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Identifying the characteristics of children with pressure ulcers

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VOL: 101, ISSUE: 11, PAGE NO: 40

Jane Willock, MSc, PGDip, BSc, RGN, RSCN, is lecturer in nursing, School of Care Sciences, University of Glamorgan, Pontypridd

Ceri Harris, BSc, SRN, is clinical nurse specialist, wound healing, Wound Healing Research Unit, University Hospital of Wales, Cardiff;Juanita Harrison, BA, RGN, RSCN, is ward manager, burns and plastic surgery unit, Royal Liverpool Children's Hospital;Christine Poole, PGDip, SRN, RSCN, is tissue viability nurse specialist, Royal Manchester Children's Hospital

Pressure ulcers are a recognised problem in debilitated or immobile adults but their incidence in children is not widely discussed in the nursing literature. Estimates of incidence in the general paediatric inpatient population vary from 0.29 per cent (Baldwin, 2002) to 5.6 per cent (Waterlow, 1997), but in children who are critically ill they are far higher, from 16.9 per cent to 53 per cent (Curley et al, 2000; Escher-Neidig et al, 1989; Schmidt et al, 1998; Zollo et al, 1996). In addition to pain and the risk of life-threatening infections (Bar-On et al, 2002), pressure ulcers can cause disfigurement (Gershan and Esterley, 1993; Kumar and Kumar, 1993), and affect the child's body image (Kozierowski, 1996).

Pressure ulcers are a recognised problem in debilitated or immobile adults but their incidence in children is not widely discussed in the nursing literature. Estimates of incidence in the general paediatric inpatient population vary from 0.29 per cent (Baldwin, 2002) to 5.6 per cent (Waterlow, 1997), but in children who are critically ill they are far higher, from 16.9 per cent to 53 per cent (Curley et al, 2000; Escher-Neidig et al, 1989; Schmidt et al, 1998; Zollo et al, 1996). In addition to pain and the risk of life-threatening infections (Bar-On et al, 2002), pressure ulcers can cause disfigurement (Gershan and Esterley, 1993; Kumar and Kumar, 1993), and affect the child's body image (Kozierowski, 1996).

They develop in areas that sustain the most pressure (Box 1). Immobility and reduced sensation seem to be major risk factors in children (Ash, 2002; Bar-On et al, 2002; Hickey et al, 2000; Pallija et al, 1999; Harris and Banta, 1990; Okamoto et al, 1983), but some authors (Waterlow et al, 1997; Zollo et al, 1996; Muller and Nordall, 1994; Matsumura et al, 1995; Okamoto et al, 1983; Phelan, 1980) have reported ulceration related to equipment such as splints, traction and endotracheal tubes.

The study
Pressure ulceration can be a significant risk to children, particularly if they are very debilitated. A multicentre survey was undertaken in 11 hospitals to ascertain the incidence, severity and position of pressure ulcers in paediatric inpatients. The aim of the study was to identify the characteristics of children most at risk of pressure ulceration. No other large studies have been found that give a detailed description of these children.

Local researchers were recruited in 11 hospitals across England and Wales:

- Birmingham Children's Hospital;

- Bristol Royal Hospital for Children;

- Pilgrim Hospital, Boston, Lincolnshire;

- University Hospital of Wales, Cardiff;

- Royal Liverpool Children's Hospital;

- Royal London Hospital;

- St George's Hospital, London;

- St Mary's Hospital, London;

- The Royal National Orthopaedic Hospital, Middlesex;

- Queen's Medical Centre, Nottingham;

- Royal Manchester Children's Hospital.

These were nurses who had either taken part in a previous study (Willock et al, 2000), members of the Paediatric Tissue Viability Society or nurses who were recruited through an advertisement in a nursing journal. All were experienced children's nurses working in children's units who took part voluntarily because they were interested in tissue viability, and in improving patient care.

Permission was obtained from the senior nurse at each hospital to carry out the study, as well as approval from ethics, and research and development committees.

An initial meeting was arranged to update their knowledge about pressure ulcers, share information on the study and finalise the data collection questionnaire. This was developed using the findings of published research on pressure ulcers in adults as well as in children, as the research in children was too limited.

The experience of the nurses involved in the study was also important in the development of the questionnaire as they had all previously seen pressure ulcers in children.

Anonymous patient data was used to trial the questionnaire, identify flaws and improve usability. It was also useful to check whether different people were giving the same answers to questions when using the same patient data.

The questionnaire included factors such as:

- Nutrition;

- Mobility;

- Sensation;

- Pain;

- Peripheral perfusion;

- Haemoglobin and serum albumin levels.

It was made as objective as possible by asking for numerical values of patient data such as haemoglobin, blood pressure and temperature rather than asking if the child was anaemic, hypertensive or pyrexial.

The questionnaire was piloted at each of the hospitals. Children selected for the pilot study were not necessarily children with pressure injury, as this stage was just to test the usability of the questionnaire.

Data was collected over an 18-month period in the 11 hospitals. Each child (aged 0-18 years) who developed a pressure ulcer was assessed by the local researcher using the questionnaire (with consent from the child and/or parent). A total of 54 children were included - 33 boys (61 per cent) and 21 girls (39 per cent) with an age range of three weeks to 17 years and eight months. Ages of children were distributed as follows:

- Six were aged under one year;

- 11 were aged 1-4 years;

- 10 were aged 5-10 years;

- 27 were aged 11-17 years.

Ulcer severity was estimated using the descriptions in Table 1, a grading scale based on one developed by Torrance (1983). Some children had more than one pressure ulcer, in which case the more severe one was graded, although all were counted (total 68 ulcers). Completed questionnaires were sent to the lead researcher for coding and analysis. The most frequently reported ulcer grade involved blistering of the skin or a superficial skin break. They occurred most often on the sacrum or buttocks, heel, thigh, ear, occipital scalp, malleolus and spine (Table 2, p43). In 50 per cent of children (n=27), pressure ulcers could be associated with equipment pressing or rubbing on the skin (Box 2).

The children had a variety of conditions, including:

- Orthopaedic, n=26 (48.1 per cent);

- Neurological/neuromuscular, n=15 (27.8 per cent);

- Multiple, n=14 (25.9 per cent).

Most of the children (92.6 per cent) had reduced mobility, and almost half were completely immobile.

Serum albumin was measured in 32 children, and of these 26 (81.2 per cent) had an albumin level of less than 35g/dL. Other frequently recorded characteristics were: evidence of pain, less than normal self-care ability and children who did not have a normal diet for their age (Box 3).

How reliable are these results?
The size of sample chosen for this survey was based on a previous study (Willock et al, 2000) in which three children developed pressure ulceration during a one-month period in a children's hospital with 277 beds.

There were over 1,450 inpatient beds in the 11 hospitals taking part in the survey. If the month of the data collection for the previous study was representative of the normal situation, and not just a month of particularly high incidence, we would have expected more than 280 children to have developed pressure ulcers in the 11 hospitals during 18 months.

Although data was collected on only 54 children, many more with pressure ulcers were reported to the local researchers. However, they were unable to assess them due to their own clinical workload. We therefore may have missed collecting data on a large proportion of children with pressure ulcers, and as a result do not know anything about the characteristics of the children who were missed.

Pressure ulceration may also have been under-reported. We would expect more children to have the non-blanching hyperaemia stage of pressure injury (redness that does not blanch with light finger pressure) than the blistering or skin break stage, as some children with non-blanching hyperaemia will develop more severe ulceration and the rest will resolve. However, significantly more children were reported with blisters and skin breaks than with non-blanching hyperaemia (Table 1).

One reason may have been a failure of ward nurses to recognise non-blanching hyperaemia as a pressure injury. While nurses collecting the data had been trained to recognise pressure injury, they relied on the ward nurses (who had not received such training) caring for the children to inform them when they saw a child with pressure injury. The ward nurses may not have recognised a pressure ulcer until it became an actual skin break or significant discoloration occurred. Baldwin's (2002) postal survey also found that more grade 2 pressure ulcers (34 per cent) were reported than grade 1 pressure ulcers (19 per cent). This would imply that some nurses caring for children do not recognise the first stage of pressure damage, and may therefore not be taking action to prevent more significant injury.

The percentages of children with pressure ulcers in each age group were similar to those found by Baldwin (2002) (Table 3).

Can the results be used?
These results reveal how many children in the sample had certain characteristics, but not how significant the results are.

To determine this, the results must be compared with data from a general sample of paediatric inpatients to find out how common the characteristics are in children who do not develop pressure ulcers as well as those who do. For example, 73.8 per cent of children with pressure ulceration had evidence of pain that was not associated with the ulceration. If a similar proportion of all children in hospital have pain, this result would not be significant. However, if only 10-20 per cent experienced pain, it is probably a significant result.

Some results, such as low serum albumin and anaemia, probably should not be used in isolation, but are likely to be an indication of the child's general poor health. More statistical tests need to be carried out to find out if some of these factors are linked.

However, this data probably does not give a completely true picture of what is happening in clinical practice - a true picture may be impossible to achieve. Despite this limitation the survey has provided some useful data.

Implications for practice
Out of seven paediatric pressure ulcer risk assessment tools identified (Curley et al, 2003; Cockett, 1998; Olding and Patterson, 1998; Waterlow, 1998; Garvin, 1997; Pickersgill, 1997; Bedi, 1993) only two (Cockett, 1998; Waterlow, 1998) included the risk of skin damage from splints, traction and other equipment. However, in our study skin damage was associated with equipment in 50 per cent of children with pressure ulcers.

Although 73.8 per cent had evidence of pain, none of the paediatric risk assessment tools mentions pain as a risk factor and only one published article (Pallija et al, 1999) described a possible association between pain and pressure ulceration. These findings call into question the validity of the risk assessment tools used in clinical practice. The National Institute for Clinical Excellence (2003) recommends that risk assessment tools should only be used as an 'aide memoire' and should not replace clinical judgement. In addition risk assessment tools should be designed for the patient group they are to be used with. Therefore, adult pressure ulcer risk assessment tools should not be used for children as they may be inappropriate and put children at risk. More work is needed to define risk factors for children.

Another question raised by this study was whether paediatric nurses receive sufficient education on how to recognise pressure damage. The numbers of children identified with non-blanching hyperaemia compared with those identified with blistering and skin breaks implies that nurses are not recognising non-blanching hyperaemia as pressure damage. All health care professionals should receive education in pressure ulcer prevention (NICE, 2003), but how much time in preregistration is spent learning about prevention, identification and treatment of pressure ulceration?

Any child can develop a pressure ulcer, which usually starts as a red mark on the skin. If the pressure is removed at this stage, the red mark will usually disappear within half an hour. If the pressure is prolonged, tissue damage will develop, the red area will not blanch when light finger pressure is applied, and it may start to become painful. Even then, if the pressure is removed this may heal within a few days and not result in deeper tissue damage. It is important that nurses recognise these initial stages and act to prevent further damage.

The NICE (2003) clinical guidance recommends that skin inspection is carried out regularly and that the frequency should depend on the condition of the patient. The most vulnerable areas of the patient's skin should be observed. These are mainly bony prominences, but anything causing friction or putting pressure on an area of skin for a prolonged period may cause ulceration.

Prolonged pressure on areas in contact with the mattress could be the result of immobility or not wanting to move due to pain, or because the child has reduced sensation and is not aware of the need to move. Children who are immobile should have their skin inspected very frequently and should be moved if it starts to become even slightly red - this may be as often as every 15 minutes. The more debilitated and immobile a child is, the more important it is to inspect the skin and relieve pressure. If children cannot be moved easily, they should be nursed on special pressure-relieving mattresses. However, even if a child is being nursed on such a mattress, it is important to inspect the skin regularly.

Nurses should be especially vigilant when children have objects or equipment pressing on or attached to their skin. These may be plaster casts, splints, nasogastric tubes, endotracheal tubes, ECG electrodes or oxygen saturation probes. They should also ensure that the child is not lying on tubes, leads or even hard toys.

Sicker children, such as those with multiple pathologies, may be at increased risk. Low serum albumin, anaemia, poor peripheral perfusion, and reduced food intake may all be indicators of poor general health, and may make the child more vulnerable to tissue damage.

Pressure ulceration is a potentially serious problem in children, and it is vital that paediatric nurses understand this and are able to recognise the early stages of pressure damage. More education, both in preregistration programmes and continuing professional education, should be made available for these nurses. While risk assessment tools designed specifically for children are needed, vigilance should enable nurses to prevent children developing pressure damage.

More research is needed to confirm the characteristics that increase children's risk of pressure ulceration and to establish the significance of individual characteristics.

- This article has been double-blind peer-reviewed.

For related articles on this subject and links to relevant websites see

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