Chapter 23 Pressure area care
INTRODUCTION
Historically, scant attention has been given to the reporting of pressure sores in the child population (Tooher et al 2003). Waterlow’s (1997) seminal study identified that children can develop pressure sores as a consequence of immobility, illness or hospitalisation, thus requiring the need for appropriate education, assessment and intervention. However, since then, the issue of research into the risk factors associated with the development of pressure sores has been scant but is now gaining momentum (Curley et al, 2003, Lane et al, 2004); although the majority of the evidence is based on studies undertaken with the adult and not the child population (Butler, 2006). More recently, however, Willock et al (2009) have developed and validated the Glamorgan Paediatric Pressure Area risk assessment scale, which is now being considered for introduction into many paediatric units across the UK.
RATIONALE
Pressure sore risk assessment is now considered an essential element of care in adults as shown in the document Essence of Care; this focuses on quality of care and benchmarking to deliver evidence-based practice (DoH 2001). While this is a positive step forward, it does not specifically include the child population; there are essential elements of pressure sore risk assessment, care and management that can be applied in principle when caring for children and young people (Waterlow 1997, DoH 2001, NICE 2003a,b, Noonan et al 2006).
FACTORS TO NOTE
Historically, pressure ulcers in children were not seen as different to those in the adult population (Noonan et al 2006). Recent studies report pressure ulcer rates in the child population ranging from 4% to 13% (Willock et al 2000, McLane et al 2004). Pressure ulcers in the critically ill child have been reported to be 27% (Curley et al 2003).
While there are various pressure risk assessment scoring methods in use within clinical and community healthcare practice when caring for adults, until recently nothing existed for the assessment of infants and children with very little evidence available to inform and support the practice (Noonan et al 2006). Consideration needs to be given to the assessment of risk for infants and children and interventions used to maintain skin integrity that are evidence-based (Noonan et al 2006).
McGurk et al (2004) have developed two assessment tools for use with infants and acutely ill children. The neonatal scale measures and assesses skin integrity taking into account gestational age; the tool to measure skin integrity in children takes into account the needs of the acutely ill child.
Curley et al (2003) developed the Braden Q scale specifically for use in the child population: this has been modified further and validated for use with neonates (The Neonatal/Infant Braden Q (McLane et al 2004).
All formal assessments of risk should be documented and accessible for other professionals within the interprofessional team and also meet the requirements of good record-keeping and hospital/Trust policies (NMC 2009).
RISK FACTORS TO CONSIDER
Samaniego (2003) identified a higher incidence of pressure ulcers within specific risk groups of infants and children, e.g. children in plaster casts; in wheelchairs and wearing prostheses. In spite of these earlier studies, Butler (2006) maintains that there is still a paucity of information regarding the risk factors that are associated with pressure ulcer development in children (Butler 2006).
Butler (2006) identified factors which affect pressure sore risk as either extrinsic or intrinsic.
Extrinsic factors
Intrinsic factors
Consideration of these factors provides identification of children who may be at risk of pressure sore development. Butler (2006) also recommends each child should be assessed with the participation and involvement of the family and should be evidence-based. The emphasis needs to be placed on accurate, consistent documentation that highlights the nature of the damage to tissues and the development and use of a skin care algorithm (Butler 2006, p 449). Although this presents a challenge when assessing the unwell child with an altered level of consciousness, an acute illness or complete immobility, a full and thorough assessment of pressure risks is essential (RCN 2001). It is important therefore to consider the following aspects in the assessment.
Body weight
Children who are underweight, overweight, or have excess weight due to fluid retention as a consequence of the side-effects of medications, may also experience difficulty in mobilising. Special consideration should be given to neonates who have less body mass, and therefore may experience increased risk over bony prominences and high localised pressure (e.g. the back of the head) (Willock et al 2000, Barnes 2004, McGurk et al 2004).
Elimination
The child who is experiencing continence problems is not only at risk of developing pressure sores but is also at increased risk of infection due to breakdown in skin integrity as a consequence of prolonged contact with urine and faecal matter (Zollo 1996). While infants may be considered as incontinent, it is prolonged contact with urine and/or faecal matter that will cause a break in skin integrity and not as a consequence of undue pressure (McLane et al 2004).
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