An Introduction into Techniques for Prevention of Stage One Pressure Sores
in the Pediatric Population
Philip Gates MD, Justina Shipley, CO, MEd, FAAOP
Shriners Hospital for Children, Shreveport, Louisiana
OBJECTIVE: Introduce methods of prosthetic and orthotic
device fabrication, fitting criteria, use of the Braden Scale, and
parental education techniques to help the prevention of stage
one pressure sores in the pediatric population.
DISCUSSION:
Pressure Sores, Pressure Ulcers or Decubitus Ulcers
Pressure sores must be taken seriously; if left unchecked, a
pressure sore can lead to amputation or in the worst case death.
Even when well cared for, a pressure sore can still become
infected such as was the case with Christopher Reeve in October
2004. Christopher had the best care and was looked after by
dedicated staff at Northern Westchester Hospital, but still his
sore became severely infected, resulting in a serious systemic
infection. This in turn led to a heart attack and coma from which
he did not recover. Check yourself for red marks and sores daily,
it should be a routine which is as second nature as brushing your
teeth.
History of the Braden Scale
The Braden Scale for Predicting Pressure Sore Risk was developed during a
Robert Wood Johnson Teaching Nursing Home project and while writing an
NIH proposal to study pressure ulcer risk factors. The Braden Scale was
initially tested for reliability and validity and these results were published in
Nursing Research in 1987. A larger multi-site study was conducted to
determine the reliability and validity of the tool in a variety of settings
resulting in revisions in the recommendations for the critical cutoff score and
the timing of assessment. Results were published in Nursing Research in
1998. A follow-up report in Nursing Research in 2002 demonstrated that the
tool could be used in Black and White subjects with similar validity. This tool is
in use on all continents and has been translated into many languages,
including Japanese, Chinese, Korean, Indonesian, Italian, German,
Portuguese, Polish, Arabic, Finnish, Norwegian, Icelandic, Flemish, Croatian,
Dutch and French.
Stage One Pressure Sore
How to recognize: Skin is not
broken but is red or discolored.
The redness or change in color
does not fade within 30 minutes
after pressure is removed.
Wound Definition
Stage 1 pressure ulcers are non-blanchable
erythermal intact skin, the heralding
lesion of skin ulceration. In individuals
with darker skin, discoloration of the skin,
warmth, edema, indurations or hardness
may also be indicators.
The Braden Scale has been disseminated widely, translated into many
languages, and is used to some extent around the world-wide. A recent
systematic review by Pancorbo-Hildalgo and colleagues (2006) examined
studies of various risk assessment tools published in Spanish, English, French
and Portuguese and performed a meta-analysis to determine which of the
many risk assessment tools available demonstrated the best reliability and
validity. They compared the Braden Scale, Norton Scale, and the Waterlow
Scale. They concluded that the Braden Scale had been tested in the largest
number of studies, had demonstrated the best reliability and validity indicators
in a variety of settings, and was a better predictor of pressure ulcers than
nursing judgment.
Visual Signs
Pediatric patient example of Stage 1
pressure ulcer due to sheer force.
Note the tell-tale redness and swelling
of the epidermis. Circumferal flaring
and use of ShearBan ® were incorporated
to treat this patient
Techniques For Pediatric Bracing:
Pressure sores are also be referred to as pressure ulcers or
decubitus ulcers. The damage from a pressure sore will range
from slight discoloration of the skin (stage 1) to open sores that
go all the way to the bone (severe). The affected area may feel
warmer than the surrounding tissue. In light-skinned people, the
discoloration may appear as dark purple or red. In darkerskinned people, the discoloration will appear darker than the
surrounding tissue.
Brace Modification: Plastic deformation
Friction Mitigating Mediums: (ShearBan),
soft shear gel sheeting or pressure relief
padding
Device Modification: Skeletal alignment,
joint positional nuetrality
A pressure sore is an injury to the skin and the tissue under it. A
pressure sore develops when the blood supplying the tissue with
oxygen and nutrients is cut off, and the tissue no longer
receiving oxygen and nutrients dies. The oxygen and nutrients
are essential to maintain healthy tissue. Sitting in the same
position for a prolonged period of time can start the process of
tissue breakdown.
Anatomical Structural Support
R eprinted by P erm ission
Even pediatric patients are at risk for pressure sores. Children are
active and may not pay attention to a developing sore especially
if they have neurological deficits. Therefore it is essential to
check the skin consistently for any pressure areas. Pediatric
patients are at risk because of rapid growth and activity levels.
Children may not even be aware of the level of potential damage
the skin is in. Using an assessment tool such as the Braden scale
when a patient is fit with a device can prove beneficial to both
practitioners and parents. The results of the prediction can help
develop a solid and effective plan of care that will both protect
the patient and the practitioner.
The Braden Scale for Predicting Pressure Sore Risk
I nstructions:
Use the Braden Scale to asses the patient's level of risk for development of pressure ulcers.
The evaluation is based on six indicators: sensory perception, moisture, activity, mobility, nutrition, and
friction or shear.
Scoring:
R eprinted by P erm ission
The Braden Scale is a summated rating scale made up of six subscales scored from 1-3 or 4, for total
sores that range 6-23. A lower Braden Scale Score indicates a lower level of functioning and, therefore,
a higher level of risk for pressure ulcer development. A score of 19 or higher, for instance, would
indicate that the patient is at low risk, with no need for treatment at the time. The assessment can also
be used to evaluate the course of a particular treatment.
Pressure Mitigating Mediums: (Moleskin),
porous foams with adhesive backing
Works Cited
Johnson, & V Fay. (2004). HOW TO IDENTIFY AND PREVENT PRESSURE ULCERS. The Gerontologist: PROGRAM ABSTRACTS: 57th Annual Scientific Meeting..., 44(1), 70. Retrieved February 7, 2011, from
ProQuest Medical Library. (Document ID: 920577101).
Stopping pressure ulcers-Before they start. (2004, May). Nursing Homes, 53(5), 30-38. Retrieved February 7, 2011, from ABI/INFORM Global. (Document ID: 649424751).
David R Thomas. (2001). Issues and dilemmas in the prevention and treatment of pressure ulcers: A review. The Journals of Gerontology: Series A Biological sciences and medical sciences, 56A(6), M32840. Retrieved February 7, 2011, from ProQuest Medical Library. (Document ID: 74000289).
Susan Hook. (1998). Guidelines to help manage pressure ulcers. Australian Nursing Journal, 6(6), 27. Retrieved February 7, 2011, from ProQuest Medical Library. (Document ID: 36781691).
Cathy Thomas Hess. (1998, July). Preventing skin breakdown. Nursing, 28(7), 28-9. Retrieved February 7, 2011, from ProQuest Medical Library. (Document ID: 31776535).
Gates, Judy L. (1996). TQM: Pressure ulcer prevention. Nursing Management, 27(4), 48E. Retrieved February 7, 2011, from ABI/INFORM Global. (Document ID: 9602622).
Carlson, M. (2009). The role of friction management in keeping our patients walking in comfort. Retrieved from http://www.tamarackhti.com/friction_management/shearban.asp
Braden, B (1998). The braden scale. Retrieved from http://www.bradenscale.com/
Hanson, D., Langemo, D. K., Anderson, J., Thompson, P., & Hunter, S. (2010). Advances in Skin & Wound Care, 23(1), 21-24.doi:10.1097/01.ASW.0000363489.38996.13