Pediatric Annals

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CME Article 

Common Skin Problems in Children with Special Healthcare Needs

Shubhra Mukherjee, MD, FRCP(C); Teri Coha, RN, MSN, CWOCN; Zaida Torres, BSN, RN

Abstract

Children with multiple medical problems are particularly prone to skin problems, which may be difficult to prevent, diagnose, and treat. Many of these children develop skin breakdown that may progress to pressure ulcers as a result of underlying medical conditions and prolonged periods spent in a wheelchair or bed. Other children may have medical devices, such as a gastrostomy tube or an ostomy, which contribute to the development of wounds.

Abstract

Children with multiple medical problems are particularly prone to skin problems, which may be difficult to prevent, diagnose, and treat. Many of these children develop skin breakdown that may progress to pressure ulcers as a result of underlying medical conditions and prolonged periods spent in a wheelchair or bed. Other children may have medical devices, such as a gastrostomy tube or an ostomy, which contribute to the development of wounds.

Shubhra Mukherjee MD, FRCP(C), is Attending Physiatrist, Rehabilitation Institute of Chicago, and Assistant Professor, Physical Medicine and Rehabilitation, Northwestern University, Feinberg School of Medicine. Teri Coha, RN, MSN, CWOCN, is Advanced Practice Nurse, Children’s Memorial Hospital. Zaida Torres, BSN, RN, is with Children’s Memorial Hospital.

Dr. Mukherjee; Ms. Coha; and Ms. Torres have disclosed no relevant financial relationships.

Address correspondence to: Shubhra Mukherjee, MD, FRCP(C), 345 E. Superior Street, Chicago, IL 60611; fax 312-238-1208; or e-mail: smukherjee@ric.org.

Children with multiple medical problems are particularly prone to skin problems, which may be difficult to prevent, diagnose, and treat. Many of these children develop skin breakdown that may progress to pressure ulcers as a result of underlying medical conditions and prolonged periods spent in a wheelchair or bed. Other children may have medical devices, such as a gastrostomy tube or an ostomy, which contribute to the development of wounds.

This article discusses the management of common pressure ulcers in pediatric settings, focusing mainly on the outpatient perspective, in children with complex medical conditions. Specific information on skin problems associated with gastrostomy and ostomy sites is also included.

Pressure Ulcers

The National Pressure Ulcer Advisory Panel defines a pressure ulcer as a localized area of tissue destruction that develops when soft tissues are compressed between a bony prominence and an external surface for a prolonged time.1 Pressure ulcers in the pediatric population are not as prevalent as in adults but occur frequently enough to cause concern. Prevalence rates range from 0.47% to 13%2 and are as high as 27% in neonatal intensive care units (NICU) and pediatric intensive care unit (PICU) settings.3 The incidence of pressure ulcers in certain populations is particularly high. For example, the incidence of pressure ulcers in patients with spina bifida is 20% to 43%.4 Other high-risk populations include neonates; those with disabilities, particularly neurologic disabilities; patients in the intensive care setting; those with multiple medical issues; and children in palliative care.

The primary anatomical areas that affect infants and young children include the occipital region, sacral region, ear lobes, and calcaneous region.5,6 In older children and adults, the sacrum is the largest bony area and is the most common location for pressure ulcers.

Although children differ from adults, the treatment of pressure ulcers remains the same.7 Most pediatric wound treatment recommendations are based on extrapolation of data from adults, although recently some assessment tools and guidelines became available based on pediatric data. The key management steps for skin breakdown include assessment and documentation, prevention, and treatment.

Risk Factors

There is limited information in the pediatric population regarding risk factors that affect skin breakdown.8 Risk factors noted for adults include immobility, neurological impairment, impaired perfusion, decreased oxygenation, poor nutritional status, presence of infection, moisture, acidemia, vasopressin therapy, surgery, hypovolemia, and obesity. In one study of a children’s hospital, risk factors associated with pressure ulceration included the difficult-to-position child, anemia, equipment pressing or rubbing on a child’s body, reduced mobility for age, prolonged surgery, and persistent fever.9 Other factors, such as traction devices, casts, splints, and tubing, as well as terminal illness, are known causes.10,11 In PICU patients, duration of ICU stay, duration of ventilation, and edema were noted as risk factors for occipital pressure ulcers. Pressure ulcers frequently occur because of a lack of head repositioning, which may be difficult with children receiving endotracheal tube ventilation, because repositioning may cause air leakage.

In a 4-year study by Pallija and colleagues,4 there were 11 risk factors associated with skin breakdown in children with spina bifida and those with spinal cord injuries: urticaria, obesity, edema, trauma, surgical incision, paralysis, insensate areas, immobility, poor nutrition, incontinence, and impaired cognition. Other studies on specific populations note further connections. Fiore, for example, linked endocrine problems, including precocious puberty and growth hormone deficiencies, to obesity, which makes one prone to pressure ulcer development.12 Another example is the patient with myelomeningocele, who tends to be of short stature and who has lower extremity contractures causing disproportionate weight distribution that results in skin breakdown. Orthopedic problems can lead to skin issues, such as in clubfoot, other skeletal deformities, fractures, and casts.

Belief among clinicians that pressure ulcers are not of concern in the pediatric population can result in poor implementation of prevention strategies and delayed diagnosis and treatment.13 The Norton14 scale, shown in Table 1 or Braden15 scale, shown in Table 2 (see page 209), can be utilized for the prediction of pressure ulcers and may assist in rectifying this lack of recognition.

The Norton Scale for Predicting Pressure Sore Risk*

Table 1. The Norton Scale for Predicting Pressure Sore Risk

Braden Scale for Predicting Risk for Pressure Ulcers

Table 2. Braden Scale for Predicting Risk for Pressure Ulcers

Wound Assessment and Documentation

Assessment and documentation of the status of the skin is vital in the treatment of the wound. Staging of the wound is the first element in determining management. The system of staging is from the National Pressure Ulcer Advisory Panel, described in Table 3 (see page 210), and depicted in Figure 1 (see page 207). Pressure ulcer staging was defined by Shea in 1975 to describe the degree of anatomical tissue loss. Dimensions of the wound, including depth if applicable, are important to document to follow the wound’s progress. Exudate, type and amount, surrounding skin changes, odor and signs of bleeding, healing and infection should be documented. An example of a wound assessment chart is given in Table 4 (see page 211). Photos for documentation are often helpful to determine changes in the wound for follow-up.

Pressure Ulcer Staging

Table 3.23: Pressure Ulcer Staging

Staging of Pressure Ulcers. Stage 1: Nonblanchable Erythema (redness that Does not Quickly Fade) of Intact (unbroken) Skin; Could also Include Warmth, Swelling. Dark Skin Might Appear Discolored Instead of Red. Stage 2: Superficial (not Very Deep) Ulcers with Loss of Epidermis (outer Layers of Skin), Dermis (underlying, Still Developing Skin Tissue) or Both. They May Look Similar to a Scrape, Blister, “zit,” or Crater. Stage 3: Skin Loss to Outer and Underlying Layers of Skin Tissue, with Damage All the Way down to Fascia (connective Tissue of Body). Stage 4: Skin Loss to Outer and Underlying Layers of Skin Tissue, with a Great Deal of Damage and Dead Tissue in the Fascia, Muscle, Bone, Tendon, or Joint Capsule. Images Reproduced with Permission from National Pressure Ulcer Advisory Panel.

Figure 1. Staging of Pressure Ulcers. Stage 1: Nonblanchable Erythema (redness that Does not Quickly Fade) of Intact (unbroken) Skin; Could also Include Warmth, Swelling. Dark Skin Might Appear Discolored Instead of Red. Stage 2: Superficial (not Very Deep) Ulcers with Loss of Epidermis (outer Layers of Skin), Dermis (underlying, Still Developing Skin Tissue) or Both. They May Look Similar to a Scrape, Blister, “zit,” or Crater. Stage 3: Skin Loss to Outer and Underlying Layers of Skin Tissue, with Damage All the Way down to Fascia (connective Tissue of Body). Stage 4: Skin Loss to Outer and Underlying Layers of Skin Tissue, with a Great Deal of Damage and Dead Tissue in the Fascia, Muscle, Bone, Tendon, or Joint Capsule. Images Reproduced with Permission from National Pressure Ulcer Advisory Panel.

Assessment Table

Table 4. Assessment Table

Treatment

The treatment strategy must be multipronged, including patient and caregiver education, as well as appropriate wound care, which may include irrigation, debridement, a dressing, surgery, and infection prevention or treatment.

Patient or Caregiver Education

The patient must be assessed for the cause or source of the pressure, to prevent sores, and to treat a sore and facilitate healing (see Sidebar, page 211). The cause is not always evident. Shear and friction during transfers, mobility, assistive equipment, or rest surfaces may cause skin damage. Positioning may be to blame, such as bony prominences pressing against each other at night when in side-lying position. Education about causes of pressure sores, nutrition, and how to ameliorate the sources of pressure, friction, moisture, and shear will help provide strategies to heal the sore more quickly. Adequate protein intake, iron stores, and vitamins, as well as calories, are needed to facilitate optimal wound healing conditions. Printable educational materials for families are available at http://npuap.org.

Pressure Wound Care Principles

  1. Wounds that are created from pressure will only heal once pressure is removed. This is especially important for people with spina bifida and others with insensate areas who do not feel when skin is damaged from pressure.

  2. Infected wounds will not heal. The wound may drain white, yellow, green, or brown liquid or pus. The surrounding skin may be red and or swollen, or there may be a foul odor to the wound or its drainage.

Factors that Stop Wound Healing:

  1. Pressure

  2. Infection

  3. Stool or urine in the wound

  4. Too much moisture/wetness

  5. Too dry

  6. Shear or friction

Factors that Slow Wound Healing:

  1. Low iron stores

  2. Low protein nutrition

  3. Dehydration

  4. Other illnesses (infections, etc)

  5. Low vitamin stores (zinc, vitamins A, B, C, E)

Wound Care

Wounds should be washed with sterile water or saline. Tap water can be used for older children, and sterile water is preferred for neonates. Saline is preferred when dealing with very large wounds. Using a syringe, irrigate the wound to flush away exudate and gently debride the wound. Topical antibiotics, such as bacitracin or polymixins, are not recommended except for very small superficial abrasions because they can cause allergic dermatitis or sensitization. They also may remove gram-positive bacteria and promote gram-negative growth, leading to difficult infections.16,17 Wound care recommendations for neonates are described elsewhere3 and should be followed appropriately, as transdermal fluid loss and sensitization or toxicity from topical agents can occur. Wounds should be reassessed every few weeks by a medical professional until closed (see Sidebar, page 211).

Debridement

For more severe ulcers, debridement may be necessary. Although a dry eschar can provide a protective covering for wound healing, it can also harbor bacteria and lead to infection. When debridement is appropriate, it can be performed using topical enzymes or water. If perfusion is good, then sharp debridement with a scalpel or debriding loop can clean non-viable tissue from the surface of the wound. A slightly bleeding base of the wound demonstrates tissue that is actively growing and releases platelet-derived growth factors. Pain sensation in the area should be assessed. If the area is sensate or painful, preparing it with a topical or injectable analgesic is important.

Dressings

In general, most dressings have not been tested specifically in children, except in a few case series; recommendations are based on adult guidelines. Dressings create a moist wound healing environment and control excess exudate, inhibit bacterial growth, and allow air in while keeping contaminants, such as stool and urine, out of the wound.

Non-adhesive dressings can be secured using gauze wrap to prevent irritation from tape. Dressings that are dried on can be loosened using saline or water irrigation, or by dampening for a few minutes with moistened gauze. Adhesive dressings are removed by pulling parallel to the skin (forward, away from the center of the dressing) to allow it to lift from the skin, and not perpendicularly, which can cause skin tears and pain.

Below is a list of common dressings used with pressure ulcers (see Table 5, page 213):

  • Film dressing (eg, Tegaderm): Primary or secondary dressing used for skin tears and wounds with minimal to no drainage. Change daily or as needed. Seals wounds from contaminants.

  • Hydrogel (eg, Carragauze, Carradress): Primary, semi-occlusive dressing used for minimal to moderate exudates. Adds moisture and provides autolytic debridement. Change daily.

  • Hydrocolloid dressing (eg, Duoderm): Primary occlusive dressing impermeable to bacteria and contaminants, with minimal absorption. Promotes autolytic debridement. Can change up to every 3 to 4 days, depending on amount of exudate, as absorptive capacity is limited.

  • Foam dressing (eg, Polymem, Mepilex): Primary, semi-occlusive dressing that absorbs moderate to heavy exudates and is nonadherent. Change as needed, but may remain in place for 3 to 4 days. Do not use on dry wounds. The dressings are not meant to be used as “padding” and should fit just over the wound and margins.

  • Calcium alginates (eg, Aquacel, Fibrocal): Primary, semi-occlusive dressing containing alginate fibers (from seaweed) that absorb exudate and convert it into a gel to provide moisture. These absorb moderate to heavy drainage. Change daily or alternate days. Trauma-free removal.

  • Silver dressings: Some foam and alginate type dressings are now made with silver ions, which are bactericidal. Silver sulfadiazine in cream or ointment form can be used topically for superficial bacterial growth. If infection is in deeper tissues, topical treatment will not be sufficient.

  • Wet-to-dry dressings: Gauze dressings moistened with saline and placed over a wound are favored by many surgeons and work well in healthy tissue. However, these do not provide much absorption. With frequent changing (three to four times a day), this method appears to control bacterial growth, but is labor intensive. If the dressings dry in place, trauma to the wound bed may occur during removal, slowing healing. These are more suitable for postsurgical wounds and are not recommended for pressure sores.

  • Other: Other artificial skin dressings are also available but are expensive and not as easily available. These are usually used only by tertiary wound clinics. Wound vacuum treatments and hyperbaric oxygen are used with good effect for larger and more chronic wounds.

Examples of Wound Care Options

Table 5. Examples of Wound Care Options

Treating Infection

Deeper tissue infections may occur and present with swelling, copious drainage, and sometimes odor. Deep tissue infections can cause limb or area edema, cellulitis, and even risk of deep venous thrombosis, especially in an immobile post-pubertal child. Culture swabs generally grow some bacteria, but if there are clinical signs of infection, then antibiotics may be warranted. Generally, gram-positive coverage via oral antibiotics is effective. With signs of infection, a culture swab may help if gram-negative or Pseudomonas growth is suspected. In those cases, more wide-spectrum coverage is needed.

Surgical Treatment of Wounds

When wounds are large and healing slowly, surgery may provide a faster solution. Various skin and/or tissue flaps cover the defect and provide vasculature to the tissue. As flap donor sites are limited, care of the recipient site is of utmost importance to promote long-term success. If the wound can be kept clean and from enlarging, the patient will be more likely able to protect the skin or tissue flap once it has been put in place.

Prevention

The ultimate treatment for all pressure ulcers is prevention. Although prevention is important in the hospital setting, it is equally vital to educate caregivers and patients on prevention techniques.

To prevent sores, all medical equipment should be properly fitted and checked frequently. More than 50% of pressure ulcers are related to equipment and devices, including blood pressure cuffs, transcutaneous oxygen pressure probes, tracheostomy plates, nasal prongs and continuous positive air pressure (CPAP) or bilevel positive airway pressure (BIPAP) masks, arm boards, plaster casts, and traction boots.18 Accommodation for growth must be assessed regularly. Splints or orthotics, wheelchairs, and cushions should be adjusted for growth or weight changes. Orthotists can assist in readjusting or-thoses for a better fit to prevent or ameliorate skin breakdown. Patients are encouraged to wear cotton socks with orthotics to help manage moisture.

Intraoperative positioning with foam blocks and repositioning every 2 hours has been shown to reduce occipital pressure sores in the PICU.6 Occipital and sacral sore studies have shown that convoluted foam, foam overlays, and foam and gel pillows have reduced sores and interface pressures.19,20

Those patients with impaired sensation, such as those with spina bifida, have a significant probability of developing skin breakdown. These patients and their families should be taught early to inspect skin after use of durable medical equipment, such as wheelchairs and braces, and to use proper transfer techniques. If redness occurs, they are instructed to relieve pressure to the site.

When teaching wound care and prevention techniques, especially to children, it is important to keep the information simple and clear. Repeated instruction and hands-on demonstration can lead to a personal plan of care that will encourage participation. It is important for the affected youth to take responsibility when possible, to ensure long-term success in prevention and treatment of pressure ulcers.

Skin Issues Associated with Gastrostomy Tubes

Gastrostomy tubes (GT) are usually placed in children with congenital and acquired disorders and diseases that prevent them from taking enough calories or fluids orally to sustain growth and development. Common skin issues with GTs include hypergranulation tissue, peristomal skin irritation, candidiasis, and cellulitis.

Hypergranulation Tissue

Peristomal hypergranulation tissue (HGT) is a common problem for patients with GTs. HGT is granulation tissue protruding beyond the level of the skin, as shown in Figure 2a. Plausible causes include the presence of a foreign body (ie, a tube or button) through the skin, friction caused by movement of the tube, and moisture. Drainage from HGT can be green, brown, yellow or serosanguinous. The drainage from HGT, in combination with the unpleasant appearance and odor, often leads parents and practitioners to believe that the gastrostomy is infected. It is critically important to distinguish between granulation tissue and infection to treat both correctly. Systemic antibiotics are not necessary for HGT and may contribute to antibiotic resistance in the future.

Gastrostomy Skin Problems. 2a: Hypergranulation Tissue. 2b: Foam Gastrostomy Dressing. 2c: Gastrostomy Skin Irritation. 2d: Gastrostomy Dressed with Thick Barrier Paste. 2e: Cellulitis at Gastrostomy Site.

Figure 2. Gastrostomy Skin Problems. 2a: Hypergranulation Tissue. 2b: Foam Gastrostomy Dressing. 2c: Gastrostomy Skin Irritation. 2d: Gastrostomy Dressed with Thick Barrier Paste. 2e: Cellulitis at Gastrostomy Site.

Although not always preventable, especially with new gastrostomy sites, there are some strategies that may assist in inhibiting HGT development. Occlusive dressings should be avoided. Ensure that the button, tube, and external bumper, when applicable, fit appropriately and do not move excessively. Prevention of trauma to the site by securing tubes and extension sets can be helpful.

When HGT occurs, treatment options in order of preference include application of a topical steroid, specifically triamcinolone cream 0.1% or 0.5%, use of silver nitrate, and, in more severe cases, surgical excision.

Triamcinolone cream is applied with a cotton tip applicator two to three times per day when HGT is visible. It is not used when HGT is not seen at the site, even if there is drainage, as a small amount of drainage from a GT site is considered acceptable. Gauze may be used to protect the child’s clothing from drainage but is not required. When using gauze under a GT, be sure to tape only across the top of the cut side of the gauze to prevent it from falling off. Gauze taped to the skin may result in additional skin damage from tape irritation.

Silver nitrate is also used for treatment of HGT. Many children experience pain with its application, so it should be used only in cases of significant HGT. The peristomal skin is protected with petrolatum before application. Because silver nitrate will not prevent regrowth, parents are instructed to use triamcinolone cream at home after the silver nitrate treatment.

Foam dressings, as seen in Figure 2b (see page 212), are another option for the prevention or treatment of HGT. Foam is more effective than gauze at absorbing drainage and does not leave particles of fiber in the wound, which may trigger the inflammatory process, giving rise to HGT. Foam is available in a variety of sizes. To keep costs down, it is best to order a larger piece of foam (8 x 8 inches), and then have the patient cut it into 2 x 2 pieces, a good size for use under skin-level devices.

In rare cases, surgical removal of HGT may be required.

Skin Irritation

Skin irritation, as seen in Figure 2c (see page 212), is most often caused by HGT, leakage of formula, and secretions from the gastric mucosa that lines the tract of the GT. Gastric mucosa secretes gastric acid that may burn the skin. Skin irritation can be treated with barrier pastes, such as those used to protect the diaper area from irritant dermatitis. A thick layer of paste, as seen in Figure 2d (see page 212), is applied to the skin and covered with gauze or foam. Stomahesive powder or petrolatum applied over the barrier paste prevents the dressing from sticking to the paste, allowing the dressing to be changed as necessary without removal of the paste. Foam is the best dressing because it absorbs more fluid and effectively wicks the fluid away from the skin.

The presence of gastric mucosa accompanied by significant leakage and skin irritation may require revision of the gastrostomy. Until revision can be scheduled, the skin must be protected, as outlined above.

Bacterial and Yeast Infections

Cutaneous candidiasis can occur with drainage from granulation tissue or leakage of formula, even when there is relatively little moisture around the tube. It may consist of a few pustules, satellite lesions, and slight erythema, or may be severe, with significant erythema, maceration, and excoriation. Mild cases can be treated easily with a topical antifungal. Severe localized candida, or cases of yeast in the diaper area in addition to the GT site, may require systemic, as well as local treatment.

An infected stoma can be seen in Figure 2e (see page 212). Cellulitis at the GT site is very uncommon. The peristomal skin is typically bright red, hot, and very painful. Frequently, there is no drainage. A culture of the site is not necessary, and treatment is systemic antibiotic therapy.

Peristomal Skin Issues at Bowel Ostomy Sites

Infants and children with ileostomies and colostomies can develop skin problems around their stomas. A variety of factors place children at risk, including overall health of the child at the time of the surgery, consistency of the stool, location of the stoma, and the appearance of the stoma. Ostomy surgery in children is rarely a planned event that occurs when the child’s clinical status and nutrition are optimal. Rather, infants and children are often critically ill when undergoing surgery requiring bowel resection and an ostomy.

During the initial postoperative period, patients are at risk at for mucocutaneous junction separation and wound dehiscence. Skin breakdown occurring after the initial healing phase is generally irritant dermatitis from contact of effluent with skin.

Peristomal irritant dermatitis can occur when skin barriers, or wafers, are left on too long. A wafer is a stiff, two-sided, adhesive dressing that fits around the ostomy, to which the collection pouch attaches. Infant and pediatric skin barriers are designed for delicate skin. They are less aggressive, an important feature for infant skin, but also less durable.21 The wafer may remain intact around the outer edges, although it has melted near the stoma, leaving the peristomal skin exposed and unprotected. When changing the pouch, the wafer should be assessed for meltdown. It may be necessary to change the pouch and wafer more frequently to limit peristomal skin breakdown. Another solution would be the addition of a barrier ring or strip paste to add a layer of protection near the stoma. Strip pastes and barrier rings are preferable to stomahesive pastes in tubes. Strip pastes and barrier rings are alcohol-free, can be cut or molded to the shape needed, are easier to remove from the skin, and are more likely to be used correctly.

Another problem contributing to peristomal skin breakdown is the belief that wafers should not be applied over irritated or denuded skin. The caregiver, therefore, cuts the wafer large enough to prevent it from covering the irritated skin, and the result is further peristomal skin damage from additional exposure to effluent. Stoma wafers are designed to protect the skin by preventing exposure to stool. They are also designed to go over denuded and irritated skin. It may be necessary to add other products, such as a no-sting skin preparation or stomahesive powder under the wafer to help with adhesion. This is done in layers. Powder is sprinkled on the skin, then dusted off. Next, skin prep is applied. It is important to dab the skin prep over the powder because rubbing it on will remove the powder. This process can be done two or three times, always ending with skin prep, as the wafer will not stick to powder. The wafer can then be applied over the final layer of skin prep.

Stomas in infants and children are often brought out through the incision because of limited abdominal space and to minimize scarring. When the incision heals, there is an indentation in the skin, as seen in Figure 3. This is an area where stool may leak under the wafer, causing wafer failure and skin breakdown. It can be managed by the addition of strip paste to fill in the defect created by the scar.

Ostomy with Skin Indentation.

Figure 3. Ostomy with Skin Indentation.

Yeast overgrowth is also a common problem. It can occur under the wafer and/or on the skin under the pouch where the pouch film holds moisture between it and the skin.19 An antifungal powder with skin prep dabbed over it will treat the yeast overgrowth. It may be necessary to add an oral antifungal to the treatment.

As infants grow, they outgrow their pouches. A 5-lb, premature infant will have a larger volume of stool when he reaches 10 lb. The continued use of pouches designed for premature infants on larger infants will result in frequent pouch changes and possible skin breakdown. Patients should follow-up with the ostomy nurse for changes in products as they grow and for ongoing difficulties with ostomy management.

Conclusion

Children with special healthcare needs may have issues with their skin related to pressure or medical devices. Factors, such as infection, metabolic, or nutritional concerns, may contribute to the problem. Access to wound-care clinicians can help the community and hospital-based pediatrician to manage wounds and skin issues effectively. Wound and ostomy care nurses have specialized training and may be a good local resource, including in the homecare setting. Tertiary centers may have specialists, including dermatology, plastic surgery, general surgery, or rehabilitation medicine for referral.

Optimizing nutrition and acting promptly to identify and treat wounds can prevent wounds from becoming large and complex ones that require surgery or tertiary clinics. Educating children and families to be vigilant in preventing sores and monitoring skin frequently, especially around medical devices, will enhance success as the children enter adulthood.

References

  1. Quigley SM, Curley MA. Skin integrity in the pediatric population: preventing and managing pressure ulcers. J Society Pediatr Nurs. 1996;1(1):7–18. doi:10.1111/j.1744-6155.1996.tb00050.x [CrossRef]
  2. Groeneveld A, Anderson M, Allen S. The prevalence of pressure ulcers in a tertiary care pediatric and adult hospital. J Wound Ostomy Continence Nurs. 2004;31(3):108–120.
  3. Baharestani MM, Ratliff CR. Pressure ulcers in neonates and children: an NPUAP White paper. Adv Skin Wound Care. 2007;20(4):208–220. doi:10.1097/01.ASW.0000266646.43159.99 [CrossRef]
  4. Pallija G, Mondozzi M, Webb AA. Skin care of the pediatric patient. J Pediatr Nurs. 1999;14(2):80–87. doi:10.1016/S0882-5963(99)80041-4 [CrossRef]
  5. Neidig J, Kleiber C, Oppliger RA. Risk factors associated with pressure ulcers in the pediatric patient following open heart surgery. Prog Cardiovasc Nurs. 1989;4(3):99–106.
  6. Willock J, Hughes J, Tickle S, Rossiter G, Johnson C, Pye H. Pressure sores in children: the acute hospital perspective. J Tissue Viab. 2000;10(2):59–62.
  7. Butler TC. Pediatric skin care: guidelines for assessment, prevention, and treatment. Pediatr Nurs. 2006: 32(5):443–449.
  8. Neidig J, Kleiber C, Oppliger RA. Risk factors associated with pressure ulcers in the pediatric patient following open heart surgery. Prog Cardiovasc Nurs. 1989;4(3):99–106.
  9. Willock J, Baharestani MM, Anthony D. The development of the Glamorgan paediatric pressure ulcer risk assessment scale. J Wound Care. 2009;18(1):17–21.
  10. Baldwin K. Incidence and prevalence of pressure ulcers in children. Adv Skin Wound Care. 2002;15(3):121–124. doi:10.1097/00129334-200205000-00007 [CrossRef]
  11. Waterlow JAPressure sore risk assessment in children. Pediatr Nurs. 1997;9(6):21–24.
  12. Fiore P, Picco P, Castagnola E, et al. Nutritional survey of children and adolescents with myelomeningocele (MMC): overweight associated with reduced energy intake. Eur A Pediatr Surg. 1998;8(Suppl 1): S34–S36. doi:10.1055/s-2008-1071250 [CrossRef]
  13. Storm K, Lund JT. Skin care of preterm infants:strategies to mimimize potential damage. J Neonatal Nurs. 1999;5(2):13–15.
  14. Norton D. Calculating the risk: reflections on the Norton Scale. Decubitus. 1989;2(3):24.
  15. Braden B, Bergstrom N. Pressure ulcers in adults: prediction and prevention. Clinical Practice Guideline. 1992;2:14–17
  16. Association of Women’s Health, Obstetric and Neonatal Nurses. Neonatal skin care evidence-based clinical practice guideline. Washington, DC: Association of Women’s Health, Obstetric and Neonatal Nurses; 2001.
  17. Association of Women’s Health, Obstetric and Neonatal Nurses. Neonatal skin care evidence-based clinical practice guideline. Washington, DC: Association of Women’s Health, Obstetric and Neonatal Nurses; 2001.
  18. Willock J, Harris C, Harrison J, Poole C. Identifying the characteristics of children with pressure ulcers. Nurs Times. 2005;101(11):40–43.
  19. Solis I, Krouskop T, Trainer N, Marbuger R. Supine interface pressure in children. Arch Phys Med Rehabil. 1988;69(7):524–526.
  20. McLane KM, Krouskop TA, McCord S, Fraley JK. Comparison of interface pressures in the pediatric population amoung various support surfaces. J Wound Ostomy Continence Nurs. 2002;29(5):242–251.
  21. Harrison B, Boarini J. Pediatric ostomies: pathophysiology and management. In: Fecal and Urinary Diversions, Management Principles. Colwell J, Goldberg M, Carmel J, eds. St. Louis, MO; Mosby; 2004:263–307.
  22. Updated Staging System. http://npuap.org/resources.htm. Accessed January 24, 2010.

The Norton Scale for Predicting Pressure Sore Risk*

CriterionScore
Physical condition4 = Good; 3 = Fair; 2 = Poor; 1 = Very bad
Mental condition4 = Alert; 3 = Apathetic; 2 = Confused; 1 = Stupor
Activity4 = Ambulant; 3 = Walk with help; 2 = Chair bound; 1 = Bed bound
Mobility4 = Full; 3 = Slightly impaired; 2 = Very limited; 1 = Immobile
Incontinent4 = Not; 3 = Occasionally; 2 = Usually/Urine; 1 = Doubly

Braden Scale for Predicting Risk for Pressure Ulcers

Patient’s Name:_________Evaluator’s Name:____________Date of Assessment:_____
Sensory Perception (ability to respond meaningfully 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 pain over most of body surface.2. Very limited: Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness, OR has a sensory impairment which limits the ability to feel pain or discomfort over one-half of body.3. Slightly limited: Responds to verbal commands but cannot always communicate discomfort or need to be turned, OR has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities.4. No impairment: Responds to verbal commands. Has no sensory deficit which would limit ability to feel or voice pain or discomfort.
Moisture (degree to which skin is exposed to moisture)1. Constantly moist: Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time patient is moved or turned.2. Moist: Skin is often but not always moist. Linen must be changed at least once a shift.3. Occasionally moist: Skin is occasionally moist, requiring an extra linen change approximately once a day.4. Rarely moist: Skin is usually dry; linen requires changing only at routine intervals.
Activity (degree of 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 wheel chair.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. Walks frequently: Walks outside the room at least twice a day and inside room at least once every 2 hours during waking hours.
Mobility (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 make frequent or significant changes 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.
Nutrition (usual food intake pattern)1. Very poor: Never eats a complete meal. Rarely eats more than one-third of any food offered. Eats two servings or less of protein (meat or dairy products) per day. Takes fluids poorly. Does not take a liquid dietary supplement, OR is NPO and/or maintained on clear liquids or IV for more than 5 days.2. Probably inadequate: Rarely eats a complete meal and generally eats only about one-half of any food offered. Protein intake includes only three servings of meat or dairy products per day. Occasionally will take a dietary supplement, OR receives less than optimum amount of liquid diet or tube feeding.3. Adequate: Eats more than half of most meals. Eats a total of four servings of protein (meat, dairy products) each day. Occasionally will refuse a meal, but will usually take a supplement if offered, OR is on a tube feeding or TPN regimen, which probably meets most of nutritional needs4. Excellent: Eats most of every meal. Never refuses a meal. Usually eats a total of four or more servings of meat and dairy products. Occasionally eats between meals. Does not require supplementation
Friction and Shear1. 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. Spasticity, contractures, or agitation leads to almost constant friction.2. 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 relatively good position in chair or bed most of the time but occasionally slides down.3. No apparent problem: 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.
Total Score: _________

Pressure Ulcer Staging

StageCharacteristics
IPressure-related changes of intact skin compared with the adjacent or opposite areas: color (non-blanchable redness in lightly pigmented skin; red, blue, or purple hues in darkly pigmented skin). There may also be changes in temperature (increased warmth or coolness); consistency (firm or boggy feel); or sensation (pain).
IIPartial-thickness skin loss into but not deeper than the dermis, including abrasions, intact or ruptured blisters, and other shallow defects. No exposure of subcutis or deeper structures.
IIIFull-thickness skin loss down to subcutaneous fat or, in areas without underlying fat (eg, nose, malleolus), to fascia, perichondrium, or periosteum. No exposure of muscle, tendon, cartilage or bone. Sometimes devitalized tissue, undermining, or tunneling but that does not hide deeper injury.
IVFull-thickness skin loss with exposure of muscle, tendon, bone, or adjacent structures (eg, joint spaces). Potentially extensive destruction and increased risk of osteomyelitis.

Assessment Table

Site of WoundDateMeasurementsShapeExudateTypeInfection?
Eg, right lateral ankleLength cm x width cm x depth cmRound/oval/irregularMinimal/moderate/copiousSerous/sanguinous/purulentYes/no

Examples of Wound Care Options

ExudateStage IStage IIStage IIIStage IV
MinimalFilmHydrogelHydrogel or hydrocolloidUsually requires packing
ModerateHydrocolloidFoamPacking + foam
CopiousFoam (unusual)Alginate + foamAlginate packing + foam (may include silver dressings)

CME Educational Objectives

  1. Describe the risk factors for developing pressure ulcers.

  2. Discuss the rationale for choosing specific dressings for pressure ulcers.

  3. Identify the appearance of, and causes for, skin irritation and breakdown around gastrostomy tubes, ilieostomies, and colostomies.

Pressure Wound Care Principles

  1. Wounds that are created from pressure will only heal once pressure is removed. This is especially important for people with spina bifida and others with insensate areas who do not feel when skin is damaged from pressure.

  2. Infected wounds will not heal. The wound may drain white, yellow, green, or brown liquid or pus. The surrounding skin may be red and or swollen, or there may be a foul odor to the wound or its drainage.

Factors that Stop Wound Healing:

  1. Pressure

  2. Infection

  3. Stool or urine in the wound

  4. Too much moisture/wetness

  5. Too dry

  6. Shear or friction

Factors that Slow Wound Healing:

  1. Low iron stores

  2. Low protein nutrition

  3. Dehydration

  4. Other illnesses (infections, etc)

  5. Low vitamin stores (zinc, vitamins A, B, C, E)

Authors

Shubhra Mukherjee MD, FRCP(C), is Attending Physiatrist, Rehabilitation Institute of Chicago, and Assistant Professor, Physical Medicine and Rehabilitation, Northwestern University, Feinberg School of Medicine. Teri Coha, RN, MSN, CWOCN, is Advanced Practice Nurse, Children’s Memorial Hospital. Zaida Torres, BSN, RN, is with Children’s Memorial Hospital.

Dr. Mukherjee; Ms. Coha; and Ms. Torres have disclosed no relevant financial relationships.

Address correspondence to: Shubhra Mukherjee, MD, FRCP(C), 345 E. Superior Street, Chicago, IL 60611; fax 312-238-1208; or e-mail: .smukherjee@ric.org

10.3928/00904481-20100318-05

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