Pressure Ulcers

What is a Pressure Ulcer?

Pressure ulcers or bed sores are areas of damaged skin caused by pressure, shearing forces and friction. A pressure ulcer develops when there is poor blood flow with unrelieved pressure to an area of the body. The ulcer is most likely to occur where boney structures lie beneath the skin. If good blood flow is interrupted due to the child's inability to move independently, the tissue will begin to break down.

When a pressure ulcer is noted, it is graded by the degree of injury to the skin. There are 4 grades of pressure ulcers, ranging from grade 1 (superficial skin discoloration) to grade 4 (deep tissue damage with bone involvement).

Where do Pressure Ulcers Occur?

Pressure ulcers can appear anywhere on the body, however, common areas on children are:

• Back of the head
• Ears
• Tailbone (sacrum / coccyx)
• Heels
• Elbows
• Spine and shoulder blades

Are Pressure Ulcers Serious?

The skin is a natural barrier to infection. Pressure ulcers create breaks in the skin that can place your child at risk of complications, such as infections. These infections may cause serious illness in children with suppressed immunity.

Who is at Risk of Getting a Pressure Ulcer?

Most people perform their own pressure ulcer prevention by constantly repositioning themselves, even when they are asleep. Some medical treatments, e.g. a plaster cast, and congenital conditions can limit children's movement. Children most at risk are those who:

• Have limited or no voluntary movement.
• Have reduced or impaired sensation.
• Are in constant contact with another surface e.g. wheelchair; orthotics.
• Are restricted to bed for long periods of time.

What to Do for Prevention

If you believe that your child is at risk of developing a pressure ulcer or may already have one, please talk to your child's: General Practitioner; Nurse; Occupational Therapist; Community Nurse or other health professional. They can discuss options that are suitable for your child. Actions you can take include:

• Check your child's skin regularly, morning and night.
• Change your child's position regularly, we recommend every two hours through the day and every four hours overnight.
• Change your child's nappy regularly, we recommend as soon as the nappy becomes wet or soiled. Every two to four hours is usual.
• Use soaps or creams that are pH neutral. Be very gentle when you apply creams to the areas at risk on your child's body.
• Make sure your child's skin is neither too moist nor too dry.
• Encourage your child to be active, where appropriate.
• Make sure your child has adequate nutrition and fluid intake.

Things to Avoid

• Stretching or pulling on the skin e.g. do not drag your child up the bed over the sheet.
• Massaging or rubbing red areas. This may cause further damage to the area.
• Using foam and / or air donut or ring cushions. These items can prevent fluid from draining out of the tissues. They may cause swelling and increase the chances of having a pressure sore.

Identifying a Pressure Ulcer

It is important to find the source of pressure and remove it where possible. Common signs of pressure areas are:

• Red marks.
• Broken skin.
• Blistering to areas where an object has been pressing on the skin.
• Pain (unless your child has reduced or impaired sensation).

Ask your child to tell you if there are any sore areas on their body, or look for the following signs:

• Unsettled behaviours, inconsolable crying (unable to be settled).
• Unexplained fever.
• Excessive sweating.
• Reduced or no appetite.
• An area of skin that your child will not allow you to touch.
• An area under a plaster, splint or brace that has a foul odour or is leaking fluid.

• A pressure ulcer is much easier to prevent than treat.
• Pressure ulcers can be a sign of a deeper wound and need to be treated as soon as possible.
• Be aware of the signs of a developing pressure ulcer.
• Find the cause and where possible, remove the cause.
• Talk to your health professional if your child is at risk.

References

Butler, C. (2006) Paediatric Skin Care: Guidelines for Assessment, Prevention and Treatment Paediatric Nursing 32(5)
National Pressure Ulcer Advisory Panel (2007) Pressure Ulcer Stages Revised by NPUAP www.npuap.org last accessed 1st April 2008
Suddaby, E., Barnett, S. & Facteau, L. (2006) Skin Breakdown in Acute Care Paediatrics Dermatology Nursing 18(2):155-161
Victoria Health Service, Better Health Channel (2008) Pressure Sores Fact Sheet www.betterhealth.vic.gov.au, last accessed 1st April 2008
Paraplegic and Quadriplegic Association New South Wales, Skin Care Fact Sheet