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, PaO 2/ 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 re-adhering 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 semi-occlusive.
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 semi-occlusive 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.
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Table 1. The Braden Q Scale
Intensity and Duration of Pressure
Mobility
The ability to
change and
control body
position
Score
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.
4. No
Limitations:
Makes major and
frequent changes
in position
without
assistance.
Activity:
1. Bedfast:
The degree of
Confined to bed
current physical
activity
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
2. Very
Limited:
Responds only
to painful
3. Slightly
Limited:
Responds to
verbal
4. No
Impairment:
Responds to
verbal
1. Completely
Limited:
Unresponsive
(does not moan,
developmentally
appropriate way
to pressurerelated
discomfort
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.
stimuli. Cannot
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.
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.
commands. Has
no sensory
deficit that would
limit ability to feel
or communicate
pain or
discomfort.
Tolerance of the Skin and Supporting Structure
Score
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 than
5 days OR
2. Inadequate:
Is on liquid diet
or tube
feedings/TPN
that provide
inadequate
3. Adequate:
Is on tube
feedings or
TPN which
provide
adequate
4. Excellent:
Is on a normal
diet providing
adequate
calories for age.
For example:
Tissue
Perfusion and
Oxygenation
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.
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.
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.
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
supplementation.
1. Extremely
Compromised:
Hypotensive(MAP
< 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.
Absorbs
moderate to
Brand
Names
Kaltostat
Comments
Choose secondary
dressings according to
manufacturers´
recommendations
(usually a combined
dressing [ABD pad],
gauze dressing, or
transparent film to take
away excess fluid and


Film
Dressing
Foam
Dressing
Primary or
Secondary
(depending on
use), Occlusive

Primary, SemiOcclusive



Hydrocolloid Primary,
dressing
Occlusive



Hydrogel
Primary,SemiOcclusive



Skin Barrier
N/A


secure the dressing in
place).
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 cm.
Tegaderm
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.
Protects area
around
wound/dressing.
Use under tape
to protect skin.
Skin Prep
Allow to dry thoroughly
prior to dressing
application.
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.