HOW TO MAINTAIN A HEALTHY SKIN BARRIER
Good skin care should be initiated for all patients in order to maintain a healthy skin barrier (Nicol, 2005). This, in turn, will prevent skin breakdown. Prevention of a skin injury begins with proper cleansing, hydration, and protection of the skin barrier (Figure 2). The steps are simple, but for a child who is critically ill, skin care is often not prioritized and can be overlooked (Schindler et al., 2007). The goal for simple skin care is to maintain a supple skin barrier, one that is not too dry or too moist (Nicol, 2005). If the skin barrier is disrupted, resulting in cracks from dryness or maceration from excessive moisture, the skin barrier loses its protective mechanism from the environment.
A healthy skin barrier maintains the pH balance of the skin in a range of 4.5–6.0. This range is called the acid mantel (Baranoski & Ayello, 2004a). When cleansing the skin, always use a gentle pH neutral cleanser that is fragrance-free, preservative-free, and dye-free (Nicol, 2005). Although the fragrances may be pleasing, products with fragrances, dyes, or preservatives can increase the risk for a child to develop an allergic or a sensitivity reaction.
Avoid scrubbing the skin: The stratum corneum has a protective role, and the purpose of cleansing is not to scrub off this protective barrier (Turnage-Carrier et al., 2008). Gentle cleansing is all that is needed and will remove the dead cells that have been shed. In addition, avoid overbathing or the use of astringents because this can strip the skin of the lipids it contains, resulting in a dry disrupted skin barrier (Nicol, 2005).
Always rehydrate the skin after bathing: Following a bath, immediately seal in the moisture of the skin by applying an effective moisturizer (Nicol, 2005). If the skin is not relubricated after bathing, moisture evaporates, which causes the barrier to become dry and irritated. Hydration of the skin after bathing keeps the skin barrier intact and flexible (Nicol, 2005). In a dryer climate, a cream or an ointment-based moisturizer is more effective in sealing in this moisture than a lotion is. Lotions, creams, and ointments differ in their composition, but the biggest difference is the water content. Lotions have a higher water content contained in them and therefore are not as effective in sealing in moisture or hydrating the skin (Nicol, 2005).
Avoid antimicrobial soaps: The skin has resident bacteria on it—called normal flora (Baranoski & Ayello, 2004a). This normal flora has a protective role against harmful pathogens (Turnage-Carrier et al., 2008). Antimicrobial soaps wash away this protective flora of the skin. Once it is removed, there is no protection against the harmful pathogens should the integrity of the skin be disrupted.
Do not to use topical antibiotics on an open wound that is infection free (Baranoski & Ayello, 2004a): Topical antibiotics may result in an allergic or sensitivity type of reaction (Figure 3). Topical antibiotics are often used to promote moist wound healing and to prevent infection (Dyson, Young, Hart, Lynch, & Lang, 1993). However, studies have shown that what promotes moist wound healing and prevents infection is not the antibiotic but rather the ointment that the antibiotic is contained in (Cowan & Stechmiller, 2009). Therefore, a petrolatum ointment or a hydrogel, if used to promote moist wound healing, will not only heal the wound faster by promoting the ease of cell migration but will not also result in an allergic or sensitivity reaction (Dyson et al., 1993).
Pressure injuries usually occur to the skin overlying a bony prominence (Baharestani & Ratliff, 2007). Excessive pressure leads to the death of the skin and the structures underlying it. Low amounts of pressure over extended periods of time or high amounts of pressure over a short period of time have the same end result: tissue death, necrosis, and ulceration of the skin (Baranoski & Ayello, 2004a).
Risk factors for a pressure injury may be extrinsic or intrinsic (Baharestani & Ratliff, 2007). Examples of extrinsic risk factors include the duration of pressure, the amount of pressure, friction, shear, moisture, and the exposure to hospital devices (Baharestani & Ratliff, 2007). Intrinsic risk factors are factors that are not controlled by the environment. These factors can include tissue perfusion/oxygenation problems, critical illness, previous ulcerations, malnutrition, prematurity, infection, neurological deficits, and immobility (Baharestani & Ratliff, 2007).
Other mechanical forces that can contribute to the development of a pressure ulcer include friction and shear (Butler, 2007). “Friction is a mechanical force which occurs when the skin is dragged across a coarse surface, resulting in an abrasion of the skin” (Schindler et al., 2007). This damaged skin increases the risk for an additional injury to occur to this area. “Shear is a mechanical force which occurs on the skin in a direction parallel to the surface of the body” (Schindler et al., 2007). Shearing injuries occur when the bone and attached muscle slide parallel to a stationary epidermis and dermis (Schindler et al., 2007). This parallel slide compromises the blood supply to the affected area leading to cellular death and tissue necrosis.
CLASSIFICATION OF PRESSURE ULCERS
Pressure injuries are classified by the depth of the injury within the skin and to its underlying structures (Butler, 2007). If a pressure injury does occur, it is essential that all healthcare providers classify this injury correctly. Having a clear understanding of the anatomy of the skin and its related structures is necessary to identify the depth of an injury correctly.
The skin consists of two layers: the epidermis and the dermis. The subcutaneous tissue and muscle and the bone are located beneath the skin layers (Baranoski & Ayello, 2004a). The top layer of the skin is called the epidermis, which consists of five individual layers: the stratum basale/stratum germinativum, the stratum spinosum, the stratum granulosum, the stratum lucidum, and the stratum corneum.
The second layer of the skin is called the dermis. The main function of the dermis is to provide strength, retain moisture, and provide nourishment to the epidermis with blood and oxygen (Baranoski & Ayello, 2004a). The dermis consists of two layers called the papillary dermis and the reticular dermis. The papillary dermis is located directly beneath the epidermis. This layer contains capillaries, which help to nourish the epidermis. Collagen, elastin, and the pain/touch receptors are also located in this area. The reticular dermis is located beneath the papillary dermis. This layer of the skin is anchored to the subcutaneous tissue with supporting structures called collagen bundles (Baranoski & Ayello, 2004a). This layer also contains the larger blood vessels, nerves, sweat glands, and hair follicles.
The subcutaneous tissue is located beneath the skin layers. The major role of the subcutaneous tissue is to provide insulation, cushioning, and protection of the skin, muscles, and bones. It also contains the larger blood vessels, lymphatic vessels, and the nerves (Baranoski & Ayello, 2004a).
NATIONAL PRESSURE ULCER ADVISORY PANEL CLASSIFICATION SYSTEM
Pressure injuries are classified using the National Pressure Ulcer Advisory Panel classification system (Butler, 2007). Pressure injuries are classified either as a Suspected Deep Tissue Injury, Stage I Pressure Injury, Stage II Pressure Injury, Stage III Pressure Injury, Stage IV Pressure Injury, or an Unstageable Pressure Injury. Listed below is the recommended National Pressure Ulcer Advisory Panel 6 stage classification system (National Pressure Ulcer Advisory Panel, 2007).
Suspected Deep Tissue Injury: This stage is characterized by a discoloration most commonly located over a bony prominence (Butler, 2007). This discoloration is often purple or gray in color (Figure 3). Tissue consistency changes, such as bogginess of the skin along with temperature changes of the skin, may also be noted. Another characterization of a suspected deep tissue injury is a blood-filled blister (Baranoski & Ayello, 2004a). A deep tissue injury is suspected because of the color of fluid that is observed within the blister. This blood-filled blister indicates that the injury, which has occurred, has reached the level of skin where the blood vessels are located, therefore indicating a deeper injury.
Stage I Pressure Injury: This stage is characterized by redness located most commonly over a bony prominence (Figure 4). This redness does not blanch (nonblanchable erythema) when it is pressed and is a key indicator in the identification of a Stage I Pressure Injury (Baranoski & Ayello, 2004a). Blanchable erythema is not caused by pressure and is secondary to some other cause outside of pressure. Temperature and tissue consistency changes may also be noted with this stage.
Stage II Pressure Injury: This stage is characterized as a partial thickness injury located most commonly over a bony prominence (Butler, 2007). The injury that has occurred has only reached the papillary dermis, therefore indicating a partial dermal injury. The wound appears as a shallow ulcer with a red or pink wound bed and contains no slough (Figure 5). Another characterization of a Stage II Injury is a serous intact blister. Fluid, which is serous in nature, is indicative of a more superficial injury (Baranoski & Ayello, 2004a).
Stage III Pressure Injury: This stage is characterized as a full thickness injury located most commonly over a bony prominence (Butler, 2007). There is no remaining epidermis or dermis, therefore indicating a complete or full dermal injury (Figure 6). The subcutaneous tissue is often exposed, and undermining/tunneling may also be present. Slough can be noted with this stage as well. This slough, however, does not obscure the depth of the injury (Baranoski & Ayello, 2004a). Slough, when noted in a pressure wound, is a key indicator of an injury which is either a Stage III or a Stage IV Pressure Injury (Baranoski & Ayello, 2004a).
Stage IV Pressure Injury: This stage is characterized by an injury most commonly located over a bony prominence, which extends to the subcutaneous tissue or muscle (Figure 7). Tendon or bone is often exposed with this stage, along with undermining and tunneling (Baranoski & Ayello, 2004a). Slough, not obscuring the depth of the injury, can also be noted with this stage.
Unstageable Pressure Injury: This stage is characterized by a pressure injury located most commonly over a bony prominence, which is covered with slough or eschar (Figure 8). This slough completely obscures the depth of the injury; therefore, the depth of the wound cannot be visualized. Because the depth of injury can not be visualized, it is classified as an Unstageable Pressure Injury (Butler, 2007).
This slough may be yellow, tan/brown, black, or mixed in color (Baranoski & Ayello, 2004a).
Pressure injuries classified as either a Stage III or a Stage IV Injury will always be classified as a Stage III or Stage IV Injury (Baranoski & Ayello, 2004a). Reverse staging does not occur as the ulceration heals. During the wound healing process, the tissue that is replaced is granulation tissue and epidermal tissue (Baranoski & Ayello, 2004a). The muscle tissue, subcutaneous tissue, and dermal tissue that are lost from the pressure injury are never replaced (Baranoski & Ayello, 2004a). Therefore, if an injury occurs at a previously injured site, which was classified as a Stage III or Stage IV Injury, then this injury will again be reclassified as a Stage III or Stage IV Pressure Ulceration. This is because there is no supporting tissue or insulation protecting the bony prominence other than granulation and epidermal tissue.
Previously healed pressure-related injuries are also prone to reinjury because of the lack of tensile strength of the epidermal and dermal skin (Baranoski & Ayello, 2004a). Once the skin is injured, the tensile strength of the newly healed skin will never return to 100% tensile strength of uninjured skin. It will only be 70%–80% as strong at the end of the wound healing process (Baranoski & Ayello, 2004a). Therefore, a previously injured pressure injury is prone to recurrence not only because of the lack of supporting tissue but also because of the lack of tensile strength of the previously injured skin.
Pressure ulcer prevention begins with an accurate head-to-toe skin assessment (Butler, 2007). A complete skin assessment includes visual inspection of the anterior surface and the posterior surface of the skin. It is also important to inspect the skin between body folds and underneath devices (Cakmak et al., 2009). During the skin assessment, pay particular attention to the skin overlying the bony prominences. This inspection includes observation not only for a current injury but also for scarring, which may represent a previously healed pressure injury. These scarred areas are especially prone for reinjury because of the lack of tensile strength of the skin and the supporting tissue for those deeper pressure injuries (Baranoski & Ayello, 2004a).
Once the skin assessment is completed, a risk assessment guide is required to determine which patients are at risk of a pressure injury (Crumble & Kane, 2010). The most commonly used assessment guides for the pediatric patient are the Modified Braden Q and the Neonatal Skin Score for preterm infants (Modified Braden Q Score for Pediatric Patient, 2007). The Modified Braden Q consists of a seven-subscale system that rates the patient on their mobility, activity level, sensory perception/neurological deficits, exposure to moisture, friction/shearing, nutritional status, and the perfusion and oxygenation of their tissue (Butler, 2007). Each subscale is rated 1 though 4; a score of 1 indicates a higher risk of injury, whereas a score of 4 indicates a lower risk of injury. Scores range from 7 to 28, with 7 putting the child at the highest risk of injury and 28 representing no risk of injury (Drake et al., 2010). Typically, a score of 15 or below indicates that the patient is at risk of some type of skin injury. Therefore, preventative measures are recommended to prevent an injury from occurring (Butler, 2007).
The Neonatal Skin Score is a skin assessment guide used for preterm infants (Lund et al., 1999). The neonatal skin score consists of three subscales: dryness, redness, and skin breakdown (Lund et al., 1999). Each subscale is rated 1 through 3 (Neonatal Skin Condition Score, 2007). This skin scoring system is opposite of the Modified Braden Q scoring system. The scoring with the Modified Braden Q system indicates that the lower the score, the higher the risk of injury. The Neonatal Skin Score system indicates the lower the score, the lower the risk of injury. Therefore, a score of 1 indicates no risk and a score of 3 represents the highest risk. Any neonate who scores higher than 5 will need additional preventative measures initiated (Lund et al., 1999).
Both skin assessment and risk assessment are recommended measurement guides to be utilized upon admission to the hospital, transferring to a different unit within the hospital, on every shift, or as per your departmental protocol. It is especially important to complete a thorough and accurate skin assessment upon admission to the hospital (Butler, 2007). Insurance companies will not pay for the cost to heal a Stage III or Stage IV pressure-related injury if it has occurred during a patient’s hospitalization. Therefore, if a patient is admitted to the hospital and has a current pressure injury, it is important that the hospital is not penalized for a pressure injury that was already present upon admission (Cakmak et al., 2009).
Prevention of a pressure injury or early detection is the goal for all healthcare providers in caring for their patients. If it is determined that an individual is at risk of a pressure injury to the skin, it is important to develop strategies to prevent their occurrence (Butler, 2007). Interventions can be creative but should include positioning of the patient, moisture and friction reduction, pressure redistribution with the use of support surfaces, nutritional interventions, and education (Baharestani & Ratliff, 2007).
Positioning of the individual: Interventions to reduce pressure over bony prominences include a turning and repositioning schedule. This schedule must be done every 2 hours (Butler, 2007). To prevent friction and shearing, remember to lower the head of the bed, as tolerated before repositioning. To prevent shearing from sliding down in the bed, avoid elevating the head of the bed for more than 2 hours at a time (Butler, 2007). “A towel roll or rolled blanket underneath the thighs or at foot of the bed can also be beneficial to prevent sliding” (Butler, 2007). However, there are exceptions to the rule of turning every 2 hours. In an unstable and critically ill child, frequent turning may be contraindicated (Schindler et al., 2007). Therefore, other preventative measures will need to be initiated to prevent a skin injury from occurring.
Protection of Bony Prominences: The anatomical sites of a pressure injury occurring in the pediatric population are most commonly found on the occipital area, the sacrum, the ear lobes, and the heels. The anatomical sites of injury do differ slightly from the anatomical sites of the adult population. The anatomical sites of injury in the adult most commonly include the sacrum, the heels, the elbows, the lateral ankles, the hips, and the ischial tuberosities (Butler, 2007). Although some locations are common to both populations, it is important to know that there are some sites that are unique to the pediatric patient, such as the occipital area. Knowledge of these differences will assist the healthcare provider in identifying appropriate interventions of prevention for these pressure-prone areas.
For those pressure-prone bony prominences, in addition to repositioning, a barrier device can be helpful to prevent an injury from occurring (Baharestani & Ratliff, 2007). One example of a bony prominence that is prone to injury in both children and adults is the heel. Protection of the heels can be accomplished by suspending the heels off the bed using pillows, gel foams, positional protective pillows, or other protective devices, such as a foam-padded boot (Baharestani & Ratliff, 2007). One example of a foam boot would be the Prevalon boot. These boots will protect the heel, the lateral ankle, and the medial ankle from injury (Figure 9; Baharestani & Ratliff, 2007).
The sacrum is also an area that is prone to injury in both children and adults. Protective barrier dressings can be helpful in preventing an injury to this area (Butler, 2007). These protective barrier dressings need to include some type of foam cushioning for the protection of the bony prominence but must also protect the skin from shearing with their removal. One example of a protective barrier dressing that is gentle on the skin is a dressing called Mepilex Border Sacrum (Figures 10 and 11). This is a silicone-based product that is nonadherent and is gentle on the skin when it is removed (Schober-Flores, 2009). Do not assume, however, that if a barrier dressing is in place, the skin is intact underneath. These products do still need to be removed, and a skin assessment should be completed as recommended by your departmental protocols.
The occipital area is a common site of injury in both infants and small children because of the larger size of the head in the pediatric population. Therefore, it is important to remember to change the position of the head when turning and repositioning these patients every 2 hours (Butler, 2007). In addition, the use of protective devices, such as a gel pillow, a foam pillow, or other positional protective pillows can be beneficial in preventing injury to this area (Baharestani & Ratliff, 2007).
Another pressure-prone area in the pediatric patient population is the ear. When repositioning a pediatric patient, pay particular attention to the ears and avoid placing any type of pressure on this area (Baharestani & Ratliff, 2007). Positional pillows or other protective barrier dressings can be beneficial in pressure reduction for this area as well. If a barrier dressing is being utilized, choose dressings that conform well to the ear but can be easily removed for a skin assessment underneath as per your departmental protocol (Butler, 2007).
DEVICE-RELATED PRESSURE INJURY
Device-related injuries are common pressure injuries in children. In the literature reviewed, 50% of the pressure injuries noted in the pediatric patient were device related (Baharestani & Ratliff, 2007). Therefore, it is important to assess what medical devices are being used and to be creative in ways to protect the underlying skin.
A common device-related injury that occurs in the pediatric patient is from a pulse oximeter. If a pulse oximeter is being used, change the location as per your departmental protocol. In addition, a fenestrated contact dressing can be used underneath the pulse oximeter to help prevent a skin injury from occurring (Schober-Flores, 2009). The fenestrations within these dressings allow to the pulse oximeter to maintain the desired reading of the oxygen and heart rate while, at the same time, protecting the skin from injury (Figure 12). Another device-related injury that can occur is from a gastrointestinal tube. The skin underneath a gastrointestinal tube is prone to injury not only from pressure, shear, and friction but also from maceration and skin breakdown from any drainage or leakage of the gastric contents (Baharestani & Ratliff, 2007). A foam protective barrier dressing can cushion and protect the skin from the pressure of the gastrointestinal tube and absorb any drainage or leakage, which may be occurring around or from the gastrointestinal tube site (Figure 13).
The rubbing of a nasal cannula can also result in device-related injury on the upper lip (Baharestani & Ratliff, 2007). To protect this area from trauma, a barrier dressing such as a silicone tape or a thin hydrocolloid can be beneficial in maintaining the skin integrity (Figure 14). However, for those patients with fragile skin, silicone products that do not have strong adhesives offer better protection because they do not result in skin shearing upon their removal.
REDUCTION OF MOISTURE
A moist environment, caused by fecal and urinary incontinence, can increase the risk of skin breakdown in the diaper area (Cakmak et al., 2009). To prevent an injury to the skin, applying a petrolatum-based ointment or a zinc oxide paste to the skin with each diaper change can be beneficial. It is also always important to change a diaper as soon as incontinence is noted and reapply the ointments after each diaper change for the best preventative skin outcomes (Butler, 2007). For skin that is not intact, it is beneficial to apply a thick coat of a prescription zinc oxide paste to the affected skin (Cakmak et al., 2009). This paste will act as a barrier from urinary and fecal incontinence and thus will protect the skin from discomfort and further injury (Cakmak et al., 2009). It is also important to change the diaper as soon as incontinence is noted. However, do not wipe off the paste, cleanse only the urine or stool off the paste, and always reapply additional paste with each diaper change for the best outcome.
PRESSURE REDISTRIBUTION WITH SUPPORT SURFACES
Support surfaces are effective in the prevention of a pressure injury but can also be used to eliminate further damage from occurring if a pressure ulcer has already been established. Examples of pressure-reducing support surfaces include a mattress overlay, an air-filled mattress, or a low air loss mattress with or without pulmonary function. These surfaces, combined with good wound healing practices, will allow the pressure injury to heal by removing the cause of injury. In addition to pressure relief, the airflow flow through the air loss mattress will also decrease the moisture on the skin resulting in a healthier skin barrier (Turnage-Carrier et al., 2008). Specialty surfaces, however, do not eliminate the need for repositioning and turning. Turning an individual every 2 hours is still required regardless of the surface a child is laying on (Butler, 2007).
A nutritional consult and treatment plan can be very beneficial for the prevention of injury or to promote better wound healing if a pressure ulcer has already been established (Butler, 2007). Low albumin levels and poor nutrition are considered risk factors for pressure ulcer development; therefore, good nutrition can help prevent an injury from occurring (Cakmak et al., 2009). In addition, if a pressure an injury has already been established, additional protein, calories, vitamins, and minerals are required to promote the wound healing process (Schober-Flores, 2009). Therefore, good nutrition is important not only in prevention but also in the promotion of optimal healing for those established ulcerations.
Teaching basic skin care, pressure ulcer prevention, and strategies for pressure reduction is important to all individuals involved in the care of a patient, including family members (Cakmak, et al., 2009). Involving the parents or other family members in this process can help give them a sense of control and reduce the sense of powerlessness that some parents may feel when their child is hospitalized. This education should be done immediately upon admission to the hospital. An individualized care plan for each patient is needed after the skin and risk assessment is completed (Drake et al., 2010). This should include the type of risk assessment guide used, it’s scoring, and what preventative measures are being utilized (Butler, 2007). These preventative measures should be maintained and reevaluated throughout the patient’s hospitalization.
Pressure ulcer prevention in the pediatric patient is accomplished through pressure ulcer awareness with education to all healthcare providers and families involved in the care of a pediatric patient. Completing a thorough skin assessment and utilizing a risk assessment guide is important to determine which patients are at a high risk of a pressure or skin injury. Pressure ulcer prevention can be accomplished by the initiation and continued implementation of preventative strategies and maintaining them on those high-risk patients (Drake et al., 2010). These strategies include addressing patient positioning, good skin practices, reducing moisture on the skin, pressure redistribution with the use of support surfaces, maintaining optimal nutrition, and lastly educating all individuals involved in the care of patient about pressure ulcer prevention. However, education, research, and evidenced-based practices will need to be continued to provide our patients with the best skin care practices. The goal of pressure ulcer prevention is obtainable, but it cannot be accomplished without education, awareness, and good skin care practices.
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Keywords:© 2012 Lippincott Williams & Wilkins, Inc.
Pressure Ulcer; Pressure Ulcer Classification; Pressure Ulcer Prevention; Skin Anatomy; Skin Care; Skin Facts