carmel boylan, princess maargret hospital for children - pressure injury prevention in the...

Pressure injury prevention

in the paediatric population

including neonates

Carmel Boylan RN, BN. STN. MN (NP)

Clinical Nurse Consultant

Stomal Therapy & Wound Management

Princess Margaret Hospital for Children

29 September 2014 Slide 2


Objectives

• Incidence/prevalence rates

• Risk factors

• Device related PI

• Screening tools

• Preventative strategies

• Parent involvement

• Mucosal injury v pressure injury


Incidence / prevalence

• Pressure injuries (PI) in paediatrics not documented as

well as in adults

• Paediatric patients often excluded from

prevalence/incidence studies

• Review of literature (2000-2010) revealed prevalence of

PI in paediatric patients as 1.6 - 27.7%

• Reported incidence in PICU was 18-27%

• Sick children can develop PI in less than 1 hr

Prevalence

• PMH PUPPS results:

• 2007 2.4% H/A 2.4%

• 2008 3.8% H/A 2.09%

• 2009 3.5% H/A 1.8%

• 2011 7.4% H/A 6.6%


Pressure Injury Data reported via Clinical Incident

Managament system and/or the Stomal Therapy&

Wound Care CNC Stage II injuries and above.


Vulnerable patient group

• Disproportionate head /

body in infant

• <36 mths head greater

portion body weight &

surface area

• Limited hair growth

• Under developed

epidermis

• Affected areas:

• Occipital

• Sacral

• Ear lobes

• Calcaneus region


Risk factors

• mechanical ventilation

• hypotension

• use of high frequency oscillatory ventilation (HFOV)

• chemical paralysis

• vasopressor therapy

• use of total parenteral nutrition (TPN)


Risk factors

• extracorporeal membrane oxygenation in neonates

(ECMO)

• paediatric intensive care unit (PICU) length of stay

greater than 96 hours

• increasing positive end-expiratory pressure (PEEP)

• weight loss

• not turning the patient

• not using a specialty bed in turning mode


Device related PI

• N/G tubes

• IV bungs

• Oxygen sats probe

• Plaster casts

• Traction

• Splints

• Ankle foot orthotics

(AFO)

• Braces

• Cervical Collars


PMH review of hospital acquired

skin injuries 2008-2010

• Towel clip (14)

• IV related (9)

• Plaster (2)

• OT Burn (3)

• Name band (1)

• PU (19) (4 during/post

PICU)

• PU post surgery (6)

• Oxygen probe (3)

• ECG dot (1)

• ET tube (1)

• NGT (1)

• Abrasion (1)

• Cast removal (3)

• Other (4)


Mucosal injury v pressure injury

• Mucosal injuries found in the mucous membranes with a

history of a medical device in use at the location of the

injury (ulcer)

• Injury can occur due to direct trauma

• Injured tissue bleeds → soft clot formation (coagulum)

• Soft clot (coagulum) may appear like slough


Mucosal injury

• Cannot stage a mucosal injury – cannot distinguish

shallow injury from deeper injury

• Muscle is seldom seen on MI

• Bone not present in soft tissue


Mucous membrane


Screening tools

• Braden Q (tissue perfusion & oxygenation)

• Glamorgan Scale

• Neonatal Skin Risk Assessment Scale for Predicting Skin

Breakdown (NSRAS)

• Burn Pressure Ulcer Skin Risk Assessment Scale

(BPUSRAS)

• Starkid Skin Scale


Skin assessment


Preventative strategies

• PI risk assessment

• Skin assessment

• Support surface

• Repositioning

• Nutrition

• Continence

• OT/Physio

• Orthotics

• Dietetics

• ‘Take the pressure down’

• Education +++


Pressure relieving equipment


Parent involvement

• ‘Health Facts’

• Demonstration

• Participation

• Simple small steps


Audit of PI under plaster cast

PMH

Emergency 30%

PMH

Fracture Clinic 25%

PMH

Plastics Clinic 20%

PMH

Theatre 25%

Plaster Applied

Average age of child with plaster 10.9 years

Average time plaster on 16 days

Above

Elbow 18%

Below Elbow

46%

Above Knee

18%

Below Knee

18%

Injury Site

Slide 23

Audit Results (cont)

PMH

Emergency 45%

PMH

Fracture Clinic 32%

PMH

Plastics Clinic 18%

Ward

5%

Injury Identified

Stage 1 52%

Stage 2+ 48%

Skin Injury Stage

All Stage 2+ Skin Injuries have a Clinical Incident form

completed

Slide 24

Discussion

• Most skin injuries occurred when plasters were applied

below the elbow (this is probably the most common

plaster type – more data required to find % of injury per

number of plasters applied).

• Even spread of site where plaster applied in relation to

skin injury occurring.

• Almost half of injuries were identified in Emergency Dept

– patients returning with symptoms of pressure.

Slide 25

Pressure Injury Data reported via Clinical Incident

Managament system and/or the Stomal Therapy&

Wound Care CNC Stage II injuries and above.


Summary

• Ongoing risk assessment

• Prevention strategies

• Encourage reporting

• Multidisciplinary approach

• Parent education

• ‘Its not OK to get a pressure injury’

• ABC is important but so is PIP


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