Pediatric Skin Care: Guidelines for Assessment,
Prevention, and Treatment
Colleen T. Butler
Pediatr Nurs. 2006;32(5):443-450. ©2006 Jannetti Publications, Inc.
Posted 12/19/2006
Abstract and Introduction
Abstract
The review of literature suggests the pediatric population is at risk for skin breakdown and
therefore pressure ulcer development. The literature reveals limited information on pediatric
skin care issues in comparison to the adult population. The prevention and treatment of
pressure ulcers and maintenance of skin integrity in the pediatric population often is not a
high priority especially in the critically ill child. Research has demonstrated that children differ
from adults in the anatomical sites of skin breakdown; however, treatment remains the same.
It is important to have an understanding of the underlying physiology of ulcer formation, the
factors responsible for ulcer development, and the factors that put infants and children at risk
for developing pressure ulcers. Accurate assessment, documentation, prevention, and
treatment are all key factors.
Introduction
The prevention and treatment of pressure ulcers and maintenance of skin integrity in the
pediatric population often is not a high priority, especially when caring for the critically ill child.
Pressure ulcers are often considered a problem in the adult population; however, research
shows that pressure ulcers do occur in the pediatric population. An abundance of nursing
research exists on the incidence, prevalence, and cost of pressure ulcer prevention and
management in adults (Quigley & Curley, 1996). The available pediatric skin care literature
has been based on the adult research in the attempt to meet the special needs of the
pediatric population.
Prevention and management of pressure ulcers is multifaceted. One must understand the
underlying physiology of ulcer formation, the factors responsible for ulcer development, and
the factors that put infants and children at risk for developing pressure ulcers. Accurate
assessment, documentation, prevention, and treatment are all important factors.
The skin is an organ that forms a protective barrier against bacteria, chemicals, and physical
action, while maintaining a homeostatic internal environment (Bryant, 2000). The largest
organ of the body, the skin receives one third of the body's circulating blood. The skin serves
many functions: protection, immunity, thermoregulation, metabolism, communication and
identification, and sensation. The skin consists of four layers: the epidermis, dermis,
subcutaneous fat, and muscle (see Figure 1). In the outermost layer, the epidermis, dead skin
cells are constantly being shed and replaced. The dermis, or second layer, has sweat glands,
blood vessels, nerve endings, and capillaries, which are all woven together to provide
nourishment and support. Destruction to either the epidermis or the dermis can cause
systemic infection (Pallija, Mondozzi, & Webb, 1999).
Figure 1.
The Four Layers of the Skin
Source: KCI's Pressure Ulcer Assessment Tool, 2002. Used with permission.
Pressure Ulcer Development
According to the National Pressure Ulcer Advisory Panel (NPUAP), a pressure ulcer is
defined as a localized area of tissue destruction that develops when soft tissue (muscle, fat,
fibrous tissue, blood vessels, or other supporting tissue of the body) is compressed between a
bony prominence and an external surface, for a prolonged period of time (Quigley & Curley,
1996). An ulcer forms when arterioles and capillaries collapse under this external pressure
(Bryant, 2000). With the compression of these vessels, the blood that nourishes the cells is
cut off, resulting in a limited oxygen supply and a decrease in the transportation of vital
nutrients to the cells. These two factors result in tissue hypoxia, causing cellular death, injury
to the surrounding area, and ultimately, a pressure ulcer (Pallija et al., 1999). Factors that
have been identified as responsible for ulcer development include intensity and duration of
pressure, and the tolerance of the skin and supporting surfaces (including soft tissue) to
endure the effects of pressure without incidence. De creased mobility, activity, and sensory
perception contribute to the intensity and duration of pressure (Quigley & Curley, 1996).
Supracappilary pressures cause occlusion of the capillary bed. This pressure leads to the
development of localized tissue ischemia, leading to cellular death and tissue necrosis.
Increased pressure, over short periods of time and slight pressure for long periods of time,
has been shown to cause equal damage (Neidig, Kleiber, & Oppliger, 1989).
Tissue tolerance includes both intrinsic and extrinsic factors. Intrinsic factors include nutrition,
tissue perfusion, and oxygenation. Tissue ischemia and damage occur when cells are
deprived of oxygen and nutrients, combined with an accumulation of metabolic waste
products for a specific period of time. Inadequate nutrition is one of the major risk factors
associated with the development of pressure ulcers. Children must be given adequate
nutrients to reduce the risk of developing pressure ulcers and to support healing. To achieve
this, nutritional support should be designed to prevent or correct nutritional deficits, maintain
or achieve positive nitrogen balance, and restore or maintain serum albumin levels. Nutrients
that have received primary attention in the prevention and treatment of pressure ulcers
include protein, arginine, vitamin C, vitamin A, and zinc (Novartis Nutrition Corporation, 2006).
Extrinsic factors that support healing and reduce the risk of pressure ulcers include: moisture,
friction, and shear. Skin injured by friction, two surfaces rubbing together, has the appearance
of an abrasion. Typically this type of superficial injury is seen on heels and elbows, resulting
from repositioning. Shearing force, such as movement on a bed sheet, creates occlusion by
laterally displacing the tissue. Bones move against the subcutaneous tissue, while the
epidermis and dermis remain, essentially, in the same position against the supporting surface.
This causes a decrease in blood flow to the skin, eventually leading to breakdown (Neidig et
al., 1989). Moisture macerates the surrounding skin, causing superficial erosion of the
epidermis. Primary sources of skin moisture include perspiration, urine, feces, and drainage
from wounds or fistulas.
Risk Factors
Limited information exists regarding the identification of risk factors associated with skin
breakdown in the pediatric patient in comparison to those found in the adult literature.
However, risk factors that have been identified in the adult population include:












immobility
neurological impairment
impaired perfusion
decreased oxygenation
poor nutritional status
presence of infection
moisture
acidemia
vasopressin therapy
surgery
hypovolemia
weight
It can be assumed that many of these factors would affect the pediatric population, similarly;
however, limited research exists at this time.
Review of Literature
A study conducted with postoperative cardiac patients identifies three risk factors for skin
breakdown in the critically ill child. These factors include age, length of intubation, and length
of stay in the intensive care unit (Neidig et al., 1989). The relationship between age and
pressure ulcer formation is due, primarily, to the disproportionately large head, in comparison
to body size, in infants and children. In children younger than 36 months, the head constitutes
a greater portion of the total body weight and surface area. When children are positioned
supine, the occipital region becomes the primary pressure point. Limited hair growth and less
subcutaneous tissue contribute to increased susceptibility to the effect of pressure and
shearing forces, often leading to pressure-induced alopecia. Vigorous side-to-side movement
of the head, as a result of agitation, also increases the shearing force and friction being
applied to the head.
Length of intubation plays a significant role in the development of pressure ulcers for several
reasons. First, the primary goal is to protect the child's airway. This sometimes means
restricting movement and immobilizing the child's head. The use of sedation and paralyzing
agents also plays a role in reducing spontaneous body movements. Unless the child's
position is changed regularly, the head experiences periods of prolonged pressure. Changing
positions can be difficult for the child on extracorporeal membrane oxygenation (ECMO) or
oscillatory ventilation. Finally, length of intubation becomes a factor when sedation and
ventilator settings are being weaned, contributing to weaning agitation. Again, frequent
vigorous side-to-side movement of the head, as a result of agitation, causes friction and shear
(Neidig et al., 1989).
A retrospective cohort study of 32 patients, supported with high frequency oscillatory
ventilation (HFOV), paired with 32 patient on conventional ventilation in a pediatric intensive
care unit (PICU), conducted by Schmidt, Berens, Zollo, Weisner, and Weigle (1998),
investigated the relationship of HFOV to skin breakdown on the scalp and ears in
mechanically ventilated children. Results indicate a higher incidence of skin breakdown in
children ventilated with HFOV than those ventilated with a conventional ventilator (53%
versus 12.5%). However, after the data analysis, it was determined that PICU time at risk was
the most important risk factor for the development of skin breakdown in this population.
Zollo, Gostisha, Berens, Schmidt, and Weigle (1996) conducted a prospective, matched-case
study in a 14- bed PICU in a tertiary care children's hospital. Subjects were assessed, daily,
for a change in skin integrity. Data were collected on 76% of all admissions to the PICU. Zollo
and colleagues concluded that skin breakdown was affected by many factors; however, the
strongest predictors of pressure ulcers were the Pediatric Risk of Mortality Score (PRISM)
completed on admission to the PICU, and White race. The Pediatric Risk of Mortality score is
used to calculate the risk of mortality for patients admitted to pediatric intensive care units. It
consists of 14 routinely measured, physiologic variables, and 23 variable ranges. These
variables include systolic blood pressure, diastolic blood pressure, heart rate, respiratory rate,
PaO2/ FI O2, PaCO2, PT/PTT, total bilirubin, calcium level, potassium level, glucose, HCO3,
pupillary reactions, and Glasgow coma score (Pollack, Ruttimann, & Getson, 1988).
Children with spina bifida and spinal cord injuries were tracked over four years at Children's
Hospital Medical Center of Akron. Pallija and colleagues (1999) identified 11 risk factors
associated with skin breakdown in children with spina bifida and spinal cord injuries: (a)
urticaria, (b) obesity, (c) edema, (d) trauma, (e) surgical incision, (f) paralysis, (g) insensate
areas, (h) immobility, (I) poor nutrition, (j) incontinence, and (k) impaired cognition.
Samaniego (2003) conducted a retrospective exploratory study at an outpatient wound clinic.
The principal diagnoses, identified in the sample, were myelodysplasia (60%), cerebral palsy
(16%), and clubfeet (6%); also included were scoliosis, constricted band syndrome, and
femoral deficiency. Four primary risk factors were identified: paralysis, insensate areas, high
activity, and immobility.
Research has demonstrated that children differ from adults in the anatomical sites of skin
breakdown. Six prominent pressure points have been identified in the adult population: the
sacrum/ coccyx, heels, elbows, lateral malleolus, the greater trochanter of the femur, and the
ischial tuberosities (Meehan, 1994). In infants and children the areas that are affected are the
occipital region (primary in infants), sacral region (primary in children), ear lobes, and
calcaneous region (the heel of the foot) (Neidig et al., 1989). Baldwin (2002) conducted a
national survey of children's health care institutions to determine the incidence and
prevalence of pressure ulcers in children. In her study, the sacrum/coccyx was the most
frequent site for pressure ulcers, heels the second and the occiput region.
Intervention and Prevention
Early intervention can be an effective preventative measure if patients at increased risk for
pressure ulcer development are identified. The principal components for early intervention are
(a) identification of at risk individuals, (b) maintenance and improvement of tissue tolerance to
injury, (c) protection against the adverse effects of pressure, friction, and shear, and (d)
reduction of the incidence of pressure ulcers through an educational program.
Prevention is a multifaceted process. Again, much of the research has been conducted on the
adult population, but it can easily be applied to pediatrics. Pressure ulcer prevention begins
with accurate assessment to identify an at-risk patient. Various tools exist for assessing
adults, and recently the Braden scale, frequently used in adults, has been adapted into the
Braden Q scale for pediatrics. Sandra Quigley and Martha Curley developed this scale in
1996. Changes from the original Braden scale reflect the unique developmental needs of the
pediatric patient, the prevalence of gastric/transpyloric tube feedings, and the availability of
blood studies and noninvasive technology in the acute-care pediatric setting (Curley, Razmus,
Roberts, & Wypij, 2003).
The Braden Q scale consists of seven subscales: mobility, activity, sensory perception,
moisture, friction/shear, nutrition, and tissue perfusion/oxygenation. The first six originate
directly from the Braden scale. Each subscale is rated one through four, with the lowest
number representing the highest risk. Total scores range from 7-28 with seven putting a child
at the highest risk for breakdown and 28 with no risk (see Table 1 ). In a multi-site prospective
cohort descriptive study, Curley and colleagues (2003) studied 322 PICU patients on bedrest
for at least 24 hours, without preexisting pressure ulcers or congenital heart defects. They
found that acutely ill pediatric patients with a Braden Q score of 16 are considered at risk for
Stage II pressure ulcers. The lower relative Braden Q scores that identify patients at risk for
Stage II pressures may reflect a unique characteristic of pediatric skin. Younger skin, which
has sufficient collagen and elastin, may be more resilient to normal and shearing pressures
(Curley et al., 2003).
Early assessment of the risk factors associated with the development of pressure ulcers is
essential in their prevention. When an assessment identifies this risk as high, interventions
should be implemented to reduce the risk. Preventing mechanical injury to the skin from
friction and shearing forces during repositioning and transfer activity is important. The key is
to have a sufficient number of personnel available to move a patient. In pediatrics, most
patients under 8 years of age can be lifted easily enough to prevent friction and shear.
Assistive devices such as lifts, trapezes, transfer boards, or mechanical lifts may be useful
adjunctive devices to minimize tissue injury. Remembering to lower the head of the bed, as
much as tolerated before repositioning, also will help minimize friction and shear. Mechanical
injury from friction can be reduced with application of a barrier dressing, such as transparent
films or hydrocolloids, over at risk areas.
Interventions to reduce pressure over bony prominences are of primary importance. A turning
schedule must be instituted for patients on strict bedrest. In a study of postoperative cardiac
patients, a significant decrease in the incidence of occipital pressure ulcers was observed
(16.9% to 4.8%) by instituting a prevention protocol of repositioning the head at least every
two hours (Neidig et al., 1989). In addition to turning, heels should be suspended off the bed
using pillows or heel lift devices, and the head of the bed should not be elevated for more
than two hours to avoid shearing injury to the sacral area. A rolled up blanket is always useful
under the patient's upper thighs, or the bottom of the bed can be elevated to reduce the
chances of a patient sliding down in the bed. Of course, repositioning is not always an option
before hemodynamic and respiratory stability is achieved. Other factors influencing the ability
to reposition a patient include line placement, edema of the head and neck, or a positional air
leak around the endotracheal tube.
Even with correct positioning methods, a therapeutic surface may need to be used (Bryant,
2000). Although a principal goal in nursing care is to reduce external forces of pressure,
shear, friction, and moisture, to prevent or treat tissue injury, frequent turning may be
contraindicated in unstable, critically ill children. Examples of such patients include a patient
who is hemodynamically unstable, a patient with acute respiratory distress syndrome (ARDS)
whose oxygen saturations may decrease with position change, or a patient on ECMO or high
frequency oscillatory ventilation.
Another important factor that can reduce the risk of the development of pressure ulcers is the
type of surface supporting the patient. The therapeutic benefit of a product and its ability to
maintain skin integrity determines which type of surface will offer the best outcome. Airflow
through the surface of a mattress will reduce moisture. The material used on the surface of a
mattress or overlay will determine the product's ability to reduce friction and shearing. A
therapeutic surface should reduce or relieve pressure, promote blood flow to the tissues, and
enable proper positioning. The ability of a product to reduce or relieve pressure is determined
by its interface and capillary-closing pressure measurements (Bryant, 2000). Capillary-closing
pressure is the amount of pressure required to impede the flow of oxygen and blood to the
tissues. In a study by Landis, where the microinjection method was used to determine blood
pressure in capillaries, 32 mmHg was found to be the average pressure in the arteriolar limb
(Quigley & Curley, 1996). Interface pressure is the amount of pressure the resting surface
places on the skin over a bony prominence. A pressure reduction mattress reduces pressure,
although only to the standard of 32 mmHg, and should be used in patients with more than one
turning surface, keeping in mind that the mattress will not provide consistent relief (Quigley &
Curley, 1996). These mattresses/overlays lower pressure, compared to a standard hospital
mattress; examples include: an eggcrate overlay, air-filled bed, or action bed overlay (also
beneficial in reducing shear). A gel pillow is also beneficial under the occiput as a means to
relieve pressure.
A pressure-relieving surface is one where pressures are consistently lower than 25mmHg.
These surfaces are ideal for children with one turning surface and in need of consistent relief;
an example of this is the use of a low air-loss bed, such as the PediaDyne and TriaDyne II
beds (Kinetic Concepts, Inc., San Antonio, Texas). A low air-loss bed consists of a bed frame
with a series of connected air-filled pillows. The amount of pressure in each pillow is
controlled, and can be calibrated to provide maximum pressure reduction for an individual
child (Bryant, 2000). The PediaDyne and TriaDyne II beds also offer percussion therapy and
rotation. It is also important to note that when a child is on a specialty surface, turning every
two hours, as tolerated, is still required for the best outcome.
Assessment and Documentation
Even in the best of circumstances, and with preventative measures in place, skin breakdown
can still occur. Accurate assessment and documentation is an essential part of determining
the course of treatment. According to Quigley and Curley (1996), "Assessment includes (a)
anatomic location, (b) accurate staging, as defined by the NPUAP (1989), (c) size in
centimeters (length up and down head to toe, width across and depth), (d) type of tissue at
the wound base (including color red, yellow or black), (e) presence of exudate or odor, (f)
presence and location of undermining or tunneling, (g) character of the wound margins, (h)
condition of the periwound skin, and (I) dressing type" (pg.15).
Undermining is defined as tissue destruction beneath intact skin along wound margins.
Tunneling can extend in any direction from the wound surface, resulting in "dead space,"
creating the potential for abscess formation if the area is not cleansed and packed correctly
(Bryant, 2000). Quigley and Curley (1996) found that an optimal wound environment,
according to Braden and Bryant, is free of nonviable tissue, clinical infection, dead space,
excessive exudate, has a moist wound surface, is protected from bacterial contamination and
reinjury, and provides pain relief.
Pressure ulcers are staged according to the NPUAP (1992). A stage I pressure ulcer is
defined as an area of nonblanchable erythema of intact skin that does not resolve after 30
minutes of pressure relief and the epidermis is intact. In individuals with dark skin,
discoloration of the skin, warmth, edema, and induration may also be indicators. Partial
thickness skin loss involving the epidermis, dermis, or both is considered a stage II pressure
ulcer. The ulcer is superficial and presents as an abrasion, blister, or shallow crater. A stage
III ulcer is full thickness skin loss, involving damage to or necrosis of subcutaneous tissue that
may extend down to, but not through, the underlying fascia. The ulcer presents as a deep
crater, with or without undermining of adjacent tissue. Stage IV pressure ulcers are those with
full thickness skin loss and involve extensive destruction, tissue necrosis, or damage to
muscle, bone, or the supporting structure. Undermining or tunneling may also be present in a
stage IV ulcer (see Figures 2-5).
Figure 2.
Stage I Pressure Ulcer
Source: KCI's Pressure Ulcer Assessment Tool, 2002. Used with permission.
Figure 3.
Stage II Pressure Ulcer
Source: KCI's Pressure Ulcer Assessment Tool, 2002. Used with permission.
Figure 4.
Stage III Pressure Ulcer
Source: KCI's Pressure Ulcer Assessment Tool, 2002. Used with permission.
Figure 5.
Stage IV Pressure Ulcer
Source: KCI's Pressure Ulcer Assessment Tool, 2002. Used with permission.
According to the NPUAP, it is also important to never reverse stage a wound. Pressure ulcers
heal to a progressively more shallow depth; they do not replace lost muscle, subcutaneous
fat, or dermis. A Stage IV ulcer cannot become a Stage III, Stage II or Stage I. When a Stage
IV ulcer has healed, it should be classified as a healed Stage IV pressure ulcer (NPUAP,
2000). It should be noted that an ulcer should never be staged if uncertainty exists about the
stage. Instead, it is recommended that the wound be described. In describing a wound, it is
important to refrain from sizing a wound using dime or quarter sizing; the wound should
always be measured. Further, wounds not related to pressure, including partial or full
thickness skin loss and burns, are never staged.
Superficial skin damage can also occur when adhesive products are used with any pediatric
patient (although the chronically ill and critically ill are at an even higher risk). A skin tear or
epidermal stripping is a partial thickness wound, involving tissue loss of the epidermis and
possibly the dermis (Bryant, 2000). It is the inadvertent removal of these layers by mechanical
means, such as tape removal. A skin tear may present as a broad wound, similar to an
abrasion or as a narrow tear in the epidermis. It may be dry with little or no drainage, or have
moderate drainage, depending on the location and the extent of epidermal involvement.
Some skin tears also will have a viable skin flap; the treatment goal should be to avoid
dislodging the flap. The flap should be positioned in an area that optimizes its chances of readhering to the wound bed. Dressing choice is important; a dressing should be used that will
not stick to the area, such as a hydrogel. If the surrounding skin also is fragile, a dressing
without an adhesive border should be considered and secured with a gauze roll. In patients
where there is good surrounding skin integrity, a transparent film can be used if little or no
drainage is present.
Skin tears or epidermal stripping, as well as tension blisters, can easily be avoided by proper
skin preparation, choice of tape, and proper application and removal of tape. Stripping can
occur when the adhesive bond between tape and skin is greater than between epidermis and
dermis. As tape is removed, the epidermis remains attached to the tape, resulting in painful
damage. Tension blisters are the result of tightly strapping the tape during application and
distention of the skin underneath. Strapping is mistakenly thought to increase adhesion;
however, as the tape resists stretching, the epidermis begins to lift, resulting in a blister at the
end of the tape.
A key component to the prevention of skin tears/stripping is to recognize fragile, thin,
vulnerable skin (Bryant, 2000). Careful and gentle care is important in routine patient care
because most skin tears occur during this time. In addition, the current focus of prevention is
on the application of products to serve as a barrier. Skin tears resulting from adhesion can be
prevented by appropriate application and removal of tape, use of solid wafer skin barriers, thin
hydrocolloids, low-adhesion foam dressings or skin sealant under adhesives, use of porous
tapes, and avoidance of unnecessary tapes.
Wound Treatment
The key to properly treating a wound is having a basic sense of the wound healing process
and understanding the various products available. For example, moist wounds heal faster
than dry wounds. It is easier for a wound in a moist environment to granulate and for the cells
to migrate across the wound bed. A moist environment also increases the effectiveness of
white blood cells in fighting infection and removing cellular debris (Bryant, 2000). However, if
a wound is draining heavily, an appropriate dressing should be used to contain the drainage.
Dressings can be categorized into four types: primary, secondary, occlusive, and semiocclusive. A primary dressing is one that comes directly in contact with the wound bed. A
secondary dressing is used to cover a primary dressing when the primary dressing does not
protect the wound from contamination. Occlusive dressings cover a wound from the outside
environment and keep nearly all moisture vapors at the wound site. And finally, a semiocclusive dressing allows some oxygen and moisture vapor to evaporate through the
dressing. For a sampling of dressings and their characteristics, see Table 2 .
Nursing Implications
According to clinical practice guideline number 15, set forth by the U.S. Department of Health
and Human Services (1994), institutions should design, develop, and implement educational
programs to address prevention and treatment of pressure ulcers for patients, caregivers, and
healthcare providers; these programs should reflect a continuum of care. Adequate
involvement of the patient and caregiver, when possible in treatment and prevention
strategies, is highly recommended. In the pediatric population, depending on age, it is not
always possible to involve the patient; however, the parents should be involved. In particular,
in the critical care environment, involving parents and caregivers can provide a sense of
involvement in the care of the child, reducing the sense of powerlessness sometimes
experienced by parents of critically ill children. Further educational programs should identify
those responsible for pressure ulcer treatment, providing a clear description of each person's
role in the treatment process.
An educational program should emphasize the need for accurate, consistent, and uniform
assessment, and documentation of the extent of tissue damage. The clinical practice
guidelines on the treatment of pressure ulcers suggest a comprehensive educational
program. Information in a educational program on the treatment of pressure ulcers should
include (a) etiology and pathology, (b) risk factors, (c) uniform terminology for stages of tissue
damage based on specific classifications, (d) principles of wound healing, (e) principles of
nutritional support, (f) individualized programs of skin care, (g) principles of cleansing and
infection control, (h) principles of postoperative care, including positioning and support
surfaces, (I) principles of prevention to reduce recurrence, (j) product selection, (k) effects of
the physical and mechanical environment on the pressure ulcer, (l) strategies for
management, and (m) mechanisms for accurate documentation and monitoring of pertinent
data, including treatment interventions and healing progress (Bergstrom et al., 1994).
Summary
A comprehensive pediatric skin care program should emphasize the need for accurate,
consistent assessment, including description and documentation of the extent of tissue
damage. Nurses should familiarize themselves with risk assessment tools, such as the
Braden Q Scale, and use it in their daily practice. A skin care algorithm, such as the one used
at the PICU at Advocate Hope Children's Hospital (see Figure 6) can also be a valuable tool
to guide nurses in prevention and treatment strategies for children who are at risk for pressure
ulcers.
Figure 6.
Skin Care Algorithm, Advocate Hope Children's Hospital
Although the research on pressure ulcers in the pediatric population is limited when compared
to that of the adult population, pressure ulcers are not age discriminate. The risk factors for
pressure ulcer development such as immobility, neurologic impairment, impaired perfusion,
and decreased oxygenation are primarily defined in the adult research. It can be assumed
that these risk factors also apply to the pediatric population. The anatomical sites of skin
breakdown differ between the adult and pediatric population. The occipital region in children
less than 36 months, the sacral region in children, and the calcaneous are the primary sites
identified in the research.
The development of pressure ulcers has major implications for both patients and nursing staff.
Pediatric nurses, especially those in a critical care setting, need to be aware that pressure
ulcers do exist in this population. The research in pediatrics is emerging drawing increased
awareness to this problem. As with adults, early recognition of an at-risk infant or child is
critical.
CE Information
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please contact the publisher, Anthony J. Jannetti, Inc.
Table 1. The Braden Q Scale
Scor
e
Intensity and Duration of Pressure
Mobility
The 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
completely
turn self
independently.
3. Slightly
Limited:
Makes
frequent
though slight
changes in
body or
extremity
position
independentl
y.
4. No
Limitations:
Makes major
and frequent
changes in
position without
assistance.
Activity:
The degree of
current
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
wheelchair.
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. If
ambulatory, all
patients too
young to
ambulate OR
walks
frequently:
Walks outside
the room at
least twice a
day and inside
room at least
once every 2
hours during
waking hours.
Sensory
Perception:
The ability to
respond in a
developmentall
1. Completely
Limited:
Unresponsive
(does not moan,
flinch, or grasp)
2. Very
Limited:
Responds only
to painful
stimuli. Cannot
3. Slightly
Limited:
Responds to
verbal
commands,
4. No
Impairment:
Responds to
verbal
commands. Has
y appropriate
way to
pressurerelated
discomfort
to painful stimuli,
due to
diminished level
of
consciousness
or sedation. OR
limited ability to
feel pain over
most of body
surface.
communicate
discomfort
except by
moaning or
restlessness
OR has
sensory
impairment
which limits
the ability to
feel pain or
discomfort
over 1/2 of
body.
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.
no sensory
deficit that
would limit
ability to feel or
communicate
pain or
discomfort.
Scor
e
Tolerance of the Skin and Supporting Structure
Moisture
Degree to
which skin is
exposed to
moisture
1. Constantly
Moist:
Skin is kept
moist almost
constantly by
perspiration,
urine, drainage,
etc. Dampness
is detected every
time patient is
moved or turned.
2. Very Moist:
Skin is often,
but not always
moist. Linen
must be
changed at
least every 8
hours.
3.
Occasionally
Moist:
Skin is
occasionally
moist,
requiring
linen change
every 12
hours.
4. Rarely
Moist:
Skin is usually
dry, routine
diaper changes,
linen only
requires
changing every
24 hours.
Friction Shear
Friction: occurs
when skin
moves against
support
surfaces
Shear: occurs
when skin and
adjacent bony
surface slide
across one
another
1. Significant
Problem:
Spasticity,
contracture,
itching or
agitation leads to
almost constant
thrashing and
friction
2. 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.
3. 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
relative good
position in
chair or bed
most of the
time but
occasionally
slides down.
4. No Apparent
Problem:
Able to
completely lift
patient during a
position
change; 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.
Nutrition
Usual food
intake pattern
1. Very Poor:
NPO and/or
maintained on
clear liquids, or
IVs for more
2. Inadequate:
Is on liquid diet
or tube
feedings/TPN
that provide
3. Adequate:
Is on tube
feedings or
TPN which
provide
4. Excellent:
Is on a normal
diet providing
adequate
calories for age.
than 5 days OR
Albumin < 2.5
mg/dl OR Never
eats a complete
meal. Rarely
eats more than
____ of any food
offered. Protein
intake includes
only 2 servings
of meat or dairy
products per
day. Takes fluids
poorly. Does not
take a liquid
dietary
supplement.
inadequate
calories and
minerals for
age OR
Albumin < 3
mg/dl OR
rarely eats a
complete meal
and generally
eats only
about 1/2 of
any food
offered.
Protein intake
includes only 3
servings of
meat or dairy
products per
day.
Occasionally
will take a
dietary
supplement.
adequate
calories and
minerals for
age OR eats
over half of
most meals.
Eats a total of
4 servings of
protein (meat,
dairy
products)
each day.
Occasionally
will refuse a
meal, but will
usually take a
supplement if
offered.
For example:
eats most of
every meal.
Never refuses a
meal. Usually
eats a total of 4
or more
servings of
meat and diary
products.
Occasionally
eats between
meals. Does not
require
supplementatio
n.
Tissue
1. Extremely
Perfusion and Compromised:
Oxygenation
Hypotensive(MA
P < 50mmHg; <
40 in a newborn)
or the patient
does not
physiologically
tolerate position
changes
2.
Compromised
:
Normotensive;
Serum pH is <
7.40; Oxygen
saturation may
be < 95 %;
Hemoglobin
maybe < 10
mg/dl;
Capillary refill
may be > 2
seconds.
3. Adequate:
Normotensive
; Serum pH is
normal;
Oxygen
saturation
may be < 95
%;
Hemoglobin
maybe < 10
mg/dl;
Capillary refill
may be > 2
seconds.
4. Excellent:
Normotensive,
Serum pH is
normal; Oxygen
saturation
>95%; Normal
Hgb; Capillary
refill < 2
seconds.
Total: If < 23, refer to Skin Care Algorithm.
Source: Quigley & Curley, 1996.
Table 2. A Sampling of Dressings and Their Characteristics
Dressing
Calcium
Alginates
Type
Primary, SemiOcclusive
Properties

Alginate fibers
absorb exudate
and convert
into a gel
providing
moisture for
healing.
Brand
Names
Kaltostat
Comments
Choose secondary
dressings according
to manufacturers´
recommendations
(usually a combined
dressing [ABD pad],
gauze dressing, or
transparent film to



Film
Dressing
Foam
Dressing
Primary or
Secondary
(depending on
use),
Occlusive

Primary, SemiOcclusive



Hydrocolloid Primary,
dressing
Occlusive



Hydrogel
Primary,SemiOcclusive



Skin Barrier
N/A


take away excess
fluid and secure the
dressing in place).
Absorbs
moderate to
heavy
drainage.
Controls minor
bleeding.
Provides a
moist healing
environment.
Use on skin
tears.
Use on wounds
with little or no
drainage.>
Bio
Overlay the wound
Occlusive margins by about 3
Tegaderm cm.
Absorbs
moderate to
heavy
exudates.
Is nonadherent.
Polymem
Allevyn
Do NOT use on dry
wounds. Extend
dressing to 1 inch or
more beyond the
edges and tape.
Combines
colloids,
elastomeres
and adhesives.
Promotes
autolytic
debridement.
Use with low to
moderate
exudates.
Duoderm
Replicare
Tegasorb
Use cautiously in
infected wounds.
Cover at least 1 inch
margin around intact
skin around the
wound.
Use with
minimal to
moderate
exudates.
Provides
autolytic
debridement.
Maintains a
moist
environment.
Vigilon
Duoderm
Gel
Solosite
Aquaflo
Discs
Cover at least 1 inch
of intact skin around
the wound.
Skin Prep Allow to dry
Protects area
thoroughly prior to
around
dressing application.
wound/dressing
.
Use under tape
to protect skin.
Source: Adapted from Kendall Healthcare Products Company, 1999.
References
1. Baldwin, K.M. (2002). Incidence and prevalence of pressure ulcers in children.
2. Bergstrom N., Alma, R., Alvarez, D., Bennett, M.A., Carlson, C.E., & Frantz, R.
(1994). Treatment of Pressure Ulcers. Clinical Practice Guideline Number 15.
3. Bryant. (2000). Acute and chronic wounds: Nursing management.
4. Curley, M.A., Razmus, I.S., Roberts, K.E., & Wypij, D. (2003). Predicting pressure
ulcer risk in pediatric patients.
5. Kendall Healthcare Products Company. (1999). Understanding wound care products
6. KCI's Pressure Ulcer Assessment Tool.
7. Meehan, M. (1994). National pressure ulcer prevalence survey.
8. National Pressure Ulcer Advisory Panel (NPUAP). (1992). Statement on pressure
ulcer prevention.
9. National Pressure Ulcer Advisory Panel (NPUAP). (2000). The facts about reverse
staging in 2000: The NPUAP position statement.
10. Neidig, J., Kleiber, C., & Oppliger, R.A. (1989). Risk factors associated with pressure
ulcers in the pediatric patient following open heart surgery.
11. Novartis Nutrition Corporation. (2006). An overview of the role of nutritional support
in wound care.
12. Pallija, G., Mondozzi, M., & Webb, A.A. (1999). Skin care of the pediatric patient.
Pollack, M.M., Ruttimann, U.E., & Getson, P.R. (1988). Pediatric risk of mortality
(PRISM) score
13. Quigley, S.M., & Curley, M.A. (1996). Skin integrity in the pediatric population:
Preventing and managing pressure ulcers.
14. Samaniego, I.A., (2003). A sore spot in pediatrics: Risk factors for pressure ulcers.
15. Schmidt, J.E., Berens, R.J., Zollo, M., Weisner, M., & Weigle, C. (1998). Skin
breakdown in children and high-frequency oscillatory ventilation.
16. Wound Care Strategies, Inc. (2002). Our Skin: Did you know - Our skin is our body's
largest organ?
17. Zollo, M.B., Gostisha, M.L., Berens, R.J., Schmidt, J.E., & Weigle, C. (1996). Altered
skin integrity in children admitted to a pediatric intensive care unit.
Suggested Readings


Garvin, G. (1997). Wound and skin care for the PICU. Critical Care Nurse Quarterly,
20(1), 62-71.
Keller, B.P., Wille, J., Ramshort, B., & Werken, C. (2002). Pressure ulcers in
intensive care patients: A review of risks and prevention. Intensive Care Medicine,
28, 1379-1388.
Colleen T. Butler, BSN, RN, is a Staff Nurse, Pediatric Intensive Care Unit, Advocate Hope
Children's Hospital, Oak Lawn, IL.