LUMPS, BUMPS AND RUMPS PEDIATRIC WOUND, OSTOMY & SKIN CARE - SHANNON MCCORD, MS, RN, CPNP-PC, CNS DIRECTOR OF ADVANCED PRACTICE PROVIDERS & ...
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LUMPS, BUMPS AND RUMPS
PEDIATRIC WOUND, OSTOMY & SKIN CARE
Shannon McCord, MS, RN, CPNP-PC, CNS
Director of Advanced Practice Providers & Nursing
Clinical Support Services
January 22, 2021
DEPARTMENT NAME
PHYSIOLOGY: INFANTILE SKIN • Weak epidermal/dermal bond • Prone to skin tears • Increased risk of infection • Premature skin less able to prevent evaporation -fluid loss is more marked DEPARTMENT NAME
GENERAL SKIN CARE
• Bath daily or QOD with neutral PH cleansers
• In hospital: disposable bathing products
• At home: Dove™, Lever 2000™, Cetaphil™
• Shower wand
• Cross contamination:
• Do not re-use basin
• CHG bath for CVC patients
• Protect IV sites and tubing
• Caution with stomas
DEPARTMENT NAME
SKIN CONDITIONS Dermatitis Epidermal skin injury Intertrigo DEPARTMENT NAME
INCONTINENCE ASSOCIATED DIAPER DERMATITIS
• Wet skin: maceration, erosion,
ulceration, fungus
• Change in acid mantle
• Acid mantle is vital in maintaining normal
bacterial flora
• Friction and shear
• Epidermal damage and inflammation
Gray, M. 2007 et.al. JWOCN, 34(2), 134
DEPARTMENT NAME
TREATMENT OF INCONTINENCE ASSOCIATED
DIAPER DERMATITIS (IDD)
• Alleviate the cause
• Change diapers frequently, open to air, sunlight
• Decrease friction and irritating chemicals
• Moisture-wicking pads; limit incontinence pads/linens to one layer - reduces friction
and interface pressure
• Cleansing
• Soft non-sterile wipes (Viva™ or cotton like paper towels), barrier wipes, avoid baby
wipes and products containing preservatives & alcohol
• Cleansing foam, peri–bottles & sprays may loosen stool & reduce friction/wiping of skin
DEPARTMENT NAME
DIAPER DERMATITIS TREATMENT
• Severe IDD EBP Guideline
#2149:
• Cleanse
• Stoma powder or antifungal
• Protective skin barrier film
• Zinc or petrolatum based
cream or ointment
www.3m.com/kci
DEPARTMENT NAME
PREVENTION & TREATMENT OF G TUBE DERMATITIS
• Goal is to keep skin clean, dry and
protected
• Assess: skin, stoma, causes of intra-
abdominal pressure (constipation,
venting), tube, adaptor size, stabilization
• Cleanse skin with soap and water
• Avoid hydrogen peroxide, alcohol and
povidone - iodine and lotions/ointments
• Plastic polymer barrier or barrier
cream/ointment
• Use foam dressing. Do NOT apply an
occlusive gauze dressing
• Treat for fungal rash (2% miconazole
ointment or antifungal powder)
DEPARTMENT NAME
BASIC OSTOMY CARE AND TREATMENT
DERMATITIS/CANDIDIASIS
• Care:
• Cleanse with soap and water
• Flat surface – fill in scars with paste,
avoid inguinal fold, umbilicus, scars
• Pattern: may need to cut wafer “off
center”
• Dermatitis:
• Powder: stoma powder, or treat with
antifungal powder if candidiasis
• Protective barrier film
DEPARTMENT NAME
SKIN INJURY: PERISTOMAL COMPLICATIONS
• Pre-op - proper site marking & selection
• Cleanse
• Protect and heal skin: barrier swab or
spray
• Pouch: customize wafer pattern, bead
of paste around wafer hole
• Limit pouch changes if possible
• Do not “leave open to air” as stool will
cause further irritation and skin
breakdown
DEPARTMENT NAMEINTERTRIGO DEPARTMENT NAME
INTERTRIGO
• Definition : Inflammation of Management:
superficial skin caused by • Decrease friction/moisture
skin-to-skin friction. • Barrier or zinc oxide, or antifungal
ointment
• Occurs in warm, moist • Absorbent cloths/pads (dry wick fabric,
Ultrasorb)
areas: body folds - groin, • Powder – antifungal
abdominal, under breasts. • Treat Underlying infections/
inflammation with antifungal,
• May lead to secondary antibacterial, or topical steroid agents.
fungal or bacterial infection
DEPARTMENT NAMEWOUND MANAGEMENT PRINCIPLES
Prevent and manage infection
Cleanse wounds
Debride
Maintain moisture balance
Eliminate dead space
Control odor
Eliminate or minimize pain
Protect wound and periwound
DEPARTMENT NAMEWOUND CLEANSING
• Goal: minimize disruption of wound surface while removing excess exudate/bacteria/debris.
• Normal saline is best
• Soap and water in home setting and for superficial wounds
• Avoid chemicals that inhibit granulation – hydrogen peroxide, alcohol, povidone-iodine
• Contaminated/colonized wounds – consider Dakins ¼ strength
• Optimal wound irrigation/cleansing:
• Range 6-8”
• Pressure per square inch 8-15 (PSI)
• Normal Saline irrigation using a 35 cc syringe with 19 gauge needle will obtain 8-15 PSI
DEPARTMENT NAMEWOUND MANAGEMENT PRINCIPLES
• Debridement
• Surgical
• Autolytic
• Enzymatic
• Mechanical: wet to dry
• Other modalities: Maggot therapy
DEPARTMENT NAMEDEBRIDEMENT DEPARTMENT NAME
WOUND MANAGEMENT: MANAGE EXUDATE
MOISTURE BALANCE
Dry wound base & minimal exudate: Wet wound base & moderate/large exudate:
• Leads to desiccation and Slower Healing • Leads to macerated peri-wound
• Dressing removal can be painful • Possible increase in wound size and
Slower Healing
• Add hydrogel or honey
• Use absorptive dressing (alginate,
• Use moist to moist saline gauze dressing hydrofiber, foam)
DEPARTMENT NAMEWOUND MANAGEMENT PRINCIPLES:
ELIMINATE DEAD SPACE
• Pack wound to prevent fluid accumulation and abscess
formation
• Hydro fiber ribbon or absorptive dressing
• Wound gels
DEPARTMENT NAMENPIAP GUIDELINE 2019 • Recommendation on moist gauze and transparent film dressing when advanced dressings are not an option. • Consider use of a hydrogel dressing : • Pain Reduction: The high water content gives a soothing, cooling effect resulting in almost immediate reduction in pain. The cooling effect may last 4- 6 hours and has been shown to be beneficial in burns and partial-thickness wounds (Coats, et al, 2002). • Hydrogels are non-adherent and have been rated by individuals with pressure injuries as more comfortable than a saline soaked dressing. (NPIAP Guidelines 2019). DEPARTMENT NAME
WOUND MANAGEMENT PRINCIPLES: PROTECT WOUND
• Protect and maintain peri-
wound skin integrity
• Avoid tape: net stretch bandage to
secure dressings
• Picture frame with skin barrier Low
adhesive, non- allergenic silicone
tape
• Avoid latex products
• Non-adherent silicone dressings
DEPARTMENT NAMEA HOLISTIC APPROACH TO WOUND MANAGEMENT
Pain management
• Consider developmental age: engage patient in dressing change
• Consult Child Life Specialists
• Premedication for pain and anxiety
• Dressing selection: decrease frequency
Circulation
• Ambulate, compression (SCD), caution use of TED hose
• Increase cardiac output, anticoagulants, correct anemia
Nutrition
• Labs: total protein, pre- albumin, Vit. C, A & Zinc
Fluids
• Prevent dehydration and edema
Neuropathy: lower extremities of spina bifida and diabetic patient
• Wear shoes, decrease pressure, change position, wheel chair evaluation
DEPARTMENT NAMETEST YOUR KNOWLEDGE:
WOUND MANAGEMENT PRINCIPLES
• What’s you assessment
• What type of dressing would
you use?
• To protect skin
• To provide moisture balance
• To avoid dead space
• How frequent would we change
the dressing?
DEPARTMENT NAMETYPES OF WOUNDS Pressure Ulcer/Injury Infectious DEPARTMENT NAME
PRESSURE ULCERS DEPARTMENT NAME
PEDIATRIC PRESSURE ULCER/INJURY PREVALENCE
• Location in children – occipital, sacral, heels
• Hospitalized pediatric patients:
• 50% pressure ulcers are device related
• Non- critical 0.47%-13%
• Critical 20-27%
• Critical care & rehabilitation units
• 3.36 and 4.41 X more likely to acquire HAPI
• Complex care patients: up to 43%
• Adults: 9.2%-15%
• HAPI Risk: JWOCN Mar/Apr 2018
DEPARTMENT NAMENEONATAL PRESSURE ULCER/INJURY RISK FACTORS
• Immature skin
• Thin, even gelatinous in very preterm
• May be dry in term infants
• Decreased epidermal-dermal cohesion
• Increased Trans-epidermal water loss (TEWL)
• Low birth weight or pre- term birth
- Minimal subcutaneous tissue
• Neonatal Skin Condition Score
• VLBW to full term infants; high risk score = >5
DEPARTMENT NAMEASSESSING RISK OF PRESSURE ULCERS/INJURY
Braden Tool Braden Q Tool
• 9 years to adult; Risk 18 or below • 3 week to 8 years; Risk =/ > 16;
• Increased moisture
• Increased moisture
• Immobility
• Immobility
• Decreased sensory perception
• Decreased sensory perception
• Friction/Shear
• Friction/Shear • Alteration in nutrition
• Alteration in nutrition • Alteration in tissue perfusion and
oxygenation
• Braden Q D – NEW
Curley, M., 2018
• 7 subscales including medical devic es
DEPARTMENT NAMERISK AND ETIOLOGY OF PRESSURE INJURIES
• “Risk Factors associated with 2 Pathways to Tissue Damage:
Pressure Ulcers in the Pediatric
Intensive Care Unit” • Ischemic Pathway- Localized damage as a
result of pressure/ shear. Pinching off of blood
• Edema vessels.
• Length of stay > 96 hours • Deformation Pathway- Disruption of
cytoskeleton, cell membrane failure,
• Increasing PEEP Inflammatory edema , ↑ interstitial pressure, cell
• Not turned/turned by a low distortion and death within minutes.
air loss bed More research is being performed in this area
• Weight loss
• 2019 NPIAP Guideline
• McCord, 2004
DEPARTMENT NAMEHOSPITAL ACQUIRED PRESSURE ULCER/INJURY (HAPI)
VERSUS COMMUNITY ACQUIRED (POA)
• Community acquired: • Hospital Acquired (HAPI)
POA
A new pressure injury
The presence of a that developed after
pressure injury on admission to the facility
admission to the • Pressure injuries can develop
facility as in 1-2 hours
documented on the
admission assessment • History can help to determine
etiology
or within 24 hours.
( NDNQI )
DEPARTMENT NAMEMEDICAL DEVICE RELATED PRESSURE
ULCER/INJURY
• Localized injury to the skin or underlying tissue
as a result of sustained pressure from a device
• Incidence rates as high as 50%
• Tissue injury typically mimics device shape
• Often seen in areas without adipose tissue
DEPARTMENT NAMEMEDICAL DEVICE RELATED INJURY PREVENTION
• Skin assessment upon admission, transfers,
post op & 3D head to toe exams
• Prevention: use of pressure redistribution
devices ; avoid blanket rolls
• Avoid use of positioning devices to reduce
pressure
• Pad and rotate medical devices
• < HOB less than 30 degrees to reduce shear
• Turn and/or reposition patients every 1-2
hours, include head
• Evaluate bed surface
DEPARTMENT NAMEMUCOSAL MEMBRANE RELATED PRESSURE INJURY • History of a medical device in use at the location of the injury • These ulcers are not staged • Prevention: device rotation DEPARTMENT NAME
KENNEDY TERMINAL ULCER
• First described in 1989. An unavoidable skin failure that
occurs as part of the dying process.
• Described as a pear, butterfly, horseshoe shaped red/yellow/
black ulcer.
• Comes on quickly and progresses rapidly, often within hours.
Gentelle, 2017
DEPARTMENT NAMEMALIGNANT/ GANGRENOUS WOUNDS • Wound Odor- Topical agents – Dakin’s solution, Metronidazole ( crushed tables sprinkled onto wound), charcoal dressings. • Room odor: coffee grounds, kitty litter, lavender or peppermint oil. • Drainage - Dressings with ↑Absorption (hydrofibers, alginates) • Bleeding - Non adherent dressings ( petrolatum gauze, contact layers); calcium alginate. • Pain – Dressing changes: premediate, decrease frequency DEPARTMENT NAME
EPIDERMOLYSIS BULLOSA
• Rare inherited disorders characterized by
marked mechanical fragility of epithelial
tissues with blistering and erosions following
minor trauma
• Various genetic mutations associated
• 4 major categories based on the level of skin
cleavage
Common complications:
• Infections (Staph, GAS, GNR, Pseudomonas)
• Skin cancer
• Malnutrition and anemia
DEPARTMENT NAMEMANAGEMENT OF EB • Skin and Wound care • Prevention and treatment of infections • Nutritional management **Multidisciplinary approach DEPARTMENT NAME
CASE STUDY: EPIDERMOLYSIS BULLOSA
March 21 March 21 March 21
DEPARTMENT NAMECASE STUDY
• What would be your approach to this patient?
• What principles would you need to keep in mind?
• Cleansing
• Dressing
• Securement
• Patient involvement
• Pain management
DEPARTMENT NAMECASE STUDY: EPIDERMOLYSIS BULLOSA March 27 March 28 April 3 DEPARTMENT NAME
SPECIAL CONSIDERATIONS
March 28, 2018 April 3, 2018
DEPARTMENT NAMEQUESTIONS? DEPARTMENT NAME
REFERENCES 1. AWHONN(2001). Neonatal skin care. Evidenced based Practice Guideline. Washington DC. 2. Baharestani, M., & Ratliff, C., (2007). Pressure ulcers in neonates and children: An NPUAP white paper. Adv Skin & Wound Care, 20 (4) 208-220. 3. Bookout, K., McCord, S. and McLane, K. (2004). Case Studies of an infant, a toddler, and an adolescent treated with negative pressure wound treatment system. J WOCN, 31(4), 184 – 193. 4. Curley, M. et.al ( 2018). Predicting pressure injury risk in pediatric patients: The Braden QD scale; J of Pediatrics, 192, 189-195. 5. Ceballos, C. (2005) Management of Infants with Ulcerated Hemangiomas. J WOCN, 32(1), 58-63. 6. Clark, M., Black, J., Alves, P. et al. (2014). Systematic review of the use of prophylactic dresings in the prevention of pressure ulcers. International Wound Journal 11(5), 460-471. 7. Gentelle, 2017. Wound Care Insider. 8. Freundlich K., (2017) Pressure injuries in medically complex children: a review. Children 4, (4) 25. 9. McCord, S., McElvain, V., Sachdeva, R. Schwartz, P. and Jefferson, L. /92004). Risk factors associated with pressure ulcers in the pediatric intensive care unit. J WOCN, 31(4) 179-183. 10. McCord, S., & Levy, M., (2006). Practical guide to pediatric wound care. Seminars in Plastic Surgery, 20 (3) 192-199 11. Lee, M.C. et al (2004). Management and outcome of children with skin and soft tissue abscesses caused by community-acquired Methicillin-Resistant Staphloccoccus Aureous. Pediatric Inf Disease J, 23(2), 123-127. 12. Quigley, S. and Curley, M.AQ. Skin integrity in the pediatric population: preventing and managing pressure ulcers. J Soc Pediatr Nurses, 1996, 1:7-18. 13. Stellar, J. (2020). Medical Device-Related Pressure Injuries in Infants and Children. JWOCN, 47(5), 10.1097/WON.0000000000000683 DEPARTMENT NAME
REFERENCES AND RESOURCES: WEBSITES Agency for Health Research and Quality (AHRQ) Guidelines www.ahrg.gov Association for the Advancement of Wound Care ( AAWC) www.aawconline.org European Pressure Injury Advisory Panel (EPIAP) National Pressure Injury Advisory Panel (NPUIP) www.npuip.org World Union of Wound Healing Societies (WUWHS) www.wuwhs.org Wound, Ostomy, and Continence Nurses Society www.wocn.org DEPARTMENT NAME
TEXTBOOKS Baranoski S, Ayello EA. Wound Care Essentials, Practice Principles, 3rd ed., Lippencot, Williams and Wilkins 2011. Bryant R, Nix D. Acute and Chronic Wounds: Current Management Concepts, 5th ed., Mosby, 2018. Doughty D, McNichols L, Wound, Ostomy, and Continence Nurses Society Core Curriculum: Wound Management by WOCN™ Society 2016 Krasner DL, Rodeheaver GT, & Sibbald RG, (eds): Chronic Wound Care: A Clinical Source Book for Healthcare Professionals, 5th ed. HMP Communications, Wayne, PA 2012 McCulloch JM, Kloth LC, (eds). Wound Healing: Evidence-Based Management, 4th ed., FA Davis, Philadelphia, 2010 Sussman C, Bates-Jensen B, (eds). Wound Care: A Collaborative Practice Manual for Health Professionsals, 4th ed. Wolters Kluwer/Lippencott Williams ad Wilkins, Phil. 2012 Shah JB Sheffield J, Fife CE (eds). Textbook of Chronic Wound Care: An Evidence-Based Approach to Diagnosis and Treatment, 1st ed. Best Publishing Company 2018 DEPARTMENT NAME
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