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In this section About Kids Health Information Fact sheets Translated fact sheets KHI app RCH TV for kids Kids Health Info podcast First aid training Contact us. Pressure injury prevention. Pressure injury prevention A pressure injury also known as pressure sore, pressure ulcer or bed sore is an area of the skin that has been damaged as a result of constant pressure, poor blood flow or chafing and rubbing of the skin.

Signs and symptoms of pressure injuries Common signs of a pressure injury include: red marks blue or purple areas in darker skin blistering broken skin pain. tubes, masks, drains etc. What causes pressure injuries? A number of factors may lead to your child developing a pressure injury, including: reduced activity — sitting or lying in the one place for too long sitting in wet clothing, a wet bed or a wet nappy for long periods pressure or friction to one area of the body lying on crumpled sheets or wearing clothing with thick seams reduced feeling in the skin.

Prevention in hospital While in hospital, nursing staff will assess and monitor your child for pressure injuries on a daily basis. This plan may include the following strategies: positioning in bed applying a dressing to bony or reddened areas using special slide sheets to move your child in bed using barrier creams using absorbent bedsheets frequent inspection of at-risk areas of skin increasing nutritional and fluid intake this may be via a tube if your child is unable to eat or drink helping your child to change their position every two to four hours during the day and night it is always best if your child can do this themselves, but staff will assist if needed repositioning medical equipment using pressure-relieving products e.

gel pads, air mattresses. Care at home Pressure injuries can be serious and may take months to heal. Observe Check your child's skin regularly, in the morning and at night.

Look for blisters, bruising, cracks, scrapes, changes in skin colour redness or darkening , or dry skin. Closely inspect high-risk areas such as bony areas heels, ears, buttocks, hips, elbows etc and skin under and around casts, splints, braces or medical equipment.

Watch for areas that are constantly moist, such as the groin and buttocks, especially if your child is incontinent or not toilet trained. As you cannot look under plaster, monitor your child if they have any increased pain or discomfort under the cast. Positioning Encourage your child to change their position at least every two hours if sitting for long periods.

If your child is spending extended periods of time in bed, encourage them to change their position regularly — every two hours during the day and four-hourly overnight. If they require your assistance to change position in bed, be careful not to drag their skin when moving.

Your child can be positioned on their left side, back and right side while in bed. Make sure bed sheets are tightly tucked in and not crumpled.

Small creases or folds in sheets can damage the skin. Encourage your child to be active where appropriate. Skin care Use lukewarm water for bathing and showering. If using soap or liquid cleanser, try to use a product that is pH neutral, unperfumed and alcohol free. We use cookies on our website to support technical features that enhance your user experience.

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Monday, 20 February Curley et al identified that of the pressure ulcers that developed in three paediatric intensive care units, 27 were caused by pressure from medical devices. This evidence indicates the clinical need for a validated risk assessment tool for children, as well as the implementation of consistent standards of preventive practices across children's health services.

Pressure ulcer risk assessment is an essential component of the admission procedure not only to identify risk but also to ensure that effective preventive strategies can be implemented. Early recognition of risk factors is the precursor to planning preventive care.

Murdoch recognised the lack of a tmiversal risk assessment tool for children, particularly in the high-risk setting of intensive care. This is supported by Barnes who identified five paediatric risk assessment tools, three of which were adapted from adult-based tools.

Dixon and Ratliff supported the implementation of a specific risk assessment tool across all paediatric care settings, and Willock et al concluded that a risk assessment tool specifically for children is paramount to pressure ulcer prevention in paediatric health care.

Although the evidence to support the prediction of pressure ulcers in children is scanty, the past decade has seen a rise in interest in this aspect of care provision. The Braden Q Scale, adapted from the adult Braden Scale was one of the earlier tools to be developed by Curley et al for use in children.

This was tested for its reliability and validity, determining 0. The Glamorgan Scale The Glamorgan Scale Willock et al has been developed more recently and has undergone rigorous testing, demonstrating This scale has high inter-rater reliability Willock et al , therefore reducing subjectivity and supporting nurses in making clinical decisions based on accurate assessment.

Its use in clinical practice is therefore supported and highly recommended. Within the Glamorgan Scale, each characteristic is weighted according to its statistical significance in relation to the development of pressure ulcers in children Willock et al For example, reduced mobility and pressure against the skin carry the highest weightings, while anaemia, pyrexia and low serum albumin are found to be less significant but risk factors nonetheless.

The weighting consequently increases the reliability of the tool and based on the calculation being used the higher the score the greater the risk of pressure ulcers, the need for additional preventive interventions is acknowledged.

Pressure ulcer prevention is multifaceted and requires skill, knowledge and consistencies in nursing practice to ensure effective outcomes for children at risk of pressure ulcer development. Risk assessment, skin assessment, repositioning and pressure relief are integral components of pressure ulcer prevention.

Baharestani and Rathff highlighted the need to identify specific age-related preventive strategies. Although timely skin assessments are recommended NHS Institute for Innovation and Improvement , the frequency is not prescribed although there is evidence to suggest that this is pertinent during episodes of repositioning Beldon Skin assessment involves examining the skin for evidence of new damage.

The skin tolerance test is a method of identifying the difference between erythema or reactive hyperaemia redness and a stage 1 pressure ulcer. Reactive hyperaemia can be defined as a temporary reaction to pressure being applied locally to the skin Collier Hyperaemia is caused by vasodilation of the intact capillaries surrounding the point of pressure.

Vasodilation is the natural body response, which allows additional oxygen and nutrients to reach the site of pressure to compensate for the temporary capillary occlusion. Reactive hyperaemia is not a stage 1 pressure ulcer and the redness will resolve following relief of pressure Bliss , Collier During inspection of the patient's skin, the skin tolerance test should be carried out on all visible red areas of skin.

This can be done by pressing a finger tightly over the reddened area for 15 seconds then lifting up the finger. If the area blanches it is not a grade 1 pressure ulcer.

If it stays red and is non-blanchable it is grade 1. Skin assessment should take place on admission as part of the risk assessment procedure National institute for Health and Clinical Excellence NICE , NHS Institute for Innovation and Improvement , DH b and of skin damage or lesion should be assessed Individually.

The cause of each lesion must be established through accurate assessment to enable appropriate nursing interventions, although nurses' ability to classify pressure ulcers correctly fails under some scrutiny Kelly and Isted When the skin is damaged as a result of pressure or shear, the European Pressure Ulcer Advisory Panel EPUAP and National Pressure Ulcer Advisory Panel classification system is recommended to classify the stage of pressure ulcer Figure 2, page When reassessing the pressure ulcer, which should take place at least weekly, NICE stipulated that pressure ulcers should not be reverse graded.

This means that, for example, a stage 3 pressure ulcer cannot become a stage 2 pressure ulcer because scar tissue replaces the layers of skin that have been lost through pressure damage.

When the skin is damaged by moisture, napkin dermatitis or a moisture lesion are likely and interventions will differ from that of a pressure ulcer Fletcher For example, pressure relief and repositionmg alone will not limit the development of the moisture lesion and other interventions, such as topical fungal treatments and keeping the skin free from moisture, may need to be considered.

While differentiating this wound type can be difficult in practice to achieve, Defloor et al and EPUAP provide a definition to enable a greater understanding of the wound-related characteristics differentiating pressure ulcers and moisture lesions Table 1.

A number of interventions can ensure that pressure is relieved effectively. A repositioning regimen must be identified for children at risk of developing pressure ulcers and this action should be recorded on a repositioning chart NICE Regular skin assessment can then evaluate the effectiveness of this intervention.

Butler recognised that mechanical injury from shear and friction is a potential hazard during repositioning and transfer activity. Use of devices such as sliding sheets and transfer boards should therefore be considered. For children, particular anatomical locations may need specific attention, such as the occipital, sacral and calcaneal heel regions for children on bed rest Butler While frequent repositioning may be contraindicated for haemodynamically unstable children, this can be compensated for by the provision of a pressure-relieving support surface.

Reducing pressure over bony prominences is integral to the intervention programme of care and while manual repositioning can maintain movement, therapeutic support surfaces may also be required Bryant Although more limited for children, a range of support surfaces is available to offer pressure reduction and pressure relief.

Pressure reduction is provided by foam mattresses that aim to redistribute body weight to avoid concentrated loads of pressure on the tissue, while pressure relief comes from alternating air systems providing the movement beneath the child that he or she cannot achieve independently. Alternating mattresses for adults have been identified as having cells that are too large to provide adequate pressure relief for children, but paediatric-specific mattress replacement systems are now more readily available Law Box 2 summarises some useful practice tips for pressure ulcer assessment and prevention in children.

The development of pressure ulcers needs to be risk managed and avoidable pressure ulcers should be prevented in paediatric health care.

Within the ethos of a quality-driven healthcare service, the existence of pressure ulcers and their prevention should be acknowledged, while continuous improvement and better outcomes for children at risk of developing pressure ulcers must remain at the forefront of care provision.

For related information, visit our online archive of more than 6, articles and search using the keywords. The author would like to thank Kirsty Hill, of Urgo Medical, for her assistance in obtaining permission to reproduce the photos included in Figure 2.

Baharestani MM, Ratliff CR Pressure ulcers in neonates and children: an NPUAP white paper. Advances in Skin and Wound Care.

It looks like your browser does not have JavaScript enabled. Please turn on JavaScript and try again. English English French Pressure ulcers bedsores By SickKids staff. Learn about pressure ulcers, who is at risk and how to prevent them.

What are pressure ulcers? Causes, risk factors and prevalence. Cause of pressure ulcers Pressure ulcers occur when there is ongoing compression of the soft tissue between bony parts of the body and an external surface. Pressure ulcer cause.

Preventing pressure ulcers The following tips will help prevent pressure ulcers from developing: Protect skin and promote good skin care Change your child's position often throughout the day and night, unless your child's doctor tells you not to. While in the hospital, the nurse will frequently change your child's position.

Make sure your child is not lying on a tube or piece of equipment for long periods of time. Check your child's skin for redness or sores at bath time, when changing their position, or when moving them from one surface to another for example from the bed to the wheelchair.

Although the evidence to support the prediction of pressure ulcers in children is scanty, the past decade has seen a rise in interest in this aspect of care provision. The Braden Q Scale, adapted from the adult Braden Scale was one of the earlier tools to be developed by Curley et al for use in children.

This was tested for its reliability and validity, determining 0. The Glamorgan Scale The Glamorgan Scale Willock et al has been developed more recently and has undergone rigorous testing, demonstrating This scale has high inter-rater reliability Willock et al , therefore reducing subjectivity and supporting nurses in making clinical decisions based on accurate assessment.

Its use in clinical practice is therefore supported and highly recommended. Within the Glamorgan Scale, each characteristic is weighted according to its statistical significance in relation to the development of pressure ulcers in children Willock et al For example, reduced mobility and pressure against the skin carry the highest weightings, while anaemia, pyrexia and low serum albumin are found to be less significant but risk factors nonetheless.

The weighting consequently increases the reliability of the tool and based on the calculation being used the higher the score the greater the risk of pressure ulcers, the need for additional preventive interventions is acknowledged.

Pressure ulcer prevention is multifaceted and requires skill, knowledge and consistencies in nursing practice to ensure effective outcomes for children at risk of pressure ulcer development. Risk assessment, skin assessment, repositioning and pressure relief are integral components of pressure ulcer prevention.

Baharestani and Rathff highlighted the need to identify specific age-related preventive strategies. Although timely skin assessments are recommended NHS Institute for Innovation and Improvement , the frequency is not prescribed although there is evidence to suggest that this is pertinent during episodes of repositioning Beldon Skin assessment involves examining the skin for evidence of new damage.

The skin tolerance test is a method of identifying the difference between erythema or reactive hyperaemia redness and a stage 1 pressure ulcer. Reactive hyperaemia can be defined as a temporary reaction to pressure being applied locally to the skin Collier Hyperaemia is caused by vasodilation of the intact capillaries surrounding the point of pressure.

Vasodilation is the natural body response, which allows additional oxygen and nutrients to reach the site of pressure to compensate for the temporary capillary occlusion. Reactive hyperaemia is not a stage 1 pressure ulcer and the redness will resolve following relief of pressure Bliss , Collier During inspection of the patient's skin, the skin tolerance test should be carried out on all visible red areas of skin.

This can be done by pressing a finger tightly over the reddened area for 15 seconds then lifting up the finger. If the area blanches it is not a grade 1 pressure ulcer.

If it stays red and is non-blanchable it is grade 1. Skin assessment should take place on admission as part of the risk assessment procedure National institute for Health and Clinical Excellence NICE , NHS Institute for Innovation and Improvement , DH b and of skin damage or lesion should be assessed Individually.

The cause of each lesion must be established through accurate assessment to enable appropriate nursing interventions, although nurses' ability to classify pressure ulcers correctly fails under some scrutiny Kelly and Isted When the skin is damaged as a result of pressure or shear, the European Pressure Ulcer Advisory Panel EPUAP and National Pressure Ulcer Advisory Panel classification system is recommended to classify the stage of pressure ulcer Figure 2, page When reassessing the pressure ulcer, which should take place at least weekly, NICE stipulated that pressure ulcers should not be reverse graded.

This means that, for example, a stage 3 pressure ulcer cannot become a stage 2 pressure ulcer because scar tissue replaces the layers of skin that have been lost through pressure damage.

When the skin is damaged by moisture, napkin dermatitis or a moisture lesion are likely and interventions will differ from that of a pressure ulcer Fletcher For example, pressure relief and repositionmg alone will not limit the development of the moisture lesion and other interventions, such as topical fungal treatments and keeping the skin free from moisture, may need to be considered.

While differentiating this wound type can be difficult in practice to achieve, Defloor et al and EPUAP provide a definition to enable a greater understanding of the wound-related characteristics differentiating pressure ulcers and moisture lesions Table 1. A number of interventions can ensure that pressure is relieved effectively.

A repositioning regimen must be identified for children at risk of developing pressure ulcers and this action should be recorded on a repositioning chart NICE Regular skin assessment can then evaluate the effectiveness of this intervention.

Butler recognised that mechanical injury from shear and friction is a potential hazard during repositioning and transfer activity. Use of devices such as sliding sheets and transfer boards should therefore be considered. For children, particular anatomical locations may need specific attention, such as the occipital, sacral and calcaneal heel regions for children on bed rest Butler While frequent repositioning may be contraindicated for haemodynamically unstable children, this can be compensated for by the provision of a pressure-relieving support surface.

Reducing pressure over bony prominences is integral to the intervention programme of care and while manual repositioning can maintain movement, therapeutic support surfaces may also be required Bryant Although more limited for children, a range of support surfaces is available to offer pressure reduction and pressure relief.

Pressure reduction is provided by foam mattresses that aim to redistribute body weight to avoid concentrated loads of pressure on the tissue, while pressure relief comes from alternating air systems providing the movement beneath the child that he or she cannot achieve independently.

Alternating mattresses for adults have been identified as having cells that are too large to provide adequate pressure relief for children, but paediatric-specific mattress replacement systems are now more readily available Law Box 2 summarises some useful practice tips for pressure ulcer assessment and prevention in children.

The development of pressure ulcers needs to be risk managed and avoidable pressure ulcers should be prevented in paediatric health care.

Within the ethos of a quality-driven healthcare service, the existence of pressure ulcers and their prevention should be acknowledged, while continuous improvement and better outcomes for children at risk of developing pressure ulcers must remain at the forefront of care provision.

For related information, visit our online archive of more than 6, articles and search using the keywords. The author would like to thank Kirsty Hill, of Urgo Medical, for her assistance in obtaining permission to reproduce the photos included in Figure 2.

Baharestani MM, Ratliff CR Pressure ulcers in neonates and children: an NPUAP white paper. Advances in Skin and Wound Care. Baldwin KM Incidence and prevalence of pressure ulcers in children. Barnes S The use of a pressure ulcer risk assessment tool for children. Nursing Times.

Bergstrom N et al Predicting pressure ulcer risk: a multisite study of the predictive validity of the Braden Scale. Nursing Research. Bryant R Acute and Chronic Wounds. Nursing Management. Please use this as advised. Balanced diet — Eating and drinking are especially important for those at risk of developing a pressure ulcer.

A good balanced diet and hydrating fluids will increase skin integrity. Again, there are circumstances where an air mattress is not suitable. We can also recommend creams and sprays to use to protect against moisture and nappy rash.

Aqueous cream — We suggesting using this instead of soap when you wash your child, as it is moisturising but not greasy. It is particularly useful if your child develops nappy rash, as it is non-irritating.

Keeping skin hydrated with a moisturising cream is also good for maintaining skin integrity. Barrier cream or spray — This helps protect the skin against urine, faeces and sweat and comes as a cream or a spray.

You can put this on areas at risk at least twice a day. Pressure ulcers can be painful and lead to complications. Some children are more prone to developing pressure ulcers than others.

Our aim is to prevent pressure ulcers before they develop. If your child has developed a pressure ulcer previously, please discuss the implications of this before you leave hospital.

If your child is re-admitted to GOSH or another hospital, please tell your nurse so that they are aware. Download Pressure ulcer prevention F A4 bw FINAL Sep pdf Download Treating and reducing the risk of pressure ulcers after leaving hospital F FINAL Sep15 ARABIC.

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