The prevention and treatment of pressure ulcers and maintenance of skin integrity in children are fundamental nursing care skills. Pressure ulcers are often considered a problem in the adult population; however, pressure ulcers also occur in the paediatric field. Prevention and management of pressure ulcers and best practice in skin care are multifaceted. One must understand the underlying physiology of skin and skin damage, the factors responsible for skin damage or ulcer development, and the factors that put infants and children at risk of poor skin integrity. Accurate assessment, documentation, prevention, and treatment are all important factors in the maintenance of skin integrity.

Risk factors that have been identified include: immobility, neurological impairment, impaired perfusion, decreased oxygenation, poor nutritional status, presence of infection and excess moisture. Even in the best of circumstances, and with preventative measures in place, skin breakdown can still occur.

Pressure ulcers are localized areas of tissue destruction occurring from soft tissue being compressed by external surfaces and bony prominences. This starves the skin of oxygen and essential nutrition. Pressure ulcers have different stages, according to the National Pressure Ulcer Advisory Panel (NPUAP). Being familiar with these stages is a sound starting point for nurses to understand what they see and then to intervene appropriately. Accurate assessment and documentation are essential parts of determining the course of treatment. The Figure outlines the key areas to document, should any skin breakdown at whatever stage occur. Skin care and assessment should also be part of a child’s care plan, which includes regular reassessment and evaluation at appropriate time intervals.

However, a fundamental principle to remember is that early assessment of the risk factors associated with the development of pressure ulcers is essential in their prevention. The most common sites for pressure ulcer development in children include the buttocks, sacrum, ears, heels, elbows, malleolus and lumbar spine. In the neonatal population, the occipital region and sites where tubes, tapes and tags exist are particularly vulnerable. Pre-term neonates are at further risk due to immaturity of the corneum stratum of the skin epidermis.

Various tools exist for assessing skin such as the Paediatric Glamorgan scale and the Braden Q scale for children. Both scales consist of several subscales: namely, mobility, activity, sensory perception, moisture, friction/shear, nutrition, and tissue perfusion/oxygenation. Each subscale is rated numerically, yielding an overall total score, which indicates the risk level for skin breakdown.

When an assessment identifies a 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. A principal goal in nursing care is to reduce the external forces of pressure, shear, friction, and moisture, to prevent or treat tissue injury. Those under 8 years of age can be moved or lifted easily to prevent friction and shear. For older children, assistive devices such as lifts, trapezes, transfer boards, or mechanical lifts may be useful adjunctive devices to minimize tissue injury.

Mechanical injury from friction can be reduced with application of a barrier dressing, such as transparent films or hydrocolloids, on at-risk areas.

Interventions to reduce pressure over bony prominences are of primary importance. A turning schedule must be instituted for patients on strict bed rest. In addition to turning, heels should be suspended off the bed using pillows or heel-lift devices. A rolled-up blanket is always useful under the child’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 haemodynamic and respiratory stability is achieved.

Even with correct positioning methods, a therapeutic surface may need to be used since frequent turning may be contraindicated in unstable, critically ill children. A therapeutic surface should reduce or relieve pressure, promote blood flow to the tissues, and enable proper positioning. The therapeutic benefit of a product and its ability to maintain skin integrity will determine which type of surface will offer the best outcome. Airflow through the surface of a mattress will reduce moisture.

Mattresses/overlays have lower pressure, compared to a standard hospital mattress; examples include: an egg-crate overlay, an air-filled bed, or a special overlay which can also be beneficial in reducing shearing. A gel pillow is also useful under the occiput as a means to relieve pressure.

Superficial skin damage can also occur when adhesive products are used, although the chronically ill and critically ill are at higher risk. A skin tear or epidermal stripping is a partial thickness wound, involving tissue loss of the epidermis and possibly the dermis. Skin tears or epidermal stripping, as well as tension blisters, can easily be avoided by proper skin preparation, choice of tape, proper application and removal of tape. Skin tears resulting from adhesion can also be prevented by appropriate application and removal of tape, use of wafer skin barriers, thin hydrocolloids dressings, low-adhesion foam dressings or skin sealant under adhesives, use of porous tapes, and avoidance of unnecessary tapes.