Skin integrity in the pediatric population: preventing and managing pressure ulcers.

PURPOSE. To summarize clinical and empirical knowledge about pressure ulcers in infants and children and to describe an approach developed at Children's Hospital, Boston, to prevent and manage pressure ulcers

POPULATION. Acutely ill children with potential or actual alteration in skin integrity due to pressure ulcers

CONCLUSIONS. The three-pronged approach for pressure ulcer prevention and management developed by the Skin Care Task Force at the Children's Hospital, Boston, decreases unnecessary variation in practice surrounding the prevention and care of pressure ulcers in acutely ill children.

PRACTICE IMPLICATIONS. The Skin Care Task Force recommends use of the Braden Q for pediatric risk assessment, a skin care algorithm for prevention of pressure ulcers, and a pressure ulcer algorithm for staging and managing pressure ulcers.

Key words: Braden Q, child, infant, pressure ulcer, skin integrity

Integral to the practice of pediatric nursing are the prevention and management of alterations in skin integrity. When first considering the broad spectrum of skin care problems in infants and children, nurses may regard pressure ulcers as irrelevant. But, given the growing number of chronically ill and chronically critically ill infants and children, it is the opinion of the authors that the incidence of skin breakdown and pressure ulcer formation in acutely ill pediatric patients is increasing.

Pressure ulcer prevention and management is multifactorial and requires expert clinical judgment and skill. While there is a plethora of nursing research on the incidence, prevalence, and high cost of pressure ulcer prevention and management in adults (most of which is noted in the clinical practice guideline, Pressure Ulcers in Adults: Prediction and Prevention, Agency for Health Care Policy and Research, [AHCPR], 1992), little empirical data exist to guide pediatric nursing practice. Care for infants and children is extrapolated from practices developed primarily for adults. Adding to the complexity are numerous wound care products and specialty support surfaces of varying costs thought to help prevent or manage pressure ulcers, again, with trials conducted with adults.

This article provides a summary of clinical and empirical knowledge about pressure ulcer formation in infants and children. It also presents the work of the Skin Care Task Force at Children's Hospital, Boston, a 325-bed tertiary care pediatric hospital. The task force was formed to decrease unnecessary variation in nursing practice in the prevention and care of skin breakdown and pressure ulcer formation.

Pressure Ulcer Formation

Pressure ulcers are localized areas of tissue destruction that develop when soft tissue is compressed between a bony prominence and an external surface for a prolonged period of time (National Pressure Ulcer Advisory Panel [NPUAP], 1989). A conceptual schema (Braden & Bergstrom, 1987) identifies the intensity and duration of pressure as well as the tolerance of the skin and its supporting structure for pressure as two major factors responsible for pressure ulcer development. Decreased mobility, activity, and sensory perception contribute to the intensity and duration of pressure. Tissue tolerance, the ability of the skin and supporting structures to endure the effects of pressure without sequelae, includes both extrinsic and intrinsic factors. Extrinsic factors include moisture, friction, and shear, whereas intrinsic factors include nutrition, tissue perfusion, and oxygenation (Braden & Bergstrom, 1987). Patients who are immobile, neurologically impaired, critically ill, malnourished, suffering from debilitating disease processes, or who experience prolonged operative procedures are at risk for pressure ulcer formation (Bergstrom, Demuth, & Braden, 1987; Exton-Smith & Sherwin, 1961; Kemp, Keithley, Smith, & Morreale, 1990; Lamers, & Shurtleff, 1983, Maklebust, 1987; Maklebust & Magnan, 1994; Manley, 1978; Okamoto). In our hospital, pressure ulcers have ranged from nonblanchable erythema of intact skin, which may be reversible, to full-thickness ulceration requiring weeks or months to heal (Figure 1).

Many have examined the relationship between the duration and amount of external pressure required for pressure ulcer development in both animal and adult human models (Dinsdale, 1974; Kosiak 1959,1961; Landis, 1930; Lindan, 1961). Tissue ischemia and damage occur when cells are deprived of oxygen and nutrients and there is an accumulation of metabolic waste products for a specific period of time (Kosiak; Lindan). High pressure maintained over a short period of time, as well as low pressure maintained for a long period of time, can cause soft tissue injury (Kosiak; Lindan). Using the microinjection method for determining blood pressure in single capillaries, Landis found the average pressure in the arteriolar limb to be 32 mmHg. As a result of this study, 32 mmHg is considered the usual capillary closing pressure in adults and is used to make decisions regarding the development, marketing, and purchase of support surfaces (Oertwich, Kindschuh, & Bergstrom, 1995). Individuals usually shift their weight periodically to allow the tissues relief of compression. The diminished ability of some patients to change position increases the likelihood that external pressure will be maintained for a critical threshold period of time resulting in tissue damage (Kosiak). Similar data for infants and children are lacking. A value of 32 mmHg, while considered a safe upper limit for some patients, may not be a …