Ccn

http://ccn.aacnjournals.org/cgi/external_ref?link_type=PERMISSIONDIRECTPersonal use only. For copyright permission information: Published online http://www.cconline.org© 2008 American Association of Critical-Care Nurses

2008;28:125-135Crit Care Nurse Spence, Allison Trent, Libby Lazzaro, Julianne Balach, Alicia Bakota and Shana WeicheckTracy Ann Pasek, Amanda Geyser, Maria Sidoni, Patricia Harris, Julia A. Warner, AnnExcellenceSkin Care Team in the Pediatric Intensive Care Unit: A Model for

http://ccn.aacnjournals.org/subscriptions/Subscription Information

http://ccn.aacnjournals.org/misc/ifora.shtmlInformation for authors

http://www.editorialmanager.com/ccnSubmit a manuscript

http://ccn.aacnjournals.org/subscriptions/etoc.shtmlEmail alerts

by AACN. All rights reserved. © 2008 ext. 532. Fax: (949) 362-2049. Copyright101 Columbia, Aliso Viejo, CA 92656. Telephone: (800) 899-1712, (949) 362-2050,Association of Critical-Care Nurses, published bi-monthly by The InnoVision Group Critical Care Nurse is the official peer-reviewed clinical journal of the American

by guest on June 6, 2012ccn.aacnjournals.orgDownloaded from

http://ccn.aacnjournals.org/cgi/external_ref?link_type=PERMISSIONDIRECT

http://ccn.aacnjournals.org/subscriptions/

http://ccn.aacnjournals.org/misc/ifora.shtml

http://www.editorialmanager.com/ccn

http://ccn.aacnjournals.org/subscriptions/etoc.shtml

http://ccn.aacnjournals.org/

http://ccn.aacnjournals.org CRITICALCARENURSE Vol 28, No. 2, APRIL 2008 125

risk associated with altered skinintegrity for critically ill children.Immature bowel and bladder controland large heads are inevitable con-tributory risk factors specific to chil-dren. Concomitant pain and alteredappearance are physical and emo-tional burdens for patients and fam-ilies already experiencing stressassociated with hospitalization in apediatric intensive care unit (PICU).

Pressure ulcers have an incidenceof 7% and a prevalence of 7% amongacutely ill children.5 The occurrenceof pressure ulcers is associated withnutritional status, mobility, and levelof consciousness. In infants andyoung children, pressure ulcers occurmost often on the head and heels.5

Noonan et al3 reported a 27% inci-dence of pressure ulcers, of which32% of the more significant ulcersinvolved the head. Fifty-seven percentof all ulcers were detected during the

Tracy Ann Pasek, RN, MSN, CCRNAmanda Geyser, RN, BSNMaria Sidoni, RN, BSNPatricia Harris, RN, BSN, CCRN, CWOCN, CCTNJulia A. Warner, RN, CWOCN, CFCNAnn Spence, RN, MSAllison Trent, RN, BSN, WOCNLibby Lazzaro, RN, BSNJulianne Balach, RNAlicia Bakota, RN, BSNShana Weicheck, RN, BSN

Skin Care Team in the PediatricIntensive Care Unit: A Modelfor Excellence

Pediatric Care

The skin is the largestorgan of the body andhas many complexfunctions.1 Intact skinis a barrier to infection;

thus, alteration in skin integrity pre-disposes patients to infection andpoor outcomes. Pressure ulcers arean important iatrogenic problem inhealth care with substantial financialcosts.2,3 In a study of adverse events,Cho et al4 reported that pressureulcers had the greatest effect onlength of stay, with a 1.84-foldincrease in stay for patients withsuch ulcers. Among the 7 groups ofadverse events examined, pressureulcers were the third most signifi-cant determinant of increasedcosts, after sepsis and pneumonia.4

Impaired perfusion, altered nutri-tion, unstable hemodynamic status,limited mobility, immunosuppres-sion, and medications contribute to

PRIME POINTS

• Alteration in skinintegrity predisposespatients to infection and poor outcomes.

• Pressure ulcers canalmost double patients’length of stay.

• A pediatric skin careteam provides expertise,trains staff, promotespolicy, and leads evidence-based initiatives.

• Having a team committed to a specificentity such as skin careenhances resource avail-ability, communication,and follow-through.



first skin assessment on the secondday in the PICU.3

Indeed, children who are patientsin a technology-rich environmentsuch as a PICU may experience pres-sure ulcers early in hospitalization.6

Moreover, the adverse effects ofimmobility and physiological insta-bility on a patient’s skin do not dis-criminate by age or developmentallevel.6 Noonan et al3 reported thatmore than 50% of medical devicesthat contributed to pressure-relatedskin injuries were pulse oximetryprobes, artificial airways, and masksfor bilevel positive airway pressure(BiPAP). These devices are oftenplaced when the patient is admittedto a PICU, so tracking quality ofcare is imperative to prevent andidentify problems.

Consumers are encouraged tolearn about the law in relation toadverse health events and reporting.Bedsores are considered an adversehealth event.7 Health care providers’assessment methods and preventionstrategies are defined and describedso that consumers are empowered tomake safe health care decisions. Forexample, a recent consumer report7

from the Minnesota Department ofHealth includes an easy-to-read piechart indicating that serious bedsores

account for 43% of adverse healthevents.

Benchmark data are available topediatric critical care nurses. More-over, skin care is a nursing researchpriority.8 Yet life-saving measures maypreclude attention to less emergentskin and wound therapies in a criti-cal care setting. At Children’s Hospi-tal of Pittsburgh, in Pennsylvania, alarge tertiary care hospital, a unit-based skin care team was establishedin the PICU. The team strives to main-tain skin care as a top priority, therebymodeling excellence in skin care.

Purpose of a PICU SkinCare Team

A PICU skin care team providesa core group with the expertise toprovide care for patients with com-plex and variable skin care needs. Ina high-acuity unit with approxi-mately 140 professional staff nurses,a team committed to a specificentity such as skin care enhancesresource availability, communica-tion, and follow-through. Nursesprovide direct patient care, conductstaff education, promote policy, andlead evidence-based initiatives. Theteam members or “champions”proactively identify and avert poten-tial adverse clinical outcomes.

Structure of the Skin CareTeam

The PICU skin care team is madeup of professional staff nurses. Anadvanced practice nurse and clini-cal leader direct the team. Two cer-tified wound ostomy care nurses(CWOCNs) support the team asconsultants. The advanced practicenurse has pain as a specialty, aug-menting skin care with comfort asanother important team focus.

Selection of new nurses for theskin care team is a joint effortbetween PICU leaders and nursescurrently on the team; considera-tion is given to having membersrepresentative of all shifts and ofweekend staffing. Because expertiseis primarily developed throughdirect patient care, modest effort isdirected at limiting the team’s sizeto approximately 8 nurses. Thislimitation increases the number ofopportunities for nurses to lead andparticipate in rounds.

The PICU skin care team isaccountable to 2 hospital councils—a nurse skin care council made upof nurses from all inpatient care areasand a nurse practice council. Skin-and wound-related initiatives involv-ing prescribed medication requireapproval by the hospital’s pharmacyand therapeutics committee.

Skin Care RoundsSkin care rounds take place each

Tuesday morning. Preparation beginswith the clinical leader Mondaynight. Skin assessment findings,plans of care, and Braden Q scores(documented every 12 hours withinthe critical care service center) areroutine components of the change-of-shift report (Table 1). This infor-mation is recorded by the night

126 CRITICALCARENURSE Vol 28, No. 2, APRIL 2008 http://ccn.aacnjournals.org

All authors are from Children’s Hospital of Pittsburgh, University of Pittsburgh MedicalCenter, Pittsburgh, Pennsylvania. Tracy Ann Pasek is an advanced practice nurse in thepediatric intensive care unit. Amanda Geyser and Julianne Balach are clinical leaders inthe pediatric intensive care unit. Maria Sidoni, Libby Lazzaro, Alicia Bakota, and ShanaWeicheck are professional staff nurses in the pediatric intensive care unit. Patricia Harrisand Julia A. Warner are certified wound ostomy care nurses. Ann Spence was a perform-ance improvement specialist and Allison Trent was a wound ostomy care nurse when thisarticle was originally submitted for publication.Corresponding author: Tracy Pasek, RN, MSN, CCRN, Pediatric Intensive Care Unit, Children’s Hospital of Pitts-burgh, 3705 Fifth Ave, Pittsburgh, PA 15213-2583 (e-mail: [email protected]).

To purchase electronic or print reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656.Phone, (800) 809-2273 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, [email protected].

Authors




Table 1 Braden Q scale used at Children’s Hospital of Pittsburgha

Continued

Intensity and duration of pressure Scoreb

MobilityThe ability to

change and control body position

1. Completely immobileDoes not make even

slight changes in body or extremity position withoutassistance

2. Very limitedMakes occasional

slight changes in body or extremity position but unable to completely turnself independently

3. Slightly limitedMakes frequent

though slight changes in body orextremity position independently

4. No limitationsMakes major and

frequent changes in position without assistance

ActivityThe degree of

physical activity

1. BedfastConfined to bed

2. ChairfastAbility to walk

severely limited or nonexistent

Cannot bear own weight and/or must be assisted into chair or wheelchair

3. Walks occasionallyWalks occasionally

during day, but for very short distances, with or without assistance

Spends majority of each shift in bed or chair

4. Patient too youngto ambulate, orwalks frequentlyWalks outside the

room at least twice a day and inside room at least once every 2 hours during waking hours

Sensory perceptionThe ability to

respond in a developmentally appropriate way to pressure-relateddiscomfort

1. Completely limitedUnresponsive (does

not moan, flinch, or grasp) to painful stimuli due to diminished level of consciousness or sedation; or has limited ability to feel pain over most of body surface

2. Very limitedResponds only to painful stimuli

Cannot communicate discomfort except bymoaning or restless-ness; or has sensory impairment that limits the ability to feel pain or discomfort over half of body

3. Slightly limitedResponds to verbal

commands, but cannot always communicate discomfort or need to be turned; orhas some sensory impairment that limits ability to feel pain or discomfort in 1 or 2 extremities

4. No impairmentResponds to verbal

commandsHas no sensory

deficit that wouldlimit ability to feelor communicate pain or discomfort

Tolerance of the skin and supporting structure Scoreb

MoistureDegree to which

skin is exposed to moisture

1. Constantly moistSkin is kept moist

almost constantly by perspiration, urine, drainage, etc

Dampness is detected every time patient is moved or turned

2. Very moistSkin is often, but not

always, moistLinen must be

changed at least every 8 hours

3. Occasionally moistSkin is occasionally

moist, requiring linen change every 12 hours

4. Rarely moistSkin is usually dry,

routine diaper changes; linen only requires changing every 24 hours

Friction and shearFriction: Occurs

when skin moves against support surface

Shear: Occurs when skin and adjacent bony surface slide across one another

1. Significant problemSpasticity, contracture,

itching, or agitation leads to almost constant thrashing and friction

2. ProblemRequires moderate

to maximum assis-tance in moving

Complete lifting without sliding against sheets is impossible

Frequently slides down in bed or chair,requiring frequent reposition-ing with maximum assistance

3. Potential problemMoves freely or

requires minimum assistance

During a move, skin probably slides to some extent againstsheets, chair, restraints, or other devices

Maintains relativelygood position in chair or bed mostof the time but occasionally slides down

4. No apparent problemAble to completely

lift patient during a position change; moves in bed andchair independentlyand has sufficient muscle strength to lift up completely during move

Maintains good position in bed or chair at all times



clinical leader or charge nurse and isused by the skin care team duringrounds the next morning.

Routinely conducting roundsearly in the week yields consistencyfor PICU staff and provides theremainder of the week for follow-upof patients. The team cares for asmany as 31 patients during rounds,a process that often consumes 3 to 4hours. An 8-week schedule is postedto identify nurses to serve as roundsleaders. The schedule is determinedin collaboration with the unit’s sched-uling committee. The nurse who leadsrounds is not assigned a patient forthe first 4 hours of the Tuesday day-light shift (7 AM to 11 AM).

The team accomplishes a varietyof work (Table 2). At the conclusion

of rounds, either the professional staffnurse leader or the advanced practicenurse prepares an electronic summaryand disseminates it to all PICU nurses(Table 3). For patients who are offthe unit for operative or diagnosticprocedures or whose condition istoo unstable for a full skin assess-ment, a member of the team returnslater in the day to complete rounds.

A full skin assessment includesbut is not limited to the examinationslisted in Table 4 as applicable. Amember of the team asks to be calledfor complex dressing changes sched-uled to happen during times otherthan rounds (eg, a fasciotomy dress-ing at 2 PM). Bedside nurses com-municate valuable information,augmenting the team’s assessments.

A skin care supply bag (Figure 1and Table 5) is carried by the teamto enhance product procurementfor nurses and to minimize unnec-essary, time-consuming trips to thesupply room. Busy nurses appreci-ate on-the-spot delivery of prod-ucts. Keeping the bag stocked andmonitoring expiration dates of sup-plies are tasks well suited to newteam members. Working with skincare supplies fosters familiaritywith products.

Education of Nursing StaffThe skin care team assumes

responsibility for education ofnursing staff. Venues for such edu-cation include in-service training(eg, process for “windowing” or


Table 1 ContinuedNutrition

Usual food intake pattern

1. Very poorNothing by mouth

and/or maintained on clear liquids, or intravenous fluids for more than 5 days, or albumin <2.5 mg/dLor never eats a com-plete meal. Rarely eatsmore than half of any food offered

Protein intake includes only 2 servings of meat or dairy productsper day

Takes fluids poorlyDoes not take a liquid

dietary supplement

2. InadequateIs on liquid diet or

tube feedings/totalparenteral nutrition, which provide inadequate caloriesand minerals for age

or albumin <3 mg/dLor rarely eats a complete meal and generally eats only about half of any food offered

Protein intake includesonly 3 servings of meat or dairy products per day

Occasionally willtake a dietary supplement

3. AdequateIs on tube feedings

or total parenteral nutrition, which provide adequate calories and minerals for age oreats more thanhalf of most meals

Eats a total of 4 servings of protein (meat, dairy prod-ucts) each day

Occasionally will refuse a meal, but will usually take a supplement if offered

4. ExcellentIs on a normal diet

providing adequate calories for age

For example, eats most of every meal

Never refuses a mealUsually eats a total

of 4 or more servings of meat and dairy products

Occasionally eatsbetween meals

Does not require supplmen-tation

Tissue perfusion andoxygenation

1. Extremely compromisedHypotensive (mean

arterial pressure <50 mm Hg; <40 mm Hg in newborn) or does not physiologicallytolerate position changes

2. CompromisedNormotensive; oxygen

saturation may be <95%; hemoglobin may be <10 mg/dL; capillary refill may be >2 seconds; serum pH is <7.40

3. AdequateNormotensive;

oxygen saturation may be <95%; hemoglobin <10 mg/dL; capillary refill may be >2 seconds; serum pH normal

4. ExcellentNormotensive;

oxygen saturation >95%; normal hemoglobin; capillary refill <2 seconds

a Adapted from Braden and Bergstrom9 and Curley et al,10 with permission. © Barbara Braden and Nancy Bergstrom, 1988.b If total score is 15 or less, notify nurse on the unit-based skin care team; refer to Support Surface Selection Algorithm.



“picture framing” a site for centralcatheter insertion with transparentand hydrocolloid dressings), updatesat monthly staff meetings (eg, newproducts), electronic managementupdates (reminders to documentBraden Q scores), and bedside edu-cation (eg, explaining how to oper-ate a vacuum-assisted wound closuredevice). New PICU nurses arerequired to attend skin care rounds1 time as part of a nurse residencyprogram or orientation. Less urgent


Table 2 Role of the skin care team in the pediatric intensive care unit

Assess each patient’s skin from head to toeAssist bedside nurse with repositioning and changes in therapeutic support surface Start/stop use of therapeutic support surfacesProcure skin care products for bedside nurses (eg, soft gel pillows, dressing supplies)Direct and assist with complex dressing changes (eg, vacuum-assisted closure of wound, Stevens-Johnson syndrome, necrotizing

fasciitis)Prevent pain with dressing changes (eg, timing around preemptive analgesia, use of adhesive removers)Evaluate accuracy of documented Braden Q skin assessment scoresAssist bedside nurse with diaper/incontinence garment and linen changesWeigh benefits and risks associated with treatments (eg, methodological therapies for best approach to eschar debridement)Consult other services (eg, recommend dietary protein assessment for new nutrition-related occipital alopecia)Provide skin care education and positive reinforcement for self-care behaviors to family membersCheck current skin and wound care orders for accuracy and adherenceEnter new or update existing skin and wound care orders via a computerized systemComplete new and follow up on prior patient safety reports related to skin careDocument skin impairment during monthly prevalence roundsCollaborate with preceptors to provide hands-on experience for new nurse orienteesCollaborate with critical care service center disciplines to tackle wound-related legal dilemmas (eg, long-term care facility repeatedly not

following wound care discharge instructions, resulting in patient’s readmission to the unit with fulminant sepsis)Educate professional staff nursesCoordinate new product trials (eg, purchased vs rented low-air-loss mattress overlays)

Table 3 Example of a summary from skin care rounds

Patient

Bed space 16, AG

Bed space 21, TP

Bed space 22, MD

Summary

Thin hydrocolloid dressing placed in operating room intact beneath tracheostomy tube ties (a hospital standard of care)

Diaper dermatitis clinical effectiveness guideline initiated in anticipation of diet changeEducated mom and dad about how to apply skin care products to diaper area

Helped nurse change cervical collar; skin on clavicles clear beneath collar under potential pressure points; trialof bilevel positive airway pressure planned for today; applied prophylactic thick hydrocolloid dressing tobridge of nose and other mask pressure points

Soft gel pillows and protective film barrier to heels added to plan of care

Paged plastic surgeon; dad requested additional information about sharp debridement (eschar excision per-formed with a surgical blade)

Wound in right side of groin redressed and healthy tissue shown to parentsUpdate on wound progress given to critical care medicine fellow

Table 4 Examination sites included in head-to-toe skin assessment

OcciputFace near endotracheal tube tape and beneath a mask for bilevel positive airway pressureNasogastric or orogastric tube insertion siteSkin beneath a cervical collarSite of pulse oximetry probeTracheostomy site, including skin beneath tracheostomy tube tiesInsertion site for abdominal gastric tube Skin beneath splints, sequential compression devices, and blood pressure cuffsSkin surrounding and beneath electrocardiography patchesInsertion sites of intravenous catheters Skin surrounding dressings for central catheters; skin beneath transparent dressings

for central cathetersAll pressure points, including elbows, heels, coccyxPerineal and buttock region



or supplemen-tal informationis reserved forthe PICU edi-tion of a criticalcare newsletter11

(Figure 2). Skincare may be thetopic of monthlycritical careevidence-basedreview clubs orjournal clubs.Educatingphysiciansabout supportsurface indica-tions is a pri-mary role ofthe hospital’sCWOCNs, but

nurses on the skin care team alsoshare in this responsibility.

Performance ImprovementHospital-wide prevalence rounds

occur monthly. Skin impairment isrecorded on prevalence day, thefirst Tuesday of each month. Dataare submitted to the quality servicesdepartment and reviewed as part ofthe hospital’s report card (Figure 3).They serve as a gauge for bench-marking against other hospitals oflike size and acuity level. The preva-lence form reflects new definitionsfrom the National Pressure UlcerAdvisory Panel.12

For the first time, 2 quality indi-cators during fiscal year 2006included prevention of epidermalstripping (skin tears) and preven-tion of BiPAP-related skin impair-ment (nose and other mask pressurepoints). Epidermal stripping wasbrought to the team’s attention byan increased number of reports ofevents related to patient safety.Both underuse of adhesive removersand the practice of taping devices(eg, urinary catheter tubing) directlyto the skin instead of atop a hydro-colloid dressing were problems.During the first quarter, the inci-dence of epidermal stripping was5%; in the second quarter, the inci-dence increased to a high of 19%.BiPAP-related skin impairment hada prevalence of 5% during the firstquarter. BiPAP skin impairmentwas proactively adopted as a processimprovement indicator in anticipa-tion of the high-census/high-acuityrespiratory illness season.

Once the underlying causes ofepidermal stripping and BiPAP-related skin impairment were iden-tified, education initiatives and


Figure 1 Skin care supply bag.

Table 5 Items in skin care supply bag(Specify quantity of each, include list inside bag, and adapt to your unit’s needs)

Dressing supplies (transparent, nonadherent, hydrogel, hydrocolloid, absorptive)

Sterile scissors

Tape rolls, adhesive, and adhesive removal products

Tracheostomy ties

Adhesive skin closures (large, small)

Staple removers

Nonprescriptive creams (in accordance with Children’s Hospital of Pittsburgh’s diaperdermatitis clinical effectiveness guideline)a

Diaper dermatitis clinical effectiveness guideline

Permanent markers

Sterile cotton swabs

Sterile tongue blades

Soft gel pillows with covers

Nonsting protective barrier film wipes

Basic stoma supplies

Emery boards

Measuring tapes

Small mirrors

Skin integrity prevalence forms

a Prescribed medications for diaper dermatitis and other skin and wound therapies are ordered via a comput-erized order entry system for providers.



The goal of a support surface is toremove localized pressure (pressurerelief ) or to redistribute pressureevenly over the contact surface (pres-sure reduction).13 Selecting a mat-tress or seating surface on the basisof the assessment of a patient’s riskfor pressure ulcers can be both effi-cacious and cost-effective.13 Regard-less of the support system used andrecommended for a patient, follow-up is imperative. When patientsare not repositioned, pressure on

bony prominences leads to skinimpairment. This skin impairmentdoes not indicate failure of a supportsurface to prevent breakdown.13

Decisions related to supportsurfaces are made by nurses. ThePICU skin care team is proactiveand strategic, placing patients onsupport surfaces depending on theevaluation of the patients’ risk forpressure ulcers. Assessment of asupport surface includes determin-ing the patient’s underlying medicalcondition and current medical status,the ability to safely provide pressureredistribution for the patient, thepatient’s current risk score for pres-sure ulcers, and significant existingcomorbid diseases. Support surfacesare ordered preemptively if risk forpressure ulcers is anticipated (eg,before starting continuous renalreplacement therapy). Challengesinclude patients whose conditiondeteriorates too quickly to procurethe best surface in time (eg, use ofextracorporeal membrane oxygena-tion in a child). Ideally, advancedplanning prevents patients in a highlyunstable condition from beingmoved at less than optimal times.

The critical care service centerhas 4 low-air-loss beds. These bedsare used only for critically ill patientsand are ordered at the discretion ofthe team and the hospital’s CWOCNs.Patients’ support surface require-ments are communicated as a freetext message in the computerizeddata system. Patients with scores of15 or less on the Braden Q scale areconsidered at high risk for pressureulcers (Table 1). Once a patient is athigh risk, a PICU nurse notifies anurse on the skin care team anddecision making about selection ofa support surface starts (Figure 4).


refined skin care standards resultedin elimination of these problems forthe remaining quarters of fiscal year2006. This success was described atlocal conferences and was showcasedas part of the nursing annual reportof Children’s Hospital of Pittsburgh.

Assessment of SupportSurfaces

A support surface is a bed, mat-tress, or seating surface that candecrease tissue interface pressure.13

Figure 2 Pediatric intensive care unit (PICU) edition of critical care newsletter.

Reprinted with permission from Children’s Hospital of Pittsburgh.

Press Release, Pressure UlcerStages Revised by NationalPressure Ulcer Advisory Panel,

Washington, D.C., February2007

http://www.nursingcenter.com/

/upload/static/403753/ASWC_BreakingNews_Feb07.htm

Accessed 5/15/07

The National Pressure Ulcer

Advisory Panel (NPUAP) hasredefined the definition of apressure ulcer & the stages of

pressure ulcers. Included are theoriginal 4 stages (I – IV) and 2

additional stages. The 2additional stages are deep tissueinjury (DTI) and unstageable

pressure ulcers. This is aculmination of over 5 years ofwork beginning with the

identification of DTI in 2001.

Pressure Ulcer Definition

A pressure ulcer is localizedinjury to the skin and/orunderlying tissue usually over a

bony prominence, as a result ofpressure, or pressure incombination with shear and/or

friction. A number ofcontributing or confounding

factors are also associated withpressure ulcers; the significanceof these factors is yet to be

elucidated.

Click on the link above to read

more. At present, thisredefinition of pressure ulcers &staging does not pose new or

different practice implications atChildren’s Hospital of Pittsburghof UPMC. The PICU Skin Care

Team in collaboration with ourCWOCN will keep you updated.

IS YOUR PATIENT AT RISKFOR SKIN TEARS?

Risk factors for skin tears include

the likelihood for friction/ shear,frail skin, dehydration, history of

tape/ adherent dressings thatwere not removed with care.(Ayello, EA, 2003).

SKIN TEAR PREVENTION

Remember to avoid securing

Foley catheters to patients’ legswith clear adhesive dressings.

This may result in skinimpairment. Instead, apply ahydrocolloid dressing to the skin

and secure the Foley to thedressing.

General Skin Updates

� Thank you to the ClinicalLeaders for improving

communication. Skincare concerns andBraden Q Scores continue

to be routinelyintegrated into patient

hand-off.

� New laminated copies ofthe Braden Q Scale have

been placed in all of thebedside charts.

� Skin care education is

planned for May’s staffmeetings. Don’t miss it!

� Please see the list of thenew skin care product

order numbers in thestaff office. Skin careteam members have a

copy of this also.

TRUE or FALSE?

The wound vacuum-assistedclosure device (V.A.C.) is

contraindicated with chronicopen Stage IV wounds.

FALSE The V.A.C. is indicated

for use with chronic open wounds(e.g. some pressure ulcers);Stage III or IV wounds; acute &

traumatic wounds; meshedgrafts; subacute wounds (e.g.

dehisced incisions) and flaps.Contraindications includenecrotic tissue with eschar;

untreated osteomyelitis andwounds containing malignancy.

QUALITY FOCUS

Braden Q Scores are being

monitored weekly. Five randomcharts are being examined for

practice associated with q. 12hour skin assessments. Forseveral weeks, the PICU has been

100% compliant. Keep up thegood work!

THE END

The following contains peer review or other sensitive information and is therefore privileged and confidential.

PICU Edition May 2007

Editor, Tracy Pasek, RN



Consider the following scenarios.

An oncology patient with unsta-ble hemodynamic status isadmitted to the PICU andrequires emergent endotrachealintubation with eventual high-frequency oscillatory ventila-tion. Her Braden Q score is 16.This child requires a pressureredistribution support surface,but her condition preventsusing this procedure. Mainte-nance with soft gel pillows,maximal turning as tolerated,and rigorous skin inspectioncan be offered to this patientuntil an appropriate supportsurface can be instituted safely.

A patient who has undergonelaryngotracheal reconstruc-tion is expected from theoperating room at 3 PM.Another PICU patient will be

started on continuous renalreplacement therapy at 1 PM.The skin care team must evalu-ate current use of support sur-faces and decide if other PICUpatients can relinquish supportsurfaces or if new support sur-faces must be rented. If newsurfaces must be rented, thenthe team must evaluate com-pany delivery time in relationto the operating room admis-sion and continuous renalreplacement therapy goals.

Nurses on the skin care team,CWOCNs, and physicians may ordersupport surfaces. Orders and chargesare tracked by the CWOCNs via acomputerized system. Occasionally,a patient’s family may ask that thepatient be permitted to stay on atherapeutic surface for comfort

when skin and wound condition nolonger warrants such treatment.These situations are thoughtfullyevaluated by the involved healthcare providers. Gentle education isprovided to help patients and theirfamilies understand the indicationsfor use of support surfaces. Fami-lies’ requests may prevail. Once, anoverlay support surface was orderedfor a solid-organ transplant recipi-ent who had severe pain fromrheumatoid arthritis. Pain ratherthan pressure redistribution wasthe primary indication for a sup-port surface.

Influence and Future Workof the PICU Skin Care Team

The skin care team had a primaryrole in developing the computerized


Figure 3 Skin integrity prevalence form.


Instructions:

1. Perform a head-to-toe skin assessment for all patients on the unit.

2. Complete one form for each patient with altered skin integrity.

3. For patients with multiple skin integrity problems, use additional forms if needed. Complete patient & unit information on each.

4. If there are no patients with altered skin integrity on Prevalence day, submit one form. Complete unit information only (see first line).

5. Fax completed form(s) to X7097 WITHIN 24 HOURS OF PREVALENCE ROUNDS.

Date: __________ Unit : ____________ Cost Center #: _____________ Number of patients assessed: ________

Medical Record Number: ________________ Age: ______ Gender: ___Male ____Female Patient’s current Braden Q score: ________

A. Ulcer Location (List only 1 ulcer per line

using options in BOX F.

Location)

B. Stage

C. Size

L x W (square cm)

D. Depth

(cm)

E. Where was

ulcer acquired?

1

2

3

4

5

6

Deep Tissue Injury

(DTI)

I

II

III

IV

Unable

to

stage

0-2

2-4

4-8

8-16

>16

0-2

2-4

4-8

>8

Hospital

Unit

Community

1.

2.

3.

4.

5.

F. Location

1 Head

2 Elbows

3 Upper Extremity (other)

4 Torso

5 Heels

6 Lower Extremity (other)

G. Other Conditions (describe)

Diaper Dermatitis

Skin Tear

Chemical/Thermal Injury

IV Infiltrate

Surgical Wound



form for collection of data on skinimpairment for the hospital (Figure5). It is an electronic rendering ofthe current skin integrity prevalenceform (Figure 3) and may be used inthe future.

In 2006, PICU professional staffnurses reported that physicians’orders did not include where toapply topical medications. At anygiven time, a critically ill child mayhave several topical medications

ordered, which could include a com-bination of analgesics, antifungalmedicines, antibiotics, steroids,diaper dermatitis prescriptives, andvasodilator ointments to promotewound healing. A team membercollaborated with a clinical pharmacyspecialist and a clinical effectivenessspecialist to develop an order setfor topical medications for PICUpatients. This order set providesspecific directions for the applica-tion of topical medications (eg, a“drop-down menu” listing face,buttocks, heels, and so on) and isbeing considered for hospital-wideuse.

The Advanced Burn Life-Savingcourse was offered to nurses at thehospital in 2006. In an effort to beprepared to manage patients withminor burns and burnlike skin con-ditions and to learn how to applyassociated dressings, nurses on thePICU skin care team were amongthe first to attend. Having severalPICU nurses who are certified inAdvanced Burn Life-Saving is alsoin keeping with the hospital’s planfor disaster preparedness.

The PICU skin care team’s rolewith intravenous therapy is expand-ing. The nurses collaborated withthe hospital nurse intravenous teamto lead hospital-wide educationrelated to dressings at new intra-venous cannulation sites. The skincare team currently manages mildcases of intravenous infiltration; asurgical service manages severecases. The team is working withsurgical physicians to improvecommunication when caring forshared patients. A digital camerahas been purchased for the team toimprove the tracking of woundhealing by nurses and physicians.


Figure 4 Algorithm for selection of support surfaces.

Generic names: Accucair Overlay, continuous airflow system; Clinitron CII, air fluidized therapy; Clinitron RiteHite, air fluidized therapy: head elevation, low to floor for easy exit out of bed; Egg Crate, convoluted foamoverlay 2-3 in (5-8 cm) in depth: prevention; Flexicair Eclipse, mobile, 5-zoned low-air-loss bed; Geomat-tress, foam mattress overlay for infants <30 lb (<15 kg); Hard Crib, upgraded foam crib mattress: pressureredistribution; Magnum II, pressure redistribution for bariatric patients; Pressure Guard II, static alternatingair mattress; Sheepskin, friction shear reduction; Total Care, static alternating air: pressure redistribution;Total Care Sport, alternating air: pressure redistribution; V-Cue, continuous lateral rotation therapy: low airloss, rotation, percussion, vibration.


Chemical paralysis/immobility with impaired gas exchange or actual pulmonary compli-

cations and/or for percussion/vibration

Burns or burnlike conditionsBraden Q score 7-12 Full body

High exudatingwound

Patient <30 lbor 15 kg

Magnum II

A patient with flaps or grafts is exempt from the algorithm and is placed on a support surface at the discretion of the hospital certified wound ostomy care nurseand physician.

Pressure Guard II Geomattress; SheepskinEgg crate—acute care only

Accucair Overlay GeomattressPressure Guard IIHard Crib

Total CareAccucair OverlayFlexicair Eclipse

Daily reassessment

Stage III and/or stage IVBraden Q score 7-15

Limited mobility with multiple stage II and single stage III pressure ulcersBraden Q score 7-15

Stage I or laryngotracheal reconstruction patients

Braden Q score 16-20

Low riskBraden Q score ≥21

Patient with weight from 350-800 lb (150-350 kg)

Total Care BedHard Crib

Flexicair Eclipse

Clinitron CII

Clinitron CII

V-Cue

Clinitron Rite-Hite

V-Cue

Total Care Sport

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

No

No

No

No

No

No

No

No

No

No weightavailable



A clinical effectiveness guidelinefor diaper dermatitis (Figure 6) is theresult of a collaborative effort amongCWOCNs and skin care nurses. Thisguideline targets prevention ratherthan treatment. The hospital’s preva-lence rate for diaper dermatitis for2007 is 2.5% whereas the nationalprevalence rate is 16% to 42%.14

Last, to assist with documenta-tion of participation on the PICUskin care team and the hospital’snurse skin care council, an agree-ment form is completed by all skincare nurses (Figure 7). The formsare kept on file with PICU leaders.These records support nurses’annual performance reviews andclinical advancement. CCN


Figure 5 Computerized form used to collect data on skin impairment.


Figure 6 Clinical effectiveness guideline for prevention and treatment of diaper dermatitis.* Physician’s order required.Based on data from Agrawal and Sammeta,14 Baharestani,15 Gray et al,16 Hoggarth et al,17 Lund et al,18 and Lekan-Rutledge.19


Diaper wipes, Aloe Vesta, Aquaphor*

(petrolatum-based barrierointment) or

Infants >30 days old 3M No Sting (acrylatepolymer film)

Wet Nystatin powder*

(antifungal agent) andXenaderm ointment*(trypsin, balsam peru,and castor oil)General guidelines

• Do not remove Ilex; reapply asneeded

• Reapply Aquaphor with eachdiaper change

• Document skin plan of care

Definitions of dermatitis

Mild: Blotchy erythema, tendernessModerate: Intense inflammation, mild erosion, discomfortSevere: Epidermal/dermal erosion, pain, weeping

Pull-through procedurePerineal cleanser/water andIlex* (zinc-based paste) andAquaphor* Dry

Nystatin ointment*(antifungal agent)

Short gut syndromePerineal cleanser/water andPittsburgh Paste,*

(cholestyramine paste*)

Skin intactMild dermatitis

Perineal cleanser/water and Extra ProtectiveCream (zinc-based barrier)

Moderate dermatitisCleanse with water, normal saline, and Extra

Protective CreamNotify unit’s skin care nurse

Severe dermatitisCleanse with normal saline and soak with

Aveeno* (colloidal oatmeal 100%) twice aday or

Domeboro’s* (aluminum acetate) compresses3 times a day and

Stomahesive powder (stoma adhesive protec-tive powder), 3M No Sting, Extra ProtectiveCream

Notify certified wound ostomy and continencenurse

No

Yes

Yes

Yes

Yes

No

No

Yeast present



AcknowledgmentsWe are grateful to Janet Aradine, RN, MSN, clinicaleffectiveness specialist, Children’s Hospital ofPittsburgh of University of Pittsburgh MedicalCenter.

Financial DisclosuresNone reported.

References1. Halpin-Landry J. Anatomy and physiology

of the skin. In: Milne CT, Corbett, LQ, DubucDL, eds. Wound, Ostomy, and ContinenceNursing Secrets: Questions and Answers Revealthe Secrets to Successful WOC Care. Philadel-phia, PA: Hanley & Belfus Inc; 2003:1-5.

2. Carnevale FA. Pressure ulcers in pediatriccritical care: examining the evidence. Pedi-atr Crit Care. 2003;4(3):383-384.

3. Noonan C, Quigley S, Curley MAQ. Skinintegrity in hospitalized infants and chil-

dren: a prevalence survey. J Pediatr Nurs.2006;21(6):445-453.

4. Cho SH, Ketefian S, Barkauskas VH, SmithDG. The effects of nurse staffing onadverse events, morbidity, mortality, andmedical costs. Nurs Res. 2003;52(2):71-79.

5. Willock J, Hughes J, Tickle S, Rossiter G,Johnson C, Pye H. Pressure sores in chil-dren: the acute hospital perspective. J Tis-sue Viability. 2000;10(2):59-62.

6. Curley MAQ, Quigley SM, Ming L. Pres-sure ulcers in pediatric intensive care: inci-dence and associated factors. Pediatr CritCare Med. 2003;4(3):284-290.

7. Minnesota Department of Health, Divisionof Health Policy, Adverse Health Events.Con sumer guide to adverse health events.http://www.health.state.mn.us/patientsafey/publications/consumerguide.pdf. PublishedJanuary 2008. Accessed March 5, 2008.

8. Harrison MB, Wells G, Fisher A, Prince M.Practice guidelines for the prediction andprevention of pressure ulcers: evaluatingthe evidence. Appl Nurs Res. 1996;9(1):9-17.

9. Braden B, Bergstrom M. Braden Scale forpredicting pressure ulcer risk. 1988.http://www.bradenscale.com/braden.PDF.Accessed March 5, 2008.

10. Curley MA, Razmus IS, Roberts KE, Wypij D.Predicting pressure ulcer risk in pediatricpatients: the Braden Q Scale. Nurs Res.2003;52:22-33.

11. Pasek T. Print or store to folder? Critical carenewsletter. Crit Care Nurse. 2003;23(1):88-87.

12. National Pressure Ulcer Advisory Panel.NPUAP announces new pressure ulcerdefinition and staging. Advances in Skinand Wound Care eNews. http://www.nursingcenter.com//upload/static/403753/ASWC_BreakingNews_Feb07.htm. Pub-lished February 2007. Accessed March 5,2008.

13. Brienza DM, Geyer MJ, Sprigle S. Seating,positioning and support surfaces. In: Bara-noski S, Ayello EA, eds. Wound Care Essen-tials: Practice Principles. Philadelphia, PA:Lippincott Williams & Wilkins; 2004:187-212.

14. Agrawal R, Sammeta V. Diaper dermatitis.http://www.emedicine.com/ped/topic2755.htm. Accessed March 5, 2008.

15. Baharestani MM. An overview of neonataland pediatric wound care knowledge andconsiderations. Ostomy Wound Manage.2007;53(6):34-55.

16. Gray M, Bliss D, Doughty D, Ermer-Seltun J,Kennedy-Evans K, Palmer M. Incontinence-associated dermatitis: a consensus. J WoundOstomy Continence Nurs. 2007;34(1):45-54.

17. Hoggarth A, Waring M, Alexander J,Greenwood A, Callaghan TA. Controlled,three-part trial to investigate the barrierfunction and skin hydration properties ofsix skin protectants. Ostomy Wound Manage.2005;51(12):30-42.

18. Lund CH, Osborne JW, Kuller J, Lane AT,Lott JW, Raines DA. Neonatal skin care:clinical outcomes of the AWHONN/NANNevidence-based clinical practice guideline. JObstet Gynecol Neonat Nurs. 2001;30(1):41-51.

19. Lekan-Rutledge D. Management of urinaryincontinence: skin care, containmentdevices, catheters, absorptive products. In:Doughty DB, ed. Urinary and Fecal Inconti-nence: Current Management Concepts. StLouis, MO: Mosby Elsevier; 2006:309-339.


Figure 7 Agreement form completed by all nurses on the skin care team.


Agreement to Participate

I agree to serve as a member of the PICU Skin Care Team for calendar year January 2008

thru December 2008. As a nurse on the PICU Skin Care Team I agree to the following during

this time:

• Attend a minimum of 75% (9) of the scheduled hospital Skin Care Council meetings;

• For those meetings I am unable to attend, I will arrange to have another RN

represent the PICU at the meeting.

• Actively participate in hospital Skin Care Council work (e.g. fulfill continuing

education requirements);

• Report information from these meetings to my manager and colleagues at scheduled

PICU staff meetings;

• Attend the annual PICU Skin Care Team strategic planning meeting;

• Commit to provide monthly education to my colleagues, either alone or with another

PICU Skin Care Team nurse;

• Adhere to Children’s Hospital of Pittsburgh’s conference attendance guidelines when

I attend skin-related continuing education offered outside the hospital;

• Assume responsibility with my schedule to ensure I lead skin care rounds with

regular frequency;

• Write skin care summaries following weekly skin care rounds;

• Collect & fax monthly prevalence data if I round on prevalence day;

• Assume active role in skin-related PICU quality initiatives (e.g. design data collection

forms, collect data, develop process improvement indicators);

• Assume active role with PICU Skin Care Team work (e.g. patient/ family education

initiatives, new product trials, standards of care);

• Act as a positive role model and Skin Care Team ambassador to services with shared

patients (e.g. Plastic Surgery, General Surgery and Dermatology).

Name (Please print) _________________________

Signature _________________________ Date _________

Unit ___________

Manager signature __________________________ Date __________

eLettersNow that you’ve read the article, create or con-tribute to an online discussion about this topicusing eLetters. Just visit http://ccn.aacnjournals.org and click “Respond to This Article” in eitherthe full-text or PDF view of the article.

To learn more about skin care in critically illchildren, read “Skin Integrity in Critically Illand Injured Children” by Christine A.Schindler, Theresa A. Mikhailov, Kay Fischer,Gloria Lukasiewicz, Evelyn M. Kuhn, andLinda Duncan in the American Journal of Crit-ical Care, 2007;16(5):568-574. Availableonline at www.ajcconline.org.

d•t



Ccn

Documents

advanced practice nurse

excellencetracy ann pasek

adverse health events

professional staff nurses

skin care team

ann spence

skin care

amanda geyser