- Email: [email protected]
Reviews and Abstracts
140 Journal of Tissue Viability 1999 Vol 9 No 4
Reviews and Abstracts Abstracts of presentations to the 1st National Conference on Pressure Sore Prevention and Management in Children on 29 July 1999 Pressure sores in children - is there a problem? Elaine Mills, Staff Nurse, Paediatric Intensive Care Unit, StGeorge's Healthcare NHS Trust, London
In the past there has been a view among healthcare professionals that children do not develop pressure sores because of their weight being less than that of adults and their activity levels being high. While that may have been true in the past (and that is debatable), it is certainly no longer the case nowadays, with increasingly sick children in acute care who would not have survived even five years ago, and increasingly disabled individuals living longer and more independently in the community. Small children are susceptible to pressure sores of the ears, occiput and bony prominences (especially knees and hips). Sacral sores and foot sores are more common in the older child or young adult. Both, if seriously ill, are susceptible to sores caused by oxygen mask straps, traction equipment, plaster casts and other medical paraphernalia. Susceptibility to sores can be divided into acute - caused by severe illness or trauma, and chronic - usually due to a neurological condition such as spina bifida. There is a degree of overlap as even minor illness in a neurologically compromised individual can make them acutely susceptible to ulceration, and, likewise, an acute condition can leave a residue of chronic susceptibility.
children cling to life due to improving medical expertise. Urgent research and development are necessary if we are to provide these children and young people with the care that they deserve.
Incidence and prevalence of pressure injury in children - a preliminary study Jane Willock, Lecturer in Nursing, University of Glamorgan, Wales
There is very little published literature on pressure sores in children and most of the existing literature is qualitative. Using literature from paediatric and adult studies, a schedule was designed to collect quantitative data on aspects that may predispose children to pressure injury. The schedule was piloted in an incidence and prevalence study, carried out at the Royal Liverpool Children's NHS Trust. The sample size was 82 children for the incidence study and 183 children for the prevalence study. Six children in the incidence study and 12 children in the prevalence study sustained pressure damage. Data from the combined studies indicated that factors most strongly associated with pressure injury were oedema, inotropic support, impaired nutritional state, immobility, reduced consciousness and inability to meet hygiene needs. Infants and young children most frequently sustained pressure injury on the occipital scalp area and the heels.
Pressure sore incidence data collection at St George's Healthcare has been taking place since the beginning of 1996 and a risk assessment scale was introduced in 1997. This allows us to give at least a partial answer to the question 'is there a problem?' The answer is yes. Not only because the incidence is surprisingly high - small babies in the paediatric intensive care unit have one of the highest incidences of any group within the hospital at around 15%, but also because there is little equipment available to prevent or manage the injuries and even less evidence-based knowledge on how to proceed.
Anne C Jones, Intermediate Care Services Manager, South Bedfordshire Community Health Care Trust, Luton
The impulse to organize this conference was our experience at a pressure sore study day. There was no mention of children and the trade representatives were not interested in our custom. They felt that children do not get pressure sores and so there is no problem. There is a problem and it will only increase in size as progressively sicker and more disabled
Pressure sores are known to be common in hospitals and in the community. Despite a wealth of literature on the subject of their prevention and management, little is written about the prevalence of the problem in children. Perhaps because of the known high prevalence of pressure sores in older people, most of the studies focus on this
© Tissue Viability Society
Although this was a very small study, it produced some useful preliminary data and was a valuable exercise in the development of a tool for data collection on a larger scale.
Pressure sore prevention and management in children - community perspective
Journal of Tissue Viability 1999 Vol 9 No 4
group. The challenge pressure sores pose in the management of sick children and those with degenerative disorders or special needs appears to have been overlooked. There is a dawning awareness that not only are children at risk of pressure sores, but their risk factors are different to those of adults. However, a literature review revealed little on paediatric pressure sore risk identification, assessment or management. The range of anti-pressure sore equipment for children appears limited and expensive, and equipment for use in cots, child-sized beds or wheelchairs is not readily available to community nurses. In recent years, focus has shifted from care delivery in hospitals and institutions to the community. NHS reforms have created opportunities for patient-centred care packages to be coordinated and delivered in a variety of care environments. This has inspired the caring agencies to develop innovative care packages and to care at home for children who might previously have spent much of their lives in hospitals or institutions. The integration of children with special needs into mainstream education has brought problems not previously encountered. Multi-disciplinary teamwork, always important in the management of children with special needs, is therefore even more crucial now. Lack of awareness of appropriate pressure sore prevention and management strategies leaves carers believing that pressure sores are an inevitable part of the child's condition. But with appropriate, timely intervention, pressure sores should be preventable and better managed when they do occur. Professionals and carers caring for children often have little knowledge of the causes and effects of pressure sores and are inexperienced in dealing with them. Paramedical and social care staff are unskilled in what is seen to be a nursing responsibility, while other carers (parents, educators) are usually not knowledgeable enough to feel able to contribute. Arguments rage about which agency is responsible for funding equipment, who should provide the care and how it should be organized. The problem remains, however, that investment is needed to develop risk assessment tools and specially designed anti-pressure sore devices, and to educate formal and informal carers if the needs of children in this area are to be met.
Ftisk assessnnent Andrea Cockett, Lecturer/Practitioner, StGeorge's Healthcare NHS Trust, and Kingston University and St George's Medical School, Faculty of Healthcare Sciences, London
The development, incidence and severity of pressure sores in children are poorly explored in the literature 1. My practice experience led me to believe that children do suffer from pressure sores and that there is a need to try to assess the risk of pressure sore development in this patient group. A literature review was undertaken, with the purpose of identifying
141
risk factors for children, particularly those nursed in an intensive care setting. This focus was appropriate as children nursed in intensive care were seen to develop quite severe sores. The literature relating to pressure sore development in paediatric and intensive care patients was therefore reviewed. Particular risk factors were identified from this review. Some of these factors related specifically to intensive care, such as the risks associated with inotropic 2 and respiratory support3 . Others were specific to children, such as splinting for limbs, orthopaedic casts, extravasation injury and prolonged surgery 1. These factors were classified according to the risk they posed, as identified in the literature, and a paediatric pressure sore risk assessment tool was developed4 . This tool has now been in use in one unit for over a year. Although it has been difficult to quantify the benefits of using the tool, there has been an increased awareness of the risk factors that can lead to the development of pressure sores. The use of the tool by nursing staff has led to a policy of providing pressure reduction or relief for every child requiring intensive care.
References 1 Waterlow J. Pressure sore risk assessment in children. Paediatric Nursing 1987; 9(6): 21-24. 2 Cubbin B, Jackson C. Trial of a pressure area risk calculator for intensive therapy patients. Intensive Care Nursing 1991; 7: 40--44. 3 Batson S, Adams S, Hall G. Quirke S. The development of a pressure area scoring system for critically ill patients; a pilot study. Intensive and Critical Care Nursing 1993; 9: 146--151. 4 Cockett A. Paediatric pressure sore risk assessment. Journal of Tissue Viability 1998; 8(1): 30.
Equipnnent for pressure sore prevention Kr:zysztof S Gebhardt, Clinical Nurse Specialist for Pressure Sore Prevention, StGeorge's Healthcare NHS Trust, London It is recognized that anti-pressure sore devices are an essential part of any strategy for pressure sore prevention. It is
known (in adults at least) that using pressure relief or reduction is more effective than relying on manual repositioning. Although there is much less certainty about the benefits of anti-pressure sore wheelchair and other cushions, the majority view is that they too are necessary. Despite the clear need for such equipment for children, the range of available products is very limited. To the best of our knowledge, in the UK, the following are available: one company supplies an alternating pressure mattress overlay for cribs and another one for cots; three low airloss cots are available and one air-fluidized paediatric bed. There are also two static air systems. Many suppliers of foam mattresses and overlays for the adult market will supply them to fit cots and child-sized beds. However, it should be noted that, for example, cross-cut or moulded mattresses are designed for adults and may not necessarily
142
Journal of Tissue Viability 1999 Vol 9 No 4
be suitable for children. I am aware of only two companies making anti-pressure sore seating specifically for children. Compared to the adult field the above is a very short list. Until recently, most equipment manufacturers have believed that there is no market for anti-pressure sore devices for children. For progress to be made, they and healthcare service providers need to be presented with evidence of the scope of the problem and healthcare services have to be shown that proposed solutions are effective. These goals can be achieved through high-quality research measuring incidence and prevalence and efficacy and effectiveness through controlled clinical studies. The lack of evidence to justify the use of most anti-pressure sore devices for adults has been well documented 1. In paediatrics the problem is even more acute. I am not aware of any studies, either clinical or laboratory, to determine best practice. Yet there are many questions which require answering. We have found that in our paediatric intensive care unit children nursed in cribs have a particularly high incidence of pressure sores (about 14%) despite being nursed on gel pads. One alternative is to use alternating-pressure pads. These, however, often make deep indentations on the babies' skins, especially if oedematous. We simply do not know whether this is likely to lead to skin damage after prolonged use. Another alternative might be a static air pad. In an attempt to answer this question, we are investing in a randomized, controlled trial.
References I Cullum N, Deeks J, Fletcher A, Long A, Mouneimne H, Sheldon T, et a!. The prevention and treatment of pressure sores. Effective Health Care 1995; 2(1).
Tissue damage in neonates Mary Goggin, Sister, Neonatal Intensive Care Unit, St George's Healthcare NHS Trust, London
The neonate is highly dependent on the nurse who must have a sound knowledge base to prevent tissue injury. Neonates are particularly susceptible to tissue injury because of delicate and immature skin and because of nursing and medical interventions such as strapping, friction, pressure and extravasation. The effects may be severe, and may include disfiguring scarring, psychological distress to parents, long-term effects of altered or lost limb function and the need for corrective surgery. From the legal point of view, allowing injuries to happen opens the professionals responsible to claims for a long time, as the statute of limitations which normally allows a claimant three years from the time of the injury to bring a claim does not apply in the case of minors until legal maturity is reached, and in the case of a person not deemed able to look after their own affairs does not apply at all. Thus, claims on his or her behalf can be made at any time during his/her life.
Extravasation injury is probably the most common serious tissue injury that occurs in the neonatal intensive care unit. Improvements in neonatal resuscitation have resulted in changes in the population of neonates. The average birth weight of children in the neonatal intensive care unit has decreased to 450 g, while gestational age has decreased to 22-24 weeks. Advances in technology and a better understanding of the newborn physiology have resulted in increasing haemodynamic monitoring. The combination of population dynamics and availability of technology has increased indications for intravenous and intra-arterial catheterization of newborn infants. Complications of the use of these catheters, including thromboembolism and chemical (extravasation) injuries with a potential for loss of limbs or limb deformity, have long been recognized. The cost of these injuries should be viewed as major, both in financial terms, and, more importantly, in terms of health and final outcome for the pre-term infant. The neonatal nurse is pivotal in the prevention and early detection of these injuries. An awareness of best practice and an evidencebased approach to care will do much to ensure excellent results, even if this type of injury does occur.
Management of pressure sores in the community Nicola Matthews, Deputy Head of Care/Senior Nurse, Valence School, Westerham
Management is described here from the perspective of a residential school for children aged 5-19 years, with physical disabilities and complex medical needs. The three most common disabilities experienced by students at the school are spina bifida, cerebral palsy and muscular dystrophy. Because children with these conditions have problems with movement and/or sensation, they are at increased risk of developing pressure sores. The number of children at school who actually develop pressure sores is small. However, the main thrust of our work is in the area of prevention, because once pressure sores actually develop in a child with a physical disability, it can be extremely difficult to heal them successfully. The first line of prevention is multi-disciplinary assessment. Nurses, occupational therapists and physiotherapists determine the level of risk for each student. Assessment covers all activities across the 24 h period and includes suitability of equipment and seating. Each student then has an individual care plan drawn up, detailing areas of risk and the plan for prevention. It is essential to involve the child and his family in this as poor compliance with a programme at home can negate all efforts made in school. If a pressure sore develops, treatment is again from a multi-
disciplinary approach. General practitioners and district nurses are involved, to advise on wound management and dressings. Occupational therapists and physiotherapists will advise on alternative positioning and padding of equipment,
Journal of Tissue Viability 1999 Vol 9 No 4
eg spinal jackets or splints, which may be rubbing. Advice may also be sought from specialist centres such as Chailey Heritage or Queen Mary's Hospital, Roehampton. Developing a pressure sore can have a huge impact on the life of a child with a physical disability. For example, it may prevent him/her from swimming, which may be the only activity they can participate in. It may also mean that they miss out on a lot of their education because they are unable to maintain the best position for learning or access to recording work. One of the main aims of the school is to teach students independence in all areas of health care - either to manage this themselves or to direct others in managing this. It is therefore essential to involve them in skin care and pressure sore prevention from an early age so that this becomes a routine for life.
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foot sores developing. The above are just some of the possible examples. Careful and accurate assessment, measurement and regular review of a child are essential to prevent problems arising. So often a child is made to fit available equipment rather than the equipment being ordered or made to fit the child. Unfortunately, many therapists working in the field of posture and mobility do not always take into consideration the vulnerability of a child to pressure sores nor do they see it as part of their role to do so. Yet many of the children we see are immobile, dependent on carers for repositioning, unable to communicate and have feeding problems which may lead to them being nutritionally compromised. Surely, it must be our responsibility, in liaison with parents, carers and other professionals caring for the child, to guard against the development of predictable problems before they arise?
Pressure sore management - a case study Pressure sores and postural management Jacqui Romer, Head Occupational Therapist, Special Seating Team, Queen Mary's Hospital, Roehampton, London
There are a huge number of wheelchair cushions and seating products on the open market, some making greater claims than others about their efficacy in preventing pressure ulcers. Most manufacturers will, if requested, adapt their products to suit smaller-sized children. This presentation relates to children with severe and complex disabilities; usually the result of neurological conditions such as cerebral palsy, spina bifida or muscular dystrophy. These children may require more postural support than a simple cushion seat can provide and are at great risk of tissue trauma not only to the ischial and sacral areas, but also to their spine, feet, elbows and anywhere else they make contact with their wheelchair. At Queen Mary's Hospital, the special seating team provides a consultant-led, regional service to assess both adults and children who require greater postural support than the average wheelchair can provide. Part of our role is to assess the risk and to protect against the development or exacerbation of pressure damage. Whilst it is not a regular occurrence for children to present with pressure sores in the clinic, poor seating may for many reasons lead to persistent red areas or breakdown. Ill-fitting orthotic appliances and custom-made seating may cause red areas and breakdown at the apex of a prominent scoliosis/kyphosis. This can be prevented by better contouring of the seat around the fixed deformity. The positioning of pelvic straps and harnessing needs to be carefully considered if the child has a gastrostomy or ileostomy. Seat depth has to be carefully measured to enable provision of seating that does not cause breakdown in the popliteal space or chafing of tight hamstrings. Footplates and armrests require accurate positioning and adjustment to prevent elbow and
Virginia Bennett, Sister, Rupert Ward, Glan Clwyd Hospital, Denbighshire, Wales
Children are at risk of developing and do develop pressure sores. They include children wearing orthopaedic appliances and those with special needs exacerbated by a medical problem. The subject of this case study is a girl, three years of age at the time of her accident. The child was a front-seat passenger in a car which was involved in a head-on collision at moderate speed. She was sitting on hermother's lap, belted in with the same belt as her mother. There were three other passengers in the back seat of the vehicle, all of whom wore safety belts. The mother was cushioned from the impact by her child and sustained arm and shoulder injuries. The child sustained arm and shoulder injuries. The child sustained fractures of the parietal and occipital bones, unstable fractures of the spinal cord and an abdominal injury which subsequently required a bowel resection. The spinal injury was immobilized, the patient was intubated and ventilated and transferred to the regional paediatric intensive care unit. There she underwent surgery to repair her abdominal injuries, had a tracheotomy performed and a Fraser jacket and halo applied. During this Jime (approximately three weeks), the girl developed a fulY-thickness sacral pressure sore and a sore on the occipital aspect of the scull. The likely aetiological factors in the development of her pressure sores include complex injuries, nutritional problems due to an abdominal injury, incontinence of urine and faeces, hypoxia suffered at the site of the accident and during the resuscitation period, and limitations on positioning due to the halo and jacket. The sores were managed primarily with a hydrogel with a foam secondary dressing. Pressure relief consisted mainly of manual repositioning, as the Fraser jacket negated any
144 Journal of Tissue Viability 1999 Vol 9 No 4 potential benefits of a pressure-relieving mattress. However, an anti-pressure sore cushion was made for the girl's wheelchair once she was able to sit up. Development of pressure sores significantly delayed the transfer of this child to a rehabilitation centre, with significant financial costs to the health service and physical, financial and emotional costs for the patient and family. Conflicts arose between the various professionals with responsibility for her care as regards her wound manage-
ment. Attempts were made to over-ride the wishes of the nursing staff and parents who preferred to continue an evidence-based treatment which was demonstrably effective. The tissue viability nurse proved useful in ensuring an appropriate wound care regime. Nonetheless, this case illustrates the need for structured paediatric pressure sore risk assessment, using evidence-based tools in all areas of paediatric nursing - including accident and emergency departments, intensive care units, theatres and general wards - and for wound management protocols.
2nd BIOVALLEY TISSUE ENGINEERING SYMPOSIUM 25-27 November 1999 Freiburg, Germany Tissue engineering requires new approaches to the solution of clinical needs which can only be achieved by creating a communicative basis to include basic scientists, chemical engineers, industry, health administrators and. clinicians from all over the world. The purpose of the Tissue Engineering Symposium is to promote this progress and create a basis for the annual exchange of ideas. Topics covered at the symposium will include basic sciences, material sciences, the skeletal system, visceral organs, the cardiovascular system, genetic engineering, stem cells, and regulatory, economic and ethical issues. For further details contact:
Professor Bjorn Stark, Department of Plastic and Hand Surgery, University Medical Centre, HugstetterstraBe, D-791 06 Freiburg, Germany Tel: +49 761 270 2817; fax +49 761 270 2501; email: [email protected]
PRESSURE SORE REGIONAL STUDY DAYS The Society provides free in-service training for staff concerned with the prevention and treatment of pressure sores. A day can be arranged in a hospital of your choice to eliminate travel costs for delegates. It comprises two identical half-day programmes covering the prevention and management of pressure sores and wound assessment and dressing selection. If you would like further information please telephone the Society office on 01722 336262 ext 4057, or write to the Tissue Viability Society, Glanville Centre, Salisbury District Hospital, Salisbury SP2 8BJ.
Reviews and Abstracts Abstracts of presentations to the 1st National Conference on Pressure Sore Prevention and Management in Children on 29 July 1999 Pressure sores in children - is there a problem? Elaine Mills, Staff Nurse, Paediatric Intensive Care Unit, StGeorge's Healthcare NHS Trust, London
In the past there has been a view among healthcare professionals that children do not develop pressure sores because of their weight being less than that of adults and their activity levels being high. While that may have been true in the past (and that is debatable), it is certainly no longer the case nowadays, with increasingly sick children in acute care who would not have survived even five years ago, and increasingly disabled individuals living longer and more independently in the community. Small children are susceptible to pressure sores of the ears, occiput and bony prominences (especially knees and hips). Sacral sores and foot sores are more common in the older child or young adult. Both, if seriously ill, are susceptible to sores caused by oxygen mask straps, traction equipment, plaster casts and other medical paraphernalia. Susceptibility to sores can be divided into acute - caused by severe illness or trauma, and chronic - usually due to a neurological condition such as spina bifida. There is a degree of overlap as even minor illness in a neurologically compromised individual can make them acutely susceptible to ulceration, and, likewise, an acute condition can leave a residue of chronic susceptibility.
children cling to life due to improving medical expertise. Urgent research and development are necessary if we are to provide these children and young people with the care that they deserve.
Incidence and prevalence of pressure injury in children - a preliminary study Jane Willock, Lecturer in Nursing, University of Glamorgan, Wales
There is very little published literature on pressure sores in children and most of the existing literature is qualitative. Using literature from paediatric and adult studies, a schedule was designed to collect quantitative data on aspects that may predispose children to pressure injury. The schedule was piloted in an incidence and prevalence study, carried out at the Royal Liverpool Children's NHS Trust. The sample size was 82 children for the incidence study and 183 children for the prevalence study. Six children in the incidence study and 12 children in the prevalence study sustained pressure damage. Data from the combined studies indicated that factors most strongly associated with pressure injury were oedema, inotropic support, impaired nutritional state, immobility, reduced consciousness and inability to meet hygiene needs. Infants and young children most frequently sustained pressure injury on the occipital scalp area and the heels.
Pressure sore incidence data collection at St George's Healthcare has been taking place since the beginning of 1996 and a risk assessment scale was introduced in 1997. This allows us to give at least a partial answer to the question 'is there a problem?' The answer is yes. Not only because the incidence is surprisingly high - small babies in the paediatric intensive care unit have one of the highest incidences of any group within the hospital at around 15%, but also because there is little equipment available to prevent or manage the injuries and even less evidence-based knowledge on how to proceed.
Anne C Jones, Intermediate Care Services Manager, South Bedfordshire Community Health Care Trust, Luton
The impulse to organize this conference was our experience at a pressure sore study day. There was no mention of children and the trade representatives were not interested in our custom. They felt that children do not get pressure sores and so there is no problem. There is a problem and it will only increase in size as progressively sicker and more disabled
Pressure sores are known to be common in hospitals and in the community. Despite a wealth of literature on the subject of their prevention and management, little is written about the prevalence of the problem in children. Perhaps because of the known high prevalence of pressure sores in older people, most of the studies focus on this
© Tissue Viability Society
Although this was a very small study, it produced some useful preliminary data and was a valuable exercise in the development of a tool for data collection on a larger scale.
Pressure sore prevention and management in children - community perspective
Journal of Tissue Viability 1999 Vol 9 No 4
group. The challenge pressure sores pose in the management of sick children and those with degenerative disorders or special needs appears to have been overlooked. There is a dawning awareness that not only are children at risk of pressure sores, but their risk factors are different to those of adults. However, a literature review revealed little on paediatric pressure sore risk identification, assessment or management. The range of anti-pressure sore equipment for children appears limited and expensive, and equipment for use in cots, child-sized beds or wheelchairs is not readily available to community nurses. In recent years, focus has shifted from care delivery in hospitals and institutions to the community. NHS reforms have created opportunities for patient-centred care packages to be coordinated and delivered in a variety of care environments. This has inspired the caring agencies to develop innovative care packages and to care at home for children who might previously have spent much of their lives in hospitals or institutions. The integration of children with special needs into mainstream education has brought problems not previously encountered. Multi-disciplinary teamwork, always important in the management of children with special needs, is therefore even more crucial now. Lack of awareness of appropriate pressure sore prevention and management strategies leaves carers believing that pressure sores are an inevitable part of the child's condition. But with appropriate, timely intervention, pressure sores should be preventable and better managed when they do occur. Professionals and carers caring for children often have little knowledge of the causes and effects of pressure sores and are inexperienced in dealing with them. Paramedical and social care staff are unskilled in what is seen to be a nursing responsibility, while other carers (parents, educators) are usually not knowledgeable enough to feel able to contribute. Arguments rage about which agency is responsible for funding equipment, who should provide the care and how it should be organized. The problem remains, however, that investment is needed to develop risk assessment tools and specially designed anti-pressure sore devices, and to educate formal and informal carers if the needs of children in this area are to be met.
Ftisk assessnnent Andrea Cockett, Lecturer/Practitioner, StGeorge's Healthcare NHS Trust, and Kingston University and St George's Medical School, Faculty of Healthcare Sciences, London
The development, incidence and severity of pressure sores in children are poorly explored in the literature 1. My practice experience led me to believe that children do suffer from pressure sores and that there is a need to try to assess the risk of pressure sore development in this patient group. A literature review was undertaken, with the purpose of identifying
141
risk factors for children, particularly those nursed in an intensive care setting. This focus was appropriate as children nursed in intensive care were seen to develop quite severe sores. The literature relating to pressure sore development in paediatric and intensive care patients was therefore reviewed. Particular risk factors were identified from this review. Some of these factors related specifically to intensive care, such as the risks associated with inotropic 2 and respiratory support3 . Others were specific to children, such as splinting for limbs, orthopaedic casts, extravasation injury and prolonged surgery 1. These factors were classified according to the risk they posed, as identified in the literature, and a paediatric pressure sore risk assessment tool was developed4 . This tool has now been in use in one unit for over a year. Although it has been difficult to quantify the benefits of using the tool, there has been an increased awareness of the risk factors that can lead to the development of pressure sores. The use of the tool by nursing staff has led to a policy of providing pressure reduction or relief for every child requiring intensive care.
References 1 Waterlow J. Pressure sore risk assessment in children. Paediatric Nursing 1987; 9(6): 21-24. 2 Cubbin B, Jackson C. Trial of a pressure area risk calculator for intensive therapy patients. Intensive Care Nursing 1991; 7: 40--44. 3 Batson S, Adams S, Hall G. Quirke S. The development of a pressure area scoring system for critically ill patients; a pilot study. Intensive and Critical Care Nursing 1993; 9: 146--151. 4 Cockett A. Paediatric pressure sore risk assessment. Journal of Tissue Viability 1998; 8(1): 30.
Equipnnent for pressure sore prevention Kr:zysztof S Gebhardt, Clinical Nurse Specialist for Pressure Sore Prevention, StGeorge's Healthcare NHS Trust, London It is recognized that anti-pressure sore devices are an essential part of any strategy for pressure sore prevention. It is
known (in adults at least) that using pressure relief or reduction is more effective than relying on manual repositioning. Although there is much less certainty about the benefits of anti-pressure sore wheelchair and other cushions, the majority view is that they too are necessary. Despite the clear need for such equipment for children, the range of available products is very limited. To the best of our knowledge, in the UK, the following are available: one company supplies an alternating pressure mattress overlay for cribs and another one for cots; three low airloss cots are available and one air-fluidized paediatric bed. There are also two static air systems. Many suppliers of foam mattresses and overlays for the adult market will supply them to fit cots and child-sized beds. However, it should be noted that, for example, cross-cut or moulded mattresses are designed for adults and may not necessarily
142
Journal of Tissue Viability 1999 Vol 9 No 4
be suitable for children. I am aware of only two companies making anti-pressure sore seating specifically for children. Compared to the adult field the above is a very short list. Until recently, most equipment manufacturers have believed that there is no market for anti-pressure sore devices for children. For progress to be made, they and healthcare service providers need to be presented with evidence of the scope of the problem and healthcare services have to be shown that proposed solutions are effective. These goals can be achieved through high-quality research measuring incidence and prevalence and efficacy and effectiveness through controlled clinical studies. The lack of evidence to justify the use of most anti-pressure sore devices for adults has been well documented 1. In paediatrics the problem is even more acute. I am not aware of any studies, either clinical or laboratory, to determine best practice. Yet there are many questions which require answering. We have found that in our paediatric intensive care unit children nursed in cribs have a particularly high incidence of pressure sores (about 14%) despite being nursed on gel pads. One alternative is to use alternating-pressure pads. These, however, often make deep indentations on the babies' skins, especially if oedematous. We simply do not know whether this is likely to lead to skin damage after prolonged use. Another alternative might be a static air pad. In an attempt to answer this question, we are investing in a randomized, controlled trial.
References I Cullum N, Deeks J, Fletcher A, Long A, Mouneimne H, Sheldon T, et a!. The prevention and treatment of pressure sores. Effective Health Care 1995; 2(1).
Tissue damage in neonates Mary Goggin, Sister, Neonatal Intensive Care Unit, St George's Healthcare NHS Trust, London
The neonate is highly dependent on the nurse who must have a sound knowledge base to prevent tissue injury. Neonates are particularly susceptible to tissue injury because of delicate and immature skin and because of nursing and medical interventions such as strapping, friction, pressure and extravasation. The effects may be severe, and may include disfiguring scarring, psychological distress to parents, long-term effects of altered or lost limb function and the need for corrective surgery. From the legal point of view, allowing injuries to happen opens the professionals responsible to claims for a long time, as the statute of limitations which normally allows a claimant three years from the time of the injury to bring a claim does not apply in the case of minors until legal maturity is reached, and in the case of a person not deemed able to look after their own affairs does not apply at all. Thus, claims on his or her behalf can be made at any time during his/her life.
Extravasation injury is probably the most common serious tissue injury that occurs in the neonatal intensive care unit. Improvements in neonatal resuscitation have resulted in changes in the population of neonates. The average birth weight of children in the neonatal intensive care unit has decreased to 450 g, while gestational age has decreased to 22-24 weeks. Advances in technology and a better understanding of the newborn physiology have resulted in increasing haemodynamic monitoring. The combination of population dynamics and availability of technology has increased indications for intravenous and intra-arterial catheterization of newborn infants. Complications of the use of these catheters, including thromboembolism and chemical (extravasation) injuries with a potential for loss of limbs or limb deformity, have long been recognized. The cost of these injuries should be viewed as major, both in financial terms, and, more importantly, in terms of health and final outcome for the pre-term infant. The neonatal nurse is pivotal in the prevention and early detection of these injuries. An awareness of best practice and an evidencebased approach to care will do much to ensure excellent results, even if this type of injury does occur.
Management of pressure sores in the community Nicola Matthews, Deputy Head of Care/Senior Nurse, Valence School, Westerham
Management is described here from the perspective of a residential school for children aged 5-19 years, with physical disabilities and complex medical needs. The three most common disabilities experienced by students at the school are spina bifida, cerebral palsy and muscular dystrophy. Because children with these conditions have problems with movement and/or sensation, they are at increased risk of developing pressure sores. The number of children at school who actually develop pressure sores is small. However, the main thrust of our work is in the area of prevention, because once pressure sores actually develop in a child with a physical disability, it can be extremely difficult to heal them successfully. The first line of prevention is multi-disciplinary assessment. Nurses, occupational therapists and physiotherapists determine the level of risk for each student. Assessment covers all activities across the 24 h period and includes suitability of equipment and seating. Each student then has an individual care plan drawn up, detailing areas of risk and the plan for prevention. It is essential to involve the child and his family in this as poor compliance with a programme at home can negate all efforts made in school. If a pressure sore develops, treatment is again from a multi-
disciplinary approach. General practitioners and district nurses are involved, to advise on wound management and dressings. Occupational therapists and physiotherapists will advise on alternative positioning and padding of equipment,
Journal of Tissue Viability 1999 Vol 9 No 4
eg spinal jackets or splints, which may be rubbing. Advice may also be sought from specialist centres such as Chailey Heritage or Queen Mary's Hospital, Roehampton. Developing a pressure sore can have a huge impact on the life of a child with a physical disability. For example, it may prevent him/her from swimming, which may be the only activity they can participate in. It may also mean that they miss out on a lot of their education because they are unable to maintain the best position for learning or access to recording work. One of the main aims of the school is to teach students independence in all areas of health care - either to manage this themselves or to direct others in managing this. It is therefore essential to involve them in skin care and pressure sore prevention from an early age so that this becomes a routine for life.
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foot sores developing. The above are just some of the possible examples. Careful and accurate assessment, measurement and regular review of a child are essential to prevent problems arising. So often a child is made to fit available equipment rather than the equipment being ordered or made to fit the child. Unfortunately, many therapists working in the field of posture and mobility do not always take into consideration the vulnerability of a child to pressure sores nor do they see it as part of their role to do so. Yet many of the children we see are immobile, dependent on carers for repositioning, unable to communicate and have feeding problems which may lead to them being nutritionally compromised. Surely, it must be our responsibility, in liaison with parents, carers and other professionals caring for the child, to guard against the development of predictable problems before they arise?
Pressure sore management - a case study Pressure sores and postural management Jacqui Romer, Head Occupational Therapist, Special Seating Team, Queen Mary's Hospital, Roehampton, London
There are a huge number of wheelchair cushions and seating products on the open market, some making greater claims than others about their efficacy in preventing pressure ulcers. Most manufacturers will, if requested, adapt their products to suit smaller-sized children. This presentation relates to children with severe and complex disabilities; usually the result of neurological conditions such as cerebral palsy, spina bifida or muscular dystrophy. These children may require more postural support than a simple cushion seat can provide and are at great risk of tissue trauma not only to the ischial and sacral areas, but also to their spine, feet, elbows and anywhere else they make contact with their wheelchair. At Queen Mary's Hospital, the special seating team provides a consultant-led, regional service to assess both adults and children who require greater postural support than the average wheelchair can provide. Part of our role is to assess the risk and to protect against the development or exacerbation of pressure damage. Whilst it is not a regular occurrence for children to present with pressure sores in the clinic, poor seating may for many reasons lead to persistent red areas or breakdown. Ill-fitting orthotic appliances and custom-made seating may cause red areas and breakdown at the apex of a prominent scoliosis/kyphosis. This can be prevented by better contouring of the seat around the fixed deformity. The positioning of pelvic straps and harnessing needs to be carefully considered if the child has a gastrostomy or ileostomy. Seat depth has to be carefully measured to enable provision of seating that does not cause breakdown in the popliteal space or chafing of tight hamstrings. Footplates and armrests require accurate positioning and adjustment to prevent elbow and
Virginia Bennett, Sister, Rupert Ward, Glan Clwyd Hospital, Denbighshire, Wales
Children are at risk of developing and do develop pressure sores. They include children wearing orthopaedic appliances and those with special needs exacerbated by a medical problem. The subject of this case study is a girl, three years of age at the time of her accident. The child was a front-seat passenger in a car which was involved in a head-on collision at moderate speed. She was sitting on hermother's lap, belted in with the same belt as her mother. There were three other passengers in the back seat of the vehicle, all of whom wore safety belts. The mother was cushioned from the impact by her child and sustained arm and shoulder injuries. The child sustained arm and shoulder injuries. The child sustained fractures of the parietal and occipital bones, unstable fractures of the spinal cord and an abdominal injury which subsequently required a bowel resection. The spinal injury was immobilized, the patient was intubated and ventilated and transferred to the regional paediatric intensive care unit. There she underwent surgery to repair her abdominal injuries, had a tracheotomy performed and a Fraser jacket and halo applied. During this Jime (approximately three weeks), the girl developed a fulY-thickness sacral pressure sore and a sore on the occipital aspect of the scull. The likely aetiological factors in the development of her pressure sores include complex injuries, nutritional problems due to an abdominal injury, incontinence of urine and faeces, hypoxia suffered at the site of the accident and during the resuscitation period, and limitations on positioning due to the halo and jacket. The sores were managed primarily with a hydrogel with a foam secondary dressing. Pressure relief consisted mainly of manual repositioning, as the Fraser jacket negated any
144 Journal of Tissue Viability 1999 Vol 9 No 4 potential benefits of a pressure-relieving mattress. However, an anti-pressure sore cushion was made for the girl's wheelchair once she was able to sit up. Development of pressure sores significantly delayed the transfer of this child to a rehabilitation centre, with significant financial costs to the health service and physical, financial and emotional costs for the patient and family. Conflicts arose between the various professionals with responsibility for her care as regards her wound manage-
ment. Attempts were made to over-ride the wishes of the nursing staff and parents who preferred to continue an evidence-based treatment which was demonstrably effective. The tissue viability nurse proved useful in ensuring an appropriate wound care regime. Nonetheless, this case illustrates the need for structured paediatric pressure sore risk assessment, using evidence-based tools in all areas of paediatric nursing - including accident and emergency departments, intensive care units, theatres and general wards - and for wound management protocols.
2nd BIOVALLEY TISSUE ENGINEERING SYMPOSIUM 25-27 November 1999 Freiburg, Germany Tissue engineering requires new approaches to the solution of clinical needs which can only be achieved by creating a communicative basis to include basic scientists, chemical engineers, industry, health administrators and. clinicians from all over the world. The purpose of the Tissue Engineering Symposium is to promote this progress and create a basis for the annual exchange of ideas. Topics covered at the symposium will include basic sciences, material sciences, the skeletal system, visceral organs, the cardiovascular system, genetic engineering, stem cells, and regulatory, economic and ethical issues. For further details contact:
Professor Bjorn Stark, Department of Plastic and Hand Surgery, University Medical Centre, HugstetterstraBe, D-791 06 Freiburg, Germany Tel: +49 761 270 2817; fax +49 761 270 2501; email: [email protected]
PRESSURE SORE REGIONAL STUDY DAYS The Society provides free in-service training for staff concerned with the prevention and treatment of pressure sores. A day can be arranged in a hospital of your choice to eliminate travel costs for delegates. It comprises two identical half-day programmes covering the prevention and management of pressure sores and wound assessment and dressing selection. If you would like further information please telephone the Society office on 01722 336262 ext 4057, or write to the Tissue Viability Society, Glanville Centre, Salisbury District Hospital, Salisbury SP2 8BJ.