Objectives. Challenges in Pediatrics

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I have no commercial relations relevant to the topics presented, no conflicts of interest, and do not endorse any particular commercial product

Skin Risk Assessment in Pediatrics

Catherine Noonan, RN, CPNP, CWON

Catherine Noonan, RN, CPNP, CWON

Objectives

To protect patient privacy, patient pictures will not be available in the handouts.

1. Discuss risk factors for skin breakdown in the pediatric population 2. Discuss nursing interventions to prevent skin breakdown 3. Learn about the skin risk assessment scales currently available

Challenges in Pediatrics The negative effect of immobility and physiologic instability on a patient’s skin does not discriminate by age or developmental level.

(Curley, Quigley, & Lin, 2003)

• • • • •

Children of varying chronologic ages Children in varying developmental stages Children in varying physiologic stages Children with special needs Adults cared for in pediatric facilities

Each age group presents challenges! *Neonates (preterm and term) *Infants *Toddlers *School-age *Adolescents

SKIN: The Largest Organ of the Body • • • • • • •

Only organ constantly exposed to the external environment Contains sensory organs which assist with its regulatory function Provides and maintains thermoregulation Fat and water storage Vitamin D synthesis Prevents excessive fluid & electrolyte loss Body image / cosmesis

Anatomy & Physiology of the Skin Three functional layers: 1. Epidermis 2. Dermis 3. Subcutaneous

Protective barrier against: • Bacterial and viral pathogens • Ultraviolet radiation (UVR) • Mechanical and chemical assaults

Source: retrieved from internet: http://images.medicinenet.com/images

Function of Skin • Epidermis (5 layers of cells): – Outer most protective layer – Thin, avascular – Provides barrier to injury, contaminants, light – Prevents fluid loss – Melanocytes produce melanin (pigment) – Regenerates ~ every 30 days

Subcutaneous Tissue (Hypodermis) • Functions as a shock absorber, insulator, and receptacle for high calorie storage • Contains adipose tissue, blood vessels, and nerves

• Dermis – Supports and nourishes epidermis – Contains hair follicles, sebaceous glands, nails, nerve fibers, arterioles, lymphatics

Skin Alterations in the Hospitalized Patient: Risk Factors

Risk Factors for Skin Alterations in Chronic Illness Physiological effects of disease process itself

• Complications of medical and surgical treatments to sustain health and life • Complications of infusion therapy & hemodynamic monitoring • Complications of immobility, shear, friction, moisture

Chronic issues of nutrition -Underweight: Less cushioning over bony prominences -Overweight: Greater load on pressure points. Also, adipose tissue is poorly vascularized and easier to compromise

Chronic Issues of Mobility -Disease process -Psychological factors

Stressed Support Systems

Risk Factors for Skin Alterations in Critical Illness

Factors Affecting Skin Integrity

Sepsis Hypotension/Vasopressors Lack of tissue perfusion

Respiratory Distress Lack of tissue oxygenation Unstable airway/ Mechanical ventilation

Sedatives/Paralyzing Agents Fluid Overload or Deficit

• • • •

Ischemia Malnutrition Infection Excess moisture & incontinence • Immobility • Impaired sensation

• Low blood pressure • Inadequate blood oxygenation • Immunosuppression • Co-morbid conditions • Medications and treatments • Bacterial burden/necrotic tissue

Extracorporeal Life Support

What are the Most Common Skin Injuries in the Hospitalized Patients? • Incontinence Associated Dermatitis (IAD) • Pressure ulcers • Medical device-related injuries and pressure ulcers • Epidermal stripping

Incontinence Associated Dermatitis

You have to know what the issues are so you can assess patient risk and then prevent the injury!

Incontinence Associated Dermatitis

Incontinence Associated Dermatitis

• Inflammation resulting from contact with urine and feces • Epidermis may or may not be intact • Often characterized by any of the following: erythema, maceration, erosions, or a candidal rash

• Water renders skin more susceptible to friction and shear • Ammonia raises pH, promotes pathogens • Stool allows for pathogens, liquid stool erodes skin • Containment briefs exacerbate overhydration

C. Albicans: Clinical features are an erythematous rash with satellite papules and pustules often associated with pruritis

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Skin Care Practices

Prevention How is IAD prevented: Identification

of the “at risk” patient

• Assessing risk is based on H & P, and current dx and plan • Consider: Frequent stools, chemotherapy, neutropenia Prevention • Ongoing assessment • Frequent diaper changes • Thorough cleansing of skin • Consistent use of topically applied protective barrier creams & ointments

• • • •

Do not use “Witches Brew’s Standardize protocols NO Soaps or wet wipes Use pH balanced non-soap cleanser or water • Wipe off stool stained ointment • Aluminum acetate solution or colloidal soaks prn • Document skin integrity daily

Types of IAD

Assessment of IAD • • • •

Need to evaluate: 1. Integrity of epidermis 2. Presence/absence of candidal rash

What does it look like? How do I describe it? Is the skin intact or not? Is there the presence of candidal rash?

Then, classify and treat according to the findings: • • • •

The “Old” Algorithm







Reference tool to standardize skin care interventions (1999) 4 topical “regimens” based upon condition of skin and presence or absence of candidal rash Involved layering on up to 3 products at same time

Epidermis intact/no Candida Epidermis intact/ with Candida Epidermis not intact/no Candida Epidermis not intact/ with Candida

EMR -Allows RNS to order the products and the routine, based on algorithm -Care needs then show up on “to do” list

Moisture-Associated Skin Damage (MASD) • Prolonged exposure to various sources of moisture (urine/stool, perspiration, wound exudate, mucus, saliva) and their contents • Inflammation of the skin occurring with or without erosion or secondary cutaneous infection • IAD, periwound/peristomal moisture associated dermatitis, intertriginous dermatitis • Believed to be r/t both the moisture and chemical irritants within the moisture, its pH, mechanical factors such as friction, and associated microorganisms

Critical Illness IAD Risk Factors Sepsis Hypotension/Vasopressors Lack of tissue perfusion

Respiratory Distress Lack of tissue oxygenation Unstable airway/ Mechanical ventilation

Sedatives/Paralyzing Agents Fluid Overload or Deficit Extracorporeal Life Support

Definition

Pressure Ulcers and Pressure Injuries

A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated (NPUAP, 2007).

www.earthfuture.com

High Risk Sites for Pressure Ulcer Development in Pediatrics

Pediatric Pressure Ulcer Risk Factors • Altered level of consciousness (temporary or permanent)

• • • •

Occiput Ear Heels Ankles & Toes

• • • • • •

Pressure Ulcer Prevention • • • •

Altered sensation Critical illness Immobility Prolonged operative time Malnourishment Chronic illness

Pressure Ulcers IOUs of Assessment: I ⇒ Inside the patient: nutrition, oxygenation, etc.

Risk assessment Prevention interventions Support surface use/safety Prevalence surveys

O ⇒ Outside the patient: dressings, medical devices U ⇒ Under the patient: support surface, bed, commode & chair

Predicting Risk

Implications

Mobility Activity Sensory Perception

Pressure (intensity & duration)

Pressure Ulcer

Extrinsic Factors Moisture, Friction, Shear

Intrinsic Factors Nutrition, Age, BP, Edema, Stress, Smoking, Skin Temperature

Tissue Tolerance Braden and Bergstrom (1987)

• Risk assessment for pressure ulcer development should start within 24 hours of admission, then daily • Improved assessment of patient risk may help reduce unnecessary variation in the prevention and management of pressure ulcers in acutely ill infants and children • Pressure Ulcer Prevention Programs: multidisciplinary team approach, including patient and family members

Pressure Ulcer Prevention Program Skin is in!

Putting The Pressure on Prevention!

Braden Q Scale

CHB Pressure Ulcer Prevention Program (PUPP) • • • • •

Skin Subject Matter Expert (SME) Group Pressure Ulcer Prevention Policy Pressure Ulcer Prevention Algorithm Support Surface Reference Tool Pressure Ulcer Staging Guidelines

• **Wound Care Formulary and Guidelines • **Wound Assessment & Documentation Reference Tool • **Photography Guidelines

The Q’s in Braden Q

Quatrano & Quigley

Invited into Braden Q Club….

Braden Q Scale • What does it do? – Helps to assist the care provider in predicting pressure ulcer risk in the pediatric population – Incorporates the distinctive developmental needs of pediatric patients

• What doesn’t it do? – It doesn’t prevent or treat pressure ulcers! – Does not predict device related pressure ulcers (yet!)

• What does it assess? – 7 subscales: Mobility, Activity, Sensory Perception, Moisture, Friction-Shear, Nutrition, Tissue Perfusion and Oxygenation

The Braden Q Scale

Tolerance of the Skin and Supporting Structure

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 independently.

Activity The degree of physical activity 1. Bedfast: Confined to bed

Sensory Perception The ability to respond in a developmentally appropriate way to pressure-related discomfort

1. 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. Chair fast: Ability to walk severely limited or nonexistent. Cannot bear own weight and/or must be assisted in 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.

2. Very Limited: Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness OR has sensory impairment which limits the ability to feel pain or discomfort over ½ of body.

3. Slightly Limited: Responds to verbal commands, 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.

4. No Limitations: Makes major and frequent changes in position without assistance.

4. 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.

4. No Impairment: Responds to verbal commands. Has no sensory deficit, which limits ability to feel or communicate pain or discomfort.

Moisture Degree to which skin is exposed to moisture

Friction Shear Friction: occurs when skin moves against support surfaces Shear: occurs when skin and adjacent bony surface slide across one another

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.

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.

Tolerance of the Skin and Supporting Structure (continued) Nutrition Usual food intake pattern

Tissue Perfusion and Oxygenation

1. Very Poor: NPO and/or maintained on clear liquids, or IVs for more than 5 days OR Albumin