The National Pressure Ulcer Advisory Panel (NPUAP) defines a PU as a localized area of tissue damage developing when soft tissue (fat, muscle, arterial, and venous vasculature, etc.) is compressed between a bony prominence and any external surface for a prolonged period (Butler, 2006). When the blood supply to the area is compromised, delivery of oxygen and nutrients vital to cell viability is diminished, resulting in localized hypoxia, cellular death, injury to the surrounding tissue, and ultimately development of a PU. Prevalence (patients with PUs among those surveyed in a setting) and incidence (patients who developed PUs after admission to the setting) of all PUs within the home care setting in the United States have been reported as 0% to 29% and 0% to 17%, respectively (Ayello & Braden, 2002). In a study of pediatric wound clinic patients, Samaniego (2003) found PUs in 50 of 69 children with either paralysis or immobility. Also, in a study of 227 patients with myelomengiocele over a 20-year time frame, researchers reported an overall PU incidence rate of 43% (Samaniego, 2003). Recognition of patients at risk for PUs and implementation of preventative interventions should be an ongoing patient care goal for any healthcare provider, including those in the home care setting.
Angel was a small-for-her-age, healthy 5-year-old when she was involved in a head-on car collision resulting in a C3–C4 spinal cord injury. She spent 8 weeks in the intensive care unit (ICU) followed by 9 weeks in a pediatric rehabilitation facility while her family learned to care for this child, now with quadriplegia. Her hospitalization was complicated by two episodes of respiratory and cardiac arrest and numerous occurrences of respiratory insufficiency with poor oxygenation. Midway through her ICU stay, a tracheostomy was placed to facilitate ventilator support, and a gastrostomy tube was inserted for enteral nutrition. Although severely physically impaired, cognitively Angel is a normal 5-year-old and is learning to communicate her wants and needs through facial expression and eye movements. She does exhibit episodes of hypertension and flushing, which usually resolve with urinary catheterization.
Prior to discharge, Angel will be fitted with an appropriate-for-size wheelchair that can accommodate the home ventilator. She will continue home therapy including range of motion, flexibility and muscle strength work, and communication skills. Once settled, Angel will be enrolled in school to pursue a close-to-normal education tract. Home nursing care has been approved for 12 hours per day that her mother has chosen to use during the mid-portion of the day to facilitate employment.
Angel's skin care needs are complicated by the presence of a Miami-J cervical collar, immobility, and an inability to communicate sensory perceptions. Home care nurses will need to work with her mother and aunt to develop a daily plan of care that incorporates specific skin care interventions.
Although the principles of PU prevention remain the same whether caring for an adult or a child, the most common sites for PU development differ with age. McLane et al (2004) studied the incidence and prevalence of PUs in hospitalized children, reporting the sacrum/coccyx, heels (and occiput in infants) as the most commonly observed locations. Other noted areas of PU development in children include the ischium, spinous processes, scapula, trochanter, and malleolus (ankle).
Evidence-based guidelines for PU prevention and management were first published by the Agency for Healthcare Research and Quality in 1992 (AHRQ, 2010). Subsequent evidenced-based guidelines have been published by the Wound, Ostomy and Continence Nurses Society (WOCN) and the NPUAP, providing insight for the identification of at-risk patients needing preventative interventions and the factors that place these patients at risk (WOCN, 2010). Specific risk factors for skin breakdown in children include paralysis, insensate areas, immobility, poor nutritional status, decreased sensory perception, and conditions that compromise the skin such as dermatitis and maceration caused by excessive moisture (Rodriguez-Key & Alonzi, 2007).
Although there is no definitive evidence that using a risk assessment scale reduces the incidence of PUs, utilization of an approved assessment tool is thought to increase PU prevention initiatives (Pancorbo-Hidalgo et al., 2006). In 1996, Quigley and Curley adapted the adult Braden Scale into a 7-category risk assessment tool for use in the pediatric population: the Braden Q Scale (Figure 1). Each of the seven subscales is mutually exclusive, rated from 1 (least favorable) to 4 (most favorable). The total possible risk assessment score ranges from seven, denoting the highest risk for skin breakdown, to 28, virtually no risk for breakdown. Patients are considered at moderate risk with a score of 21 and at high risk with a score of 16 (WOCN, 2010). Individual subscale scores can assist the caregiver in prioritizing prevention initiatives, placing a greater focus on categories with the lowest scores.
Patient factors reported in the literature and in the Braden Q Scale as being responsible for ulcer development are intensity and duration of pressure and the tolerance of the skin and soft tissue to endure the effects of that pressure (Butler, 2006). The intensity and duration of pressure on the skin are impacted by the patient's level of mobility, activity, and sensory perception. An early researcher in pediatric skin care, Neidig et al. (1989) reported increased pressure, over short periods, could result in the same degree of injury as slight pressure over long periods. Conditions rendering the patient bedfast or chairfast with an inability to change position are at risk due to immobility. Also, the increased rate of growth experienced by children necessitates frequent careful assessment of "fit" of accessory devices and equipment such as splints and wheelchairs to avoid the creation of "pressure points."
Tissue tolerance includes intrinsic and extrinsic factors to the patient. Intrinsic factors such as nutritional status and tissue perfusion affect metabolic function at the cellular level; inadequate nutrition is one of the major risk factors associated with the development of PUs. Extrinsic factors are those that support healing and reduce the risk of PU development, specifically, the absence of moisture, friction, and shear. Primary sources of skin moisture include perspiration, urine, and feces. Friction occurs when two surfaces, such as skin and bed linen, rub together; friction injuries are typically superficial that present clinically as abrasions. Most often, friction occurs during the process of repositioning; high-risk areas include heels, elbows, and the sacrum. Shearing is the mechanism in which the blood supply is compromised by the lateral displacement of tissue. Bones move against the subcutaneous tissue, whereas the outer layers of skin remain in the same position against the bed or seat surface. Over time, this decrease in blood flow leads to skin breakdown (Butler, 2006).
Loss of Sensory Perception
When a child suffers a neurological injury resulting in an alteration in sensation, he or she no longer has the ability to sense discomfort or pain. This inability to depend on the tactile sense to know when discomfort is occurring means that awareness and assessment must be ongoing and ever vigilant. These patients' bodies also have difficulty regulating body temperature and their inability to recognize when they are too cold may lead to a decrease in perfusion. These factors severely increase their risk for skin breakdown and PUs. Their loss of sensation causes an inability to know when skin and underlying tissue is being traumatized from poor perfusion and excessive pressure. Pressure areas quickly become red and lose the ability to blanch resulting in stage one PUs that can quickly deteriorate without frequent and ongoing assessment and intervention.
Although the patient may not actually feel the pain or numbness from pressure, the signs may still be present in other ways. The ability of the caregiver and/or the patient to recognize these as signs of potential skin injury can make a difference and prevent a medical emergency. Involuntary muscle spasms and autonomic dysreflexia (AD) are often the first signs that there is discomfort somewhere on the body. AD is a syndrome affecting patients with spinal cord injury at T-6 or above, and is characterized by hypertension, bradycardia, severe headaches, and pallor below with sweating and flushing above the cord lesion. AD is the result of impaired function of the autonomic nervous system caused by simultaneous sympathetic and parasympathetic activity that may occur with bowel or bladder distension, pain, skin irritation, or a PU (Schottler et al., 2009). When these symptoms occur, rapid investigation and correction of the cause as well as assessment of any potential damage to the skin and underlying tissue are paramount.
Device-related PUs may be caused from ventilator or tracheostomy tubing lying on the skin, tracheostomy tube flanges burrowing into the skin, noninvasive positive pressure masks, and oximeter probes. Frequent skin assessment and repositioning of tubing, masks, and probes will reduce the risk of device-related breakdown. Padding with foam or hydrocolloid dressings may also be beneficial in some situations.
Patients should be repositioned frequently; turning patients every 2 hours is considered the standard of care in the hospitalized patient. At home, patients that are immobile may require a specialty bed surface to redistribute pressure. Turning and repositioning frequency should be individualized to the patients needs to maintain comfort and skin integrity. Patients must be lifted off the surface when being repositioned to reduce shear and friction injuries; often the aid of lift devices to prevent injury to both patient and healthcare provider is required. Keeping the head of the bed at 30 degrees or less will also decrease the risk of shearing injury. Pillows to pad between bony prominences and to elevate heels off surface will help reduce pressure to these areas.
Frequent position changes in the wheelchair are as important as or possibly even more important than when in bed. The use of therapeutic air or gel cushions in the wheelchair helps prevent pressure points but they do not eliminate them completely. If the child is able to understand, it is important to start reinforcing the need for repositioning from the beginning. Children capable of doing so should be taught to do "push-ups" or wiggle and lift their bottoms at least every hour (Samaniego, 2003). Many times the child in a power wheelchair will have the ability to recline or tilt the chair themselves, thus allowing them the ability to change pressure points without assistance. If the child is unable to independently reposition, the caregiver must be taught to reposition at regular intervals and to monitor the ischial and sacrocoxygeal areas for tissue damage.
Nutrition plays a major role in the prevention and treatment of skin breakdown in all patients. As many as 40% of children with special or complex healthcare needs have been estimated to be at risk for nutrition problems, making early identification essential (Rodriguez-Key & Alonzi, 2007). Maintenance of proper nutrition is complicated by the smaller body size of children, their ever-changing growth needs, and lower caloric reserves. Each child should have an individualized nutritional care plan unique to their specific needs and goals. It is not unusual for maintenance energy requirements of a child with complex health needs to be as low as 7 to 9 kcal/cm, when the normal range would be double (Rodriguez-Key & Alonzi, 2007). Although children with limited activity, immobility, or spastic cerebral palsy may be prone to obesity, those with hypertonia, hyperactivity, or athetoid cerebral palsy frequently have greatly increased kilocaloric needs. If these factors are not taken into consideration, children could be over- or undernourished, increasing the risk for the development of or prolonged healing of PUs.
Excreted body fluids are responsible for the most common breaches of skin integrity, specifically, the consequences of fecal or urinary incontinence (Sibbald et al., 2003). Patients who have fecal incontinence are at an increased risk for the development of incontinence-associated dermatitis (IAD) and secondary fungal infections (Junkin & Selekok, 2007). The enzymes in the stool weaken the barrier the skin provides, making the area more susceptible to the development of PUs (Junkin & Selekok, 2007). IAD can be mild to severe with associated degrees of pain and discomfort. Maintaining a moisture barrier paste on the skin can prevent or lessen IAD and diminish the risk of skin breakdown and PUs. When cleaning the area, it is important to gently remove only the soiled skin barrier layer. Aggressive cleansing or rubbing can contribute to skin stripping and breakdown.
Dry skin is prone to cracking, weakening the skin, making a patient more susceptible to skin breakdown. Moisturizing the skin helps to prevent breakdown by keeping skin healthy and supple. Patients with skin folds can benefit from padding between folds to prevent skin-to-skin friction and absorb moisture that can collect in folds.
Home Care Implications
Skin care in the home care setting should be continual and focus should be incorporated into daily care and routines (Table 1). Bath time should include a full inspection of the body with prompt attention to any changes or new reddened areas. Exaggerated movements during bathing and dressing incorporates passive range of motion. Although this does not usually involve a specific number of repetitions, it allows for rotation and flexing of all joints and muscles during care. Anytime the patient is repositioned or transferred back to bed from the wheelchair, an additional visual inspection of the body is needed to again assess for changes.
Awareness of potential pressure areas specific to the individual allows for appropriate preventive measures to be taken. Because the heel of the foot is often a problem area, rotating between two or three different pairs of shoes can change the areas of pressure and prevent breakdown. In a bedbound patient, elevating the heels off of the bed surface is essential. While seated, a leg strap to keep the hips midline can prevent pressure from the leg rest of the wheelchair. High-profile air cushions or gel cushions specific to the child's needs helps prevent pressure to the hip and tailbone area. If the wheelchair is equipped with the ability to recline or tilt, it is important to encourage the child to utilize these functions as they are able. This helps change pressure points and encourages accountability and autonomy of their own care. A quality air mattress, or redistribution mattress, that allows the firmness of the mattress to be adjusted as needed may decrease the need for frequent turning and repositioning at night, allowing the patient and the caregiver the opportunity to rest.
In Angel's case, she and her family are preparing for home and the new challenges her hospital discharge will bring. Her mother is well aware of her complex needs as well as the potential for complications, including those related to skin care. Her healthcare providers have developed a repositioning schedule that includes bed and wheelchair positioning, and range of motion and communication exercises. The focus of her home healthcare providers should be continual awareness of potential pressure areas, the risk factors that would increase the incidence, and follow-through with appropriate preventative measures.
The development of skin breakdown has noteworthy implications for both patients and caregivers with potentially catastrophic outcomes. Nurses caring for children should never discount that PUs can and will develop without proper attention. The identification of risk and prevention of PUs is complex, patient specific, and dependent on a collaborative approach involving the patient/family and every healthcare provider. Use of a valid and reliable risk assessment tool should be considered. Education is extremely important; parents may be overwhelmed when caring for a child with complex needs. Explaining the basics of skin care and PU prevention and providing written guidelines may help alleviate anxiety and ensure consistent care not only by all assigned nurses, but by family as well when they are caring for their child alone.
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