pressure ulcer prevention in pediatrics - healthcare jobs · pressure ulcer prevention in...
TRANSCRIPT
![Page 1: Pressure Ulcer Prevention in Pediatrics - Healthcare Jobs · Pressure Ulcer Prevention in Pediatrics Sandy Hagstrom, MA, ... –Low BP – Dehydration ... if the WOC nurse sees the](https://reader034.vdocuments.us/reader034/viewer/2022042801/5ae920867f8b9ad73f8b74e8/html5/thumbnails/1.jpg)
Pressure Ulcer Prevention in Pediatrics
Sandy Hagstrom, MA, RN, CNPIvy Booth, MN, RN, CNS
![Page 2: Pressure Ulcer Prevention in Pediatrics - Healthcare Jobs · Pressure Ulcer Prevention in Pediatrics Sandy Hagstrom, MA, ... –Low BP – Dehydration ... if the WOC nurse sees the](https://reader034.vdocuments.us/reader034/viewer/2022042801/5ae920867f8b9ad73f8b74e8/html5/thumbnails/2.jpg)
ObjectivesAt the completion of the self-study, the nurse will be able to:• Identify the causes and age related risk factors of pressure
ulcers• Give at least four examples of patient risk factors which
potentially could lead to a pressure ulcer• Apply the use of the Braden Q Risk Assessment scales to
own nursing practice• Recognize the nursing role in pressure ulcer prevention, on-
going skin assessment, ulcer treatment, documentation and reporting
![Page 3: Pressure Ulcer Prevention in Pediatrics - Healthcare Jobs · Pressure Ulcer Prevention in Pediatrics Sandy Hagstrom, MA, ... –Low BP – Dehydration ... if the WOC nurse sees the](https://reader034.vdocuments.us/reader034/viewer/2022042801/5ae920867f8b9ad73f8b74e8/html5/thumbnails/3.jpg)
Pressure Ulcer
• Any lesion caused by unrelieved pressure resulting in damage of underlying tissue
• Can develop over any dependent skin surface
![Page 4: Pressure Ulcer Prevention in Pediatrics - Healthcare Jobs · Pressure Ulcer Prevention in Pediatrics Sandy Hagstrom, MA, ... –Low BP – Dehydration ... if the WOC nurse sees the](https://reader034.vdocuments.us/reader034/viewer/2022042801/5ae920867f8b9ad73f8b74e8/html5/thumbnails/4.jpg)
Significance
• Cost (human suffering, financial expense)• Predispose patients to secondary infection• Increase length of stay• Stage III and IV ulcers are reportable events
and become public knowledge
![Page 5: Pressure Ulcer Prevention in Pediatrics - Healthcare Jobs · Pressure Ulcer Prevention in Pediatrics Sandy Hagstrom, MA, ... –Low BP – Dehydration ... if the WOC nurse sees the](https://reader034.vdocuments.us/reader034/viewer/2022042801/5ae920867f8b9ad73f8b74e8/html5/thumbnails/5.jpg)
Incidence
• Incidence– 4-13% in general pediatric inpatient population– 16.9-53% in PICU patients – Up to 29.2% in hospitalized adults
• 72% of pediatric ulcers develop in PICU• Highest risk: infants< 3 months
![Page 6: Pressure Ulcer Prevention in Pediatrics - Healthcare Jobs · Pressure Ulcer Prevention in Pediatrics Sandy Hagstrom, MA, ... –Low BP – Dehydration ... if the WOC nurse sees the](https://reader034.vdocuments.us/reader034/viewer/2022042801/5ae920867f8b9ad73f8b74e8/html5/thumbnails/6.jpg)
Pressure Ulcer Pathophysiology
Compression of soft tissue between a bony prominence and an external surface
Ischemia from obstruction of capillary blood flow caused by pressure > 32 mm Hg (capillary filling pressure)
Cells are starved of oxygen and die
![Page 7: Pressure Ulcer Prevention in Pediatrics - Healthcare Jobs · Pressure Ulcer Prevention in Pediatrics Sandy Hagstrom, MA, ... –Low BP – Dehydration ... if the WOC nurse sees the](https://reader034.vdocuments.us/reader034/viewer/2022042801/5ae920867f8b9ad73f8b74e8/html5/thumbnails/7.jpg)
Common Sites• Pediatrics
– Occipital region: infants and toddlers– Ears– Sacrum: children– Scapula– Associated with equipment pressing or rubbing on skin
• Adults– Sacrum– Heels
![Page 8: Pressure Ulcer Prevention in Pediatrics - Healthcare Jobs · Pressure Ulcer Prevention in Pediatrics Sandy Hagstrom, MA, ... –Low BP – Dehydration ... if the WOC nurse sees the](https://reader034.vdocuments.us/reader034/viewer/2022042801/5ae920867f8b9ad73f8b74e8/html5/thumbnails/8.jpg)
Patients at Risk• Significant prematurity• Critical illness, especially in patients with:
– Edema– ICU length of stay >96 hours– Increasing PEEP– Not turned
• Neurologic impairments, including myelomeningocele, spinal cord injury
![Page 9: Pressure Ulcer Prevention in Pediatrics - Healthcare Jobs · Pressure Ulcer Prevention in Pediatrics Sandy Hagstrom, MA, ... –Low BP – Dehydration ... if the WOC nurse sees the](https://reader034.vdocuments.us/reader034/viewer/2022042801/5ae920867f8b9ad73f8b74e8/html5/thumbnails/9.jpg)
Patients at Risk
• Nutritional deficits• Poor tissue perfusion or oxygenation
– Low BP– Dehydration– Anemia
• Exposed to prolonged pressure from hospital apparatus or tubes
Gray, M (2004)
![Page 10: Pressure Ulcer Prevention in Pediatrics - Healthcare Jobs · Pressure Ulcer Prevention in Pediatrics Sandy Hagstrom, MA, ... –Low BP – Dehydration ... if the WOC nurse sees the](https://reader034.vdocuments.us/reader034/viewer/2022042801/5ae920867f8b9ad73f8b74e8/html5/thumbnails/10.jpg)
Patients at Risk• Peripheral vascular disease • Prolonged surgery • Intractable pain • Diabetes
These risk factors are from the adult data, but are worth considering for our patients, especially adolescents.
![Page 11: Pressure Ulcer Prevention in Pediatrics - Healthcare Jobs · Pressure Ulcer Prevention in Pediatrics Sandy Hagstrom, MA, ... –Low BP – Dehydration ... if the WOC nurse sees the](https://reader034.vdocuments.us/reader034/viewer/2022042801/5ae920867f8b9ad73f8b74e8/html5/thumbnails/11.jpg)
Braden Q Scale
• Assessment tool for evaluating risk of pressure ulcers
• Adapted from the adult Braden Scale to reflect the developmental needs of pediatric patients
![Page 12: Pressure Ulcer Prevention in Pediatrics - Healthcare Jobs · Pressure Ulcer Prevention in Pediatrics Sandy Hagstrom, MA, ... –Low BP – Dehydration ... if the WOC nurse sees the](https://reader034.vdocuments.us/reader034/viewer/2022042801/5ae920867f8b9ad73f8b74e8/html5/thumbnails/12.jpg)
Braden Q – Categories• Intensity and duration of pressure
– Mobility– Activity– Sensory perception
• Tolerance of the skin and supporting structures– Moisture– Friction and shear– Nutrition– Tissue perfusion and oxygenation
![Page 13: Pressure Ulcer Prevention in Pediatrics - Healthcare Jobs · Pressure Ulcer Prevention in Pediatrics Sandy Hagstrom, MA, ... –Low BP – Dehydration ... if the WOC nurse sees the](https://reader034.vdocuments.us/reader034/viewer/2022042801/5ae920867f8b9ad73f8b74e8/html5/thumbnails/13.jpg)
Braden Q – Score
• Range from 7 (highest risk) to 28 (lowest risk)• Patients with scores <17
– Are at risk for skin breakdown– Require intervention
![Page 14: Pressure Ulcer Prevention in Pediatrics - Healthcare Jobs · Pressure Ulcer Prevention in Pediatrics Sandy Hagstrom, MA, ... –Low BP – Dehydration ... if the WOC nurse sees the](https://reader034.vdocuments.us/reader034/viewer/2022042801/5ae920867f8b9ad73f8b74e8/html5/thumbnails/14.jpg)
MobilityThe ability to change and control body position1. 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 independently
4. No limitations: Makes major and frequent changes in position without assistance
![Page 15: Pressure Ulcer Prevention in Pediatrics - Healthcare Jobs · Pressure Ulcer Prevention in Pediatrics Sandy Hagstrom, MA, ... –Low BP – Dehydration ... if the WOC nurse sees the](https://reader034.vdocuments.us/reader034/viewer/2022042801/5ae920867f8b9ad73f8b74e8/html5/thumbnails/15.jpg)
ActivityDegree of 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 to 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. All patients too young to ambulate OR walks frequently: Walks outside room at least twice a day and inside room at least once every 2 hours during waking hours.
![Page 16: Pressure Ulcer Prevention in Pediatrics - Healthcare Jobs · Pressure Ulcer Prevention in Pediatrics Sandy Hagstrom, MA, ... –Low BP – Dehydration ... if the WOC nurse sees the](https://reader034.vdocuments.us/reader034/viewer/2022042801/5ae920867f8b9ad73f8b74e8/html5/thumbnails/16.jpg)
Sensory PerceptionAbility to respond in a developmentally-appropriate
way to pressure-related discomfort1. Completely limited: Unresponsive (does not
moan, flinch or grasp) to painful stimuli due to diminished level of consciousness or sedation, OR, limited ability to feel pain over most of body surface.
2. Very limited: Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness; OR has sensory impairment that limits the ability to feel pain or discomfort over half of body.
![Page 17: Pressure Ulcer Prevention in Pediatrics - Healthcare Jobs · Pressure Ulcer Prevention in Pediatrics Sandy Hagstrom, MA, ... –Low BP – Dehydration ... if the WOC nurse sees the](https://reader034.vdocuments.us/reader034/viewer/2022042801/5ae920867f8b9ad73f8b74e8/html5/thumbnails/17.jpg)
Sensory PerceptionAbility to respond in a developmentally-appropriate
way to pressure-related discomfort3. Slightly limited: Responds to verbal commands,
but cannot always communicate discomfort or need to be turned; OR has some sensory impairment that limits ability to feel pain or discomfort in one or two extremities.
4. No impairment: Responds to verbal commands. Has no sensory deficit that would limit ability to feel or communicate pain or discomfort.
![Page 18: Pressure Ulcer Prevention in Pediatrics - Healthcare Jobs · Pressure Ulcer Prevention in Pediatrics Sandy Hagstrom, MA, ... –Low BP – Dehydration ... if the WOC nurse sees the](https://reader034.vdocuments.us/reader034/viewer/2022042801/5ae920867f8b9ad73f8b74e8/html5/thumbnails/18.jpg)
Case Study
• M.J. is a 10-year-old girl who has ARDS and is on the oscillator.
• She is intubated, sedated and under neuromuscular blockade.
• Her nurses are repositioning her every 2 hours.
![Page 19: Pressure Ulcer Prevention in Pediatrics - Healthcare Jobs · Pressure Ulcer Prevention in Pediatrics Sandy Hagstrom, MA, ... –Low BP – Dehydration ... if the WOC nurse sees the](https://reader034.vdocuments.us/reader034/viewer/2022042801/5ae920867f8b9ad73f8b74e8/html5/thumbnails/19.jpg)
Case Study
What is her Braden Q “Mobility” score?1 - Completely immobile2 - Very limited3 - Slightly limited4 - No limitations
![Page 20: Pressure Ulcer Prevention in Pediatrics - Healthcare Jobs · Pressure Ulcer Prevention in Pediatrics Sandy Hagstrom, MA, ... –Low BP – Dehydration ... if the WOC nurse sees the](https://reader034.vdocuments.us/reader034/viewer/2022042801/5ae920867f8b9ad73f8b74e8/html5/thumbnails/20.jpg)
Case Study
Answer: 1 – Completely immobile
![Page 21: Pressure Ulcer Prevention in Pediatrics - Healthcare Jobs · Pressure Ulcer Prevention in Pediatrics Sandy Hagstrom, MA, ... –Low BP – Dehydration ... if the WOC nurse sees the](https://reader034.vdocuments.us/reader034/viewer/2022042801/5ae920867f8b9ad73f8b74e8/html5/thumbnails/21.jpg)
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 a 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.
![Page 22: Pressure Ulcer Prevention in Pediatrics - Healthcare Jobs · Pressure Ulcer Prevention in Pediatrics Sandy Hagstrom, MA, ... –Low BP – Dehydration ... if the WOC nurse sees the](https://reader034.vdocuments.us/reader034/viewer/2022042801/5ae920867f8b9ad73f8b74e8/html5/thumbnails/22.jpg)
Friction-ShearFriction: Occurs when skin moves against support surfacesShear: Occurs when skin and adjacent bony surfaces 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.
![Page 23: Pressure Ulcer Prevention in Pediatrics - Healthcare Jobs · Pressure Ulcer Prevention in Pediatrics Sandy Hagstrom, MA, ... –Low BP – Dehydration ... if the WOC nurse sees the](https://reader034.vdocuments.us/reader034/viewer/2022042801/5ae920867f8b9ad73f8b74e8/html5/thumbnails/23.jpg)
Friction-Shear3. 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 at all times.
![Page 24: Pressure Ulcer Prevention in Pediatrics - Healthcare Jobs · Pressure Ulcer Prevention in Pediatrics Sandy Hagstrom, MA, ... –Low BP – Dehydration ... if the WOC nurse sees the](https://reader034.vdocuments.us/reader034/viewer/2022042801/5ae920867f8b9ad73f8b74e8/html5/thumbnails/24.jpg)
Case Study
• M.J. is being kept relatively hypothermic.• Skin is cool and dry to touch.• Prior to admission, she was an active child
with good muscle tone.• Since being started on sedation and
neuromuscular blockade she requires frequent repositioning.
![Page 25: Pressure Ulcer Prevention in Pediatrics - Healthcare Jobs · Pressure Ulcer Prevention in Pediatrics Sandy Hagstrom, MA, ... –Low BP – Dehydration ... if the WOC nurse sees the](https://reader034.vdocuments.us/reader034/viewer/2022042801/5ae920867f8b9ad73f8b74e8/html5/thumbnails/25.jpg)
Case Study
What is her Braden Q “Moisture” score?1 – Constantly moist2 – Very moist3 – Occasionally moist4 – Rarely moist
![Page 26: Pressure Ulcer Prevention in Pediatrics - Healthcare Jobs · Pressure Ulcer Prevention in Pediatrics Sandy Hagstrom, MA, ... –Low BP – Dehydration ... if the WOC nurse sees the](https://reader034.vdocuments.us/reader034/viewer/2022042801/5ae920867f8b9ad73f8b74e8/html5/thumbnails/26.jpg)
Case Study
Answer: 4 – Rarely moist
![Page 27: Pressure Ulcer Prevention in Pediatrics - Healthcare Jobs · Pressure Ulcer Prevention in Pediatrics Sandy Hagstrom, MA, ... –Low BP – Dehydration ... if the WOC nurse sees the](https://reader034.vdocuments.us/reader034/viewer/2022042801/5ae920867f8b9ad73f8b74e8/html5/thumbnails/27.jpg)
NutritionUsual food intake pattern
1. Very poor: NPO and/or maintained on clear liquids, or IV’s for more than 5 days OR albumin <2.5 mg/dl OR never eats a complete meal. Rarely eats more than half 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.
![Page 28: Pressure Ulcer Prevention in Pediatrics - Healthcare Jobs · Pressure Ulcer Prevention in Pediatrics Sandy Hagstrom, MA, ... –Low BP – Dehydration ... if the WOC nurse sees the](https://reader034.vdocuments.us/reader034/viewer/2022042801/5ae920867f8b9ad73f8b74e8/html5/thumbnails/28.jpg)
NutritionUsual food intake pattern
2. Inadequate: Is on liquid diet or tube feedings/ TPN which provide inadequate calories and mineral for age OR albumin <3 mg/dl OR rarely eats a complete meal and generally eats only half of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. Occasionally will take a dietary supplement.
![Page 29: Pressure Ulcer Prevention in Pediatrics - Healthcare Jobs · Pressure Ulcer Prevention in Pediatrics Sandy Hagstrom, MA, ... –Low BP – Dehydration ... if the WOC nurse sees the](https://reader034.vdocuments.us/reader034/viewer/2022042801/5ae920867f8b9ad73f8b74e8/html5/thumbnails/29.jpg)
NutritionUsual food intake pattern
3. Adequate: Is on tube feedings or TPN, which provide 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.
![Page 30: Pressure Ulcer Prevention in Pediatrics - Healthcare Jobs · Pressure Ulcer Prevention in Pediatrics Sandy Hagstrom, MA, ... –Low BP – Dehydration ... if the WOC nurse sees the](https://reader034.vdocuments.us/reader034/viewer/2022042801/5ae920867f8b9ad73f8b74e8/html5/thumbnails/30.jpg)
NutritionUsual food intake pattern
4. Excellent: Is on a normal diet providing adequate calories for age. For example, eats most of every meal. Never refuses a meal. Usually eats a total of 4 or more servings of meat and dairy products. Occasionally eats between meals. Does not require supplementation.
![Page 31: Pressure Ulcer Prevention in Pediatrics - Healthcare Jobs · Pressure Ulcer Prevention in Pediatrics Sandy Hagstrom, MA, ... –Low BP – Dehydration ... if the WOC nurse sees the](https://reader034.vdocuments.us/reader034/viewer/2022042801/5ae920867f8b9ad73f8b74e8/html5/thumbnails/31.jpg)
Tissue Perfusion & Oxygenation
1. Extremely compromised: Hypotensive (MAP <50 mm HG; <40 in a newborn) or the patient does not physiologically tolerate position changes.
2. Compromised: • Normotensive• O2 saturation may be <95%• Hemoglobin may be <10 mg/dl• Capillary refill may be >2 seconds; serum pH is
<7.4.
![Page 32: Pressure Ulcer Prevention in Pediatrics - Healthcare Jobs · Pressure Ulcer Prevention in Pediatrics Sandy Hagstrom, MA, ... –Low BP – Dehydration ... if the WOC nurse sees the](https://reader034.vdocuments.us/reader034/viewer/2022042801/5ae920867f8b9ad73f8b74e8/html5/thumbnails/32.jpg)
Tissue Perfusion & Oxygenation3. Adequate:
• Normotensive• O2 saturation may be <95%• Hemoglobin may be 10 mg/dl• Capillary refill may be >2 seconds• Serum pH is normal.
4. Excellent: • Normotensive• O2 saturation >95%• Normal hemoglobin• Capillary refill <2 seconds.
This category is only on the Braden Q, not on the Braden.
![Page 33: Pressure Ulcer Prevention in Pediatrics - Healthcare Jobs · Pressure Ulcer Prevention in Pediatrics Sandy Hagstrom, MA, ... –Low BP – Dehydration ... if the WOC nurse sees the](https://reader034.vdocuments.us/reader034/viewer/2022042801/5ae920867f8b9ad73f8b74e8/html5/thumbnails/33.jpg)
Case Study
• M.J. has been weaned to conventional ventilation.
• She is tolerating full enteral nutrition per NG.• She has been normotensive.• Hemoglobin is 9 mg/dl.• O2 saturation has consistently been >95%.
![Page 34: Pressure Ulcer Prevention in Pediatrics - Healthcare Jobs · Pressure Ulcer Prevention in Pediatrics Sandy Hagstrom, MA, ... –Low BP – Dehydration ... if the WOC nurse sees the](https://reader034.vdocuments.us/reader034/viewer/2022042801/5ae920867f8b9ad73f8b74e8/html5/thumbnails/34.jpg)
Case Study
What is her Braden Q “Tissue Perfusion and Oxygenation” score?
1 – Extremely compromised2 – Compromised3 – Adequate4 – Excellent
![Page 35: Pressure Ulcer Prevention in Pediatrics - Healthcare Jobs · Pressure Ulcer Prevention in Pediatrics Sandy Hagstrom, MA, ... –Low BP – Dehydration ... if the WOC nurse sees the](https://reader034.vdocuments.us/reader034/viewer/2022042801/5ae920867f8b9ad73f8b74e8/html5/thumbnails/35.jpg)
Case Study
Answer: 3 – Adequate
![Page 36: Pressure Ulcer Prevention in Pediatrics - Healthcare Jobs · Pressure Ulcer Prevention in Pediatrics Sandy Hagstrom, MA, ... –Low BP – Dehydration ... if the WOC nurse sees the](https://reader034.vdocuments.us/reader034/viewer/2022042801/5ae920867f8b9ad73f8b74e8/html5/thumbnails/36.jpg)
Staging Pressure Ulcers
![Page 37: Pressure Ulcer Prevention in Pediatrics - Healthcare Jobs · Pressure Ulcer Prevention in Pediatrics Sandy Hagstrom, MA, ... –Low BP – Dehydration ... if the WOC nurse sees the](https://reader034.vdocuments.us/reader034/viewer/2022042801/5ae920867f8b9ad73f8b74e8/html5/thumbnails/37.jpg)
Staging Pressure Ulcers
• Staging should only be done by the Wound OstomyContinence (WOC) nurses.
• When you document a pressure ulcer, describe it—don’t document it as a “Stage ___ pressure ulcer.”
• WOC nurses have experience and education in staging pressure ulcers—less experienced clinicians may make errors in staging, which may have legal implications.
• We are required to report Stage III and IV pressure ulcers to the MN Department of Health, which becomes public record.
• Here’s some info on staging—just as an “FYI.”
![Page 38: Pressure Ulcer Prevention in Pediatrics - Healthcare Jobs · Pressure Ulcer Prevention in Pediatrics Sandy Hagstrom, MA, ... –Low BP – Dehydration ... if the WOC nurse sees the](https://reader034.vdocuments.us/reader034/viewer/2022042801/5ae920867f8b9ad73f8b74e8/html5/thumbnails/38.jpg)
Deep Tissue Injury
• Purple or maroon localized area of discolored intact skin, OR
• Blood-filled blister due to damage of underlying soft tissue from pressure or shear
• Area may be preceded by tissue that is painful, firm, mush, boggy, warmer or cooler as compared to adjacent tissue
![Page 39: Pressure Ulcer Prevention in Pediatrics - Healthcare Jobs · Pressure Ulcer Prevention in Pediatrics Sandy Hagstrom, MA, ... –Low BP – Dehydration ... if the WOC nurse sees the](https://reader034.vdocuments.us/reader034/viewer/2022042801/5ae920867f8b9ad73f8b74e8/html5/thumbnails/39.jpg)
Stage I Pressure Ulcer
• Intact skin• Non-blanchable redness of
a localized area, usually over a bony prominence
• Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area
![Page 40: Pressure Ulcer Prevention in Pediatrics - Healthcare Jobs · Pressure Ulcer Prevention in Pediatrics Sandy Hagstrom, MA, ... –Low BP – Dehydration ... if the WOC nurse sees the](https://reader034.vdocuments.us/reader034/viewer/2022042801/5ae920867f8b9ad73f8b74e8/html5/thumbnails/40.jpg)
Stage II Pressure Ulcer
• Partial thickness loss of epidermis
• Blistering with erythema/induration
• Wound base moist and pink
• Painful wound base• Free of necrotic tissue
![Page 41: Pressure Ulcer Prevention in Pediatrics - Healthcare Jobs · Pressure Ulcer Prevention in Pediatrics Sandy Hagstrom, MA, ... –Low BP – Dehydration ... if the WOC nurse sees the](https://reader034.vdocuments.us/reader034/viewer/2022042801/5ae920867f8b9ad73f8b74e8/html5/thumbnails/41.jpg)
Stage III Pressure Ulcer
• Full-thickness tissue loss• Extends through dermis to
subcutaneous tissue• May include necrotic tissue• May include undermining
and tunneling• Wound base not painful
![Page 42: Pressure Ulcer Prevention in Pediatrics - Healthcare Jobs · Pressure Ulcer Prevention in Pediatrics Sandy Hagstrom, MA, ... –Low BP – Dehydration ... if the WOC nurse sees the](https://reader034.vdocuments.us/reader034/viewer/2022042801/5ae920867f8b9ad73f8b74e8/html5/thumbnails/42.jpg)
Stage IV Pressure Ulcer
• Deep tissue destruction• Extends through
subcutaneous tissue• May involve muscle, joint
and/or bone• Deep tracts, sinuses and
fissures usually present• Bone may be visible at the
base of the wound• Wound base not painful
![Page 43: Pressure Ulcer Prevention in Pediatrics - Healthcare Jobs · Pressure Ulcer Prevention in Pediatrics Sandy Hagstrom, MA, ... –Low BP – Dehydration ... if the WOC nurse sees the](https://reader034.vdocuments.us/reader034/viewer/2022042801/5ae920867f8b9ad73f8b74e8/html5/thumbnails/43.jpg)
Case Study
• M.J.’s nurse notices a 2-inch by 2-inch area of non-blanching erythema over her right shoulder blade.
• The skin is intact.
![Page 44: Pressure Ulcer Prevention in Pediatrics - Healthcare Jobs · Pressure Ulcer Prevention in Pediatrics Sandy Hagstrom, MA, ... –Low BP – Dehydration ... if the WOC nurse sees the](https://reader034.vdocuments.us/reader034/viewer/2022042801/5ae920867f8b9ad73f8b74e8/html5/thumbnails/44.jpg)
Case StudyWhat will you do with this information?
A. Document it as a Stage I pressure ulcer, position the patient to avoid pressure on the area, and continue to monitor.
B. Document it as a Stage I pressure ulcer, position the patient to avoid pressure on the area, complete an ICare and continue to monitor.
C. Position the patient to avoid pressure on the area, obtain an MD order to consult the Wound Ostomy Continence (WOC) nurse to evaluate the patient and make recommendations.
![Page 45: Pressure Ulcer Prevention in Pediatrics - Healthcare Jobs · Pressure Ulcer Prevention in Pediatrics Sandy Hagstrom, MA, ... –Low BP – Dehydration ... if the WOC nurse sees the](https://reader034.vdocuments.us/reader034/viewer/2022042801/5ae920867f8b9ad73f8b74e8/html5/thumbnails/45.jpg)
Case StudyAnswer: C. Position the patient to avoid pressure on the area, obtain an
MD order to consult the Wound Ostomy Continence (WOC) nurse to evaluate the patient and make recommendations.
– Staff nurses should not stage pressure ulcers.– An MD order is needed for a WOC nurse consult. (See
next slide for rationale.)– An ICare should be completed for all pressure ulcers.
You may either complete the ICare and describe the wound (not stage it), or, if the WOC nurse sees the patient during your shift, you can complete the ICareafter she has staged the ulcer.
![Page 46: Pressure Ulcer Prevention in Pediatrics - Healthcare Jobs · Pressure Ulcer Prevention in Pediatrics Sandy Hagstrom, MA, ... –Low BP – Dehydration ... if the WOC nurse sees the](https://reader034.vdocuments.us/reader034/viewer/2022042801/5ae920867f8b9ad73f8b74e8/html5/thumbnails/46.jpg)
WOC Nurse Consults
• A physician order is now required for a WOC nurse consult.
• This ensures that the patient’s physician is aware of the patient’s skin issues.
• WOC nurses can be reimbursed for the consult when it is ordered by a physician.
![Page 47: Pressure Ulcer Prevention in Pediatrics - Healthcare Jobs · Pressure Ulcer Prevention in Pediatrics Sandy Hagstrom, MA, ... –Low BP – Dehydration ... if the WOC nurse sees the](https://reader034.vdocuments.us/reader034/viewer/2022042801/5ae920867f8b9ad73f8b74e8/html5/thumbnails/47.jpg)
Case Study
• J.B. is a 5-year-old African American boy with pneumonia who is developmentally delayed.
• Moves slightly in bed occasionally.• Has soft wrist restraints in place to prevent
him from pulling his NG tube.
![Page 48: Pressure Ulcer Prevention in Pediatrics - Healthcare Jobs · Pressure Ulcer Prevention in Pediatrics Sandy Hagstrom, MA, ... –Low BP – Dehydration ... if the WOC nurse sees the](https://reader034.vdocuments.us/reader034/viewer/2022042801/5ae920867f8b9ad73f8b74e8/html5/thumbnails/48.jpg)
Case Study
• J.B. wakes up with verbal commands, but has difficulty communicating his needs.
• Has a urinary catheter.• Has developed diarrhea from his antibiotics.• Requires frequent diaper changes; his nurse
changes his linens about every 8 hours.
![Page 49: Pressure Ulcer Prevention in Pediatrics - Healthcare Jobs · Pressure Ulcer Prevention in Pediatrics Sandy Hagstrom, MA, ... –Low BP – Dehydration ... if the WOC nurse sees the](https://reader034.vdocuments.us/reader034/viewer/2022042801/5ae920867f8b9ad73f8b74e8/html5/thumbnails/49.jpg)
Case Study
• J.B. frequently slides down in his bed and requires two nurses to reposition him.
• Has been tolerating full calorie NG feedings without difficulty.
• Has been hemodynamically stable.• Hemoglobin 12• Has been difficult to maintain O2 saturations >88%
![Page 50: Pressure Ulcer Prevention in Pediatrics - Healthcare Jobs · Pressure Ulcer Prevention in Pediatrics Sandy Hagstrom, MA, ... –Low BP – Dehydration ... if the WOC nurse sees the](https://reader034.vdocuments.us/reader034/viewer/2022042801/5ae920867f8b9ad73f8b74e8/html5/thumbnails/50.jpg)
Case Study
• J.B.’s nurse finds a moist, pink wound that has a small erythematous blister on his buttocks.
• J.B. cries with each diaper change.
![Page 51: Pressure Ulcer Prevention in Pediatrics - Healthcare Jobs · Pressure Ulcer Prevention in Pediatrics Sandy Hagstrom, MA, ... –Low BP – Dehydration ... if the WOC nurse sees the](https://reader034.vdocuments.us/reader034/viewer/2022042801/5ae920867f8b9ad73f8b74e8/html5/thumbnails/51.jpg)
Case Study
What is his Braden Q “Mobility” score?1 - Completely immobile2 - Very limited3 - Slightly limited4 - No limitations
![Page 52: Pressure Ulcer Prevention in Pediatrics - Healthcare Jobs · Pressure Ulcer Prevention in Pediatrics Sandy Hagstrom, MA, ... –Low BP – Dehydration ... if the WOC nurse sees the](https://reader034.vdocuments.us/reader034/viewer/2022042801/5ae920867f8b9ad73f8b74e8/html5/thumbnails/52.jpg)
Case Study
What is his Braden Q “Activity” score?1 – Bedfast 2 – Chairfast3 – Walks occasionally4 – All patients too young to ambulate;
OR walks frequently
![Page 53: Pressure Ulcer Prevention in Pediatrics - Healthcare Jobs · Pressure Ulcer Prevention in Pediatrics Sandy Hagstrom, MA, ... –Low BP – Dehydration ... if the WOC nurse sees the](https://reader034.vdocuments.us/reader034/viewer/2022042801/5ae920867f8b9ad73f8b74e8/html5/thumbnails/53.jpg)
Case Study
What is his Braden Q “Sensory Perception”score?
1 – Completely limited 2 – Very limited 3 – Slightly limited4 – No impairment
![Page 54: Pressure Ulcer Prevention in Pediatrics - Healthcare Jobs · Pressure Ulcer Prevention in Pediatrics Sandy Hagstrom, MA, ... –Low BP – Dehydration ... if the WOC nurse sees the](https://reader034.vdocuments.us/reader034/viewer/2022042801/5ae920867f8b9ad73f8b74e8/html5/thumbnails/54.jpg)
Case Study
What is his Braden Q “Moisture” score?1 – Constantly moist 2 – Very moist3 – Occasionally moist4 – Rarely moist
![Page 55: Pressure Ulcer Prevention in Pediatrics - Healthcare Jobs · Pressure Ulcer Prevention in Pediatrics Sandy Hagstrom, MA, ... –Low BP – Dehydration ... if the WOC nurse sees the](https://reader034.vdocuments.us/reader034/viewer/2022042801/5ae920867f8b9ad73f8b74e8/html5/thumbnails/55.jpg)
Case Study
What is his Braden Q “Friction-Shear” score?1 – Significant problem 2 – Problem3 – Potential problem4 – No apparent problem
![Page 56: Pressure Ulcer Prevention in Pediatrics - Healthcare Jobs · Pressure Ulcer Prevention in Pediatrics Sandy Hagstrom, MA, ... –Low BP – Dehydration ... if the WOC nurse sees the](https://reader034.vdocuments.us/reader034/viewer/2022042801/5ae920867f8b9ad73f8b74e8/html5/thumbnails/56.jpg)
Case Study
What is his Braden Q “Nutrition” score?1 – Very poor 2 – Inadequate3 – Adequate4 – Excellent
![Page 57: Pressure Ulcer Prevention in Pediatrics - Healthcare Jobs · Pressure Ulcer Prevention in Pediatrics Sandy Hagstrom, MA, ... –Low BP – Dehydration ... if the WOC nurse sees the](https://reader034.vdocuments.us/reader034/viewer/2022042801/5ae920867f8b9ad73f8b74e8/html5/thumbnails/57.jpg)
Case Study
What is his Braden Q “Tissues Perfusion & Oxygenation” score?
1 – Extremely compromised 2 – Compromised3 – Adequate4 – Excellent
![Page 58: Pressure Ulcer Prevention in Pediatrics - Healthcare Jobs · Pressure Ulcer Prevention in Pediatrics Sandy Hagstrom, MA, ... –Low BP – Dehydration ... if the WOC nurse sees the](https://reader034.vdocuments.us/reader034/viewer/2022042801/5ae920867f8b9ad73f8b74e8/html5/thumbnails/58.jpg)
Case Study
What is his Braden Q score?A.7B.10C.16D.23
![Page 59: Pressure Ulcer Prevention in Pediatrics - Healthcare Jobs · Pressure Ulcer Prevention in Pediatrics Sandy Hagstrom, MA, ... –Low BP – Dehydration ... if the WOC nurse sees the](https://reader034.vdocuments.us/reader034/viewer/2022042801/5ae920867f8b9ad73f8b74e8/html5/thumbnails/59.jpg)
Case Study
J.T.’s Braden Q score puts him into which risk category for skin breakdown?
A.No riskB.At risk
![Page 60: Pressure Ulcer Prevention in Pediatrics - Healthcare Jobs · Pressure Ulcer Prevention in Pediatrics Sandy Hagstrom, MA, ... –Low BP – Dehydration ... if the WOC nurse sees the](https://reader034.vdocuments.us/reader034/viewer/2022042801/5ae920867f8b9ad73f8b74e8/html5/thumbnails/60.jpg)
Answer Key• Mobility: 2• Activity: 1• Sensory perception: 3• Moisture: 2• Friction-shear: 2• Nutrition: 3• Tissue perfusion & oxygenation: 3• Total Braden Q: 16• Risk category: at risk
![Page 61: Pressure Ulcer Prevention in Pediatrics - Healthcare Jobs · Pressure Ulcer Prevention in Pediatrics Sandy Hagstrom, MA, ... –Low BP – Dehydration ... if the WOC nurse sees the](https://reader034.vdocuments.us/reader034/viewer/2022042801/5ae920867f8b9ad73f8b74e8/html5/thumbnails/61.jpg)
Skin Assessment
• On admission and every 8 hours• Document on FCIS Assessment Flowsheet • Inspect in brightest light possible
![Page 62: Pressure Ulcer Prevention in Pediatrics - Healthcare Jobs · Pressure Ulcer Prevention in Pediatrics Sandy Hagstrom, MA, ... –Low BP – Dehydration ... if the WOC nurse sees the](https://reader034.vdocuments.us/reader034/viewer/2022042801/5ae920867f8b9ad73f8b74e8/html5/thumbnails/62.jpg)
Skin Assessment• If redness is discovered on a pressure point,
relieve pressure for at least an hour and recheck.
• If still red, needs more intense pressure-reducing intervention, turning more frequently.
• For darkly pigmented skin, look for purplish/blue areas of discoloration.
![Page 63: Pressure Ulcer Prevention in Pediatrics - Healthcare Jobs · Pressure Ulcer Prevention in Pediatrics Sandy Hagstrom, MA, ... –Low BP – Dehydration ... if the WOC nurse sees the](https://reader034.vdocuments.us/reader034/viewer/2022042801/5ae920867f8b9ad73f8b74e8/html5/thumbnails/63.jpg)
Skin AssessmentIs reddened skin a pressure ulcer?
Initial redness over bony prominences is reactive hyperemia, a compensatory mechanism
• When pressure is relieved, the area becomes reddened or hyperemic as blood flows back and reperfuses the area.
• Will resolve in approximately ½ to ¾ the amount of time that the area was exposed to pressure.
• This is a normal process and should not be misclassified as a Stage I pressure ulcer.
![Page 64: Pressure Ulcer Prevention in Pediatrics - Healthcare Jobs · Pressure Ulcer Prevention in Pediatrics Sandy Hagstrom, MA, ... –Low BP – Dehydration ... if the WOC nurse sees the](https://reader034.vdocuments.us/reader034/viewer/2022042801/5ae920867f8b9ad73f8b74e8/html5/thumbnails/64.jpg)
Assessment and DocumentationBraden Q is completed:• Within 8 hours of admission • Every 24 hours• Documentation
– FCIS Assessment Flowsheet eventually– Braden Q Flowsheet until available on FCIS Assessment
Flowsheet
• Skin assessment and Braden Q (pressure ulcer risk) are 2 different assessments
![Page 65: Pressure Ulcer Prevention in Pediatrics - Healthcare Jobs · Pressure Ulcer Prevention in Pediatrics Sandy Hagstrom, MA, ... –Low BP – Dehydration ... if the WOC nurse sees the](https://reader034.vdocuments.us/reader034/viewer/2022042801/5ae920867f8b9ad73f8b74e8/html5/thumbnails/65.jpg)
Evidence-Based PreventionWhat To Do
• Early enteral nutrition• ↑ protein/calories• Use of supportive bed surfaces• Turning schedules
– Even slight changes in position are helpful in the unstable patient
• Protection/elevation of heels off bed• Patients on low-air-loss mattresses in turning mode
must still be turned and heels suspendedBraden (2001)
![Page 66: Pressure Ulcer Prevention in Pediatrics - Healthcare Jobs · Pressure Ulcer Prevention in Pediatrics Sandy Hagstrom, MA, ... –Low BP – Dehydration ... if the WOC nurse sees the](https://reader034.vdocuments.us/reader034/viewer/2022042801/5ae920867f8b9ad73f8b74e8/html5/thumbnails/66.jpg)
Evidence-Based PreventionWhat To Do
• Head-of-bed elevation to lowest degree possible to prevent shear-related pressure ulcers (<30º)
• Maximal remobilization• Clean skin well, then dry• Use moisture barrier• Use lift sheet, Hover Mat • Pad between knees/ankles
Braden (2001)
![Page 67: Pressure Ulcer Prevention in Pediatrics - Healthcare Jobs · Pressure Ulcer Prevention in Pediatrics Sandy Hagstrom, MA, ... –Low BP – Dehydration ... if the WOC nurse sees the](https://reader034.vdocuments.us/reader034/viewer/2022042801/5ae920867f8b9ad73f8b74e8/html5/thumbnails/67.jpg)
Evidence-Based PreventionWhat Not To Do
• Massage reddened bony prominences• Use donut-type devices• Use drying agents on the skin• Elevate bed > 30º• Believe a special mattress eliminates the need for
turning– Pediatric patients on low air loss beds in turning mode
are at increased risk for skin breakdown because they may pivot on the occiput, contributing to shear/friction
![Page 68: Pressure Ulcer Prevention in Pediatrics - Healthcare Jobs · Pressure Ulcer Prevention in Pediatrics Sandy Hagstrom, MA, ... –Low BP – Dehydration ... if the WOC nurse sees the](https://reader034.vdocuments.us/reader034/viewer/2022042801/5ae920867f8b9ad73f8b74e8/html5/thumbnails/68.jpg)
References• Butler, C.T. (2006). Pediatric skin care: Guidelines for assessment, prevention,
and treatment. Pediatric Nursing, 32(5), 443-450.• Curley, M.A.Q., Quigley, S.M., & Lin, M. (2003). Pressure ulcers in pediatric
intensive care: Incidence and associated factors. Pediatric Critical Care Medicine, 4(3), 284-290.
• Curley, M.A.Q., Razmus, I.S., Roberts, K.E. & Wypij, D. (2003). Predicting pressure ulcer risk in pediatric patients: The Braden Q scale. Nursing Research, 52(1), 22-33.
• Gray, M. (2004). Which pressure ulcer risk scales are valid and reliable in a pediatric population? Journal of Wound, Ostomy, Continence Nurses 31(4), 157-160.
• McLane, K.M., Bookout, K., McCord, S., McCain, J., & Jefferson, L.S. (2004). The 2003 national pediatric pressure ulcer and skin breakdown prevalence survey: A multisite study. Journal of Wound, Ostomy, Continence Nurses 31(4), 168-178.
• McCord, S. McElvain, V., Sachdeva, R., Schwartz, P. & Jefferson, L.S. (2004). Risk factors associated with pressure ulcers in the pediatric intensive care unit. Journal of Wound, Ostomy, Continence Nurses 31(4), 179-183.
![Page 69: Pressure Ulcer Prevention in Pediatrics - Healthcare Jobs · Pressure Ulcer Prevention in Pediatrics Sandy Hagstrom, MA, ... –Low BP – Dehydration ... if the WOC nurse sees the](https://reader034.vdocuments.us/reader034/viewer/2022042801/5ae920867f8b9ad73f8b74e8/html5/thumbnails/69.jpg)
References• Neidig, J.R., Kleiber, C., & Oppliger, R.A. (1989). Risk factors associated with
pressure ulcers in the pediatric patient following open-heart surgery. Progress in Cardiovascular Nursing, 4, 99-106.
• Noonan, C., Quigley, S. & Curley, M.A.Q. (2006). Skin integrity in hospitalized infants and children: A prevalence survey. Journal of Pediatric Nursing, 21(6), 445-453.
• Suddaby, E.C., Barnett, S. & Facteau, L. (2005). Skin breakdown in acute care pediatrics. Pediatric Nursing, 31(2), 132-148.
• Willock, J., Harris, C., Harrison, J., & Poole, C. (2005). Identifying the characteristics of children with pressure ulcers. Nursing Times, 101(11), 40-43.
• Willock, J. & Maylor, M. (2003). Pressure ulcers in infants and children. Nursing Standard, 18(24), 56-62.
![Page 70: Pressure Ulcer Prevention in Pediatrics - Healthcare Jobs · Pressure Ulcer Prevention in Pediatrics Sandy Hagstrom, MA, ... –Low BP – Dehydration ... if the WOC nurse sees the](https://reader034.vdocuments.us/reader034/viewer/2022042801/5ae920867f8b9ad73f8b74e8/html5/thumbnails/70.jpg)
On completion of all three attached learning activites,Pediatric Falls Prevention
NG Placement and VerificationPressure Ulcer Prevention in Pediatric
Patientsplease print and fill out the verification form
(separate attachment) and place in the marked envelope located on your unit.