, C., & Oppliger, R.A. (1989). Risk factors associated with pressure ulcers in the pediatric patient following open heart surgery.

11. Novartis Nutrition Corporation. (2006). An overview of the role of nutritional support in wound care.

12. Pallija, G., Mondozzi, M., & Webb, A.A. (1999). Skin care of the pediatric patient. Pollack, M.M., Ruttimann, U.E., & Getson, P.R. (1988). Pediatric risk of mortality (PRISM) score

13. Quigley, S.M., & Curley, M.A. (1996). Skin integrity in the pediatric population: Preventing and managing pressure ulcers.

14. Samaniego, I.A., (2003). A sore spot in pediatrics: Risk factors for pressure ulcers. 15. Schmidt, J.E., Berens, R.J., Zollo, M., Weisner, M., & Weigle, C. (1998). Skin breakdown in

children and high-frequency oscillatory ventilation. 16. Wound Care Strategies, Inc. (2002). Our Skin: Did you know - Our skin is our body's largest

organ?

17. Zollo, M.B., Gostisha, M.L., Berens, R.J., Schmidt, J.E., & Weigle, C. (1996). Altered skin integrity in children admitted to a pediatric intensive care unit.

Suggested Readings

Garvin, G. (1997). Wound and skin care for the PICU. Critical Care Nurse Quarterly, 20(1), 62-71.

Keller, B.P., Wille, J., Ramshort, B., & Werken, C. (2002). Pressure ulcers in intensive care patients: A review of risks and prevention. Intensive Care Medicine, 28, 1379-1388.

Colleen T. Butler, BSN, RN, is a Staff Nurse, Pediatric Intensive Care Unit, Advocate Hope Children's Hospital, Oak Lawn, IL.