Pressure ulcers

 
 DO

• Take a history and perform careful physical examination of the entire skin.  
• Grade pressure ulcers based on the NPIAP/EPUAP pressure ulcer classification system.

Stages of pressure ulcers according to the NPIAP/EPUAP pressure ulcer classification system

Category I Non-expressible redness in intact skin

Intact skin with non-obscured redness in a localised area at the level of a bony protrusion. Dark skin may not show visible discoloration and is therefore more difficult to assess. The area may be painful, stiff, tender, warmer or colder compared to adjacent tissue.

Category II Loss of part of the skin layer or blister

A shiny or dry superficial wound with a pink wound base, without wound impaction or bruising. Part of the dermis (dermis) has disappeared. The wound may look like an intact, an open or a ruptured blister. A blister filled with fluid (plasma) and/or blood also belongs to category II.

Category III Loss of an entire layer of skin (fat visible)

A layer of skin has fallen away, leaving subcutaneous fat visible. Bone, tendons and muscle are not exposed. Wound attachment, undermining or tunnelling may be present. The depth of Category III decubitus varies by body location. The bridge of the nose, the ear, the back of the head and the ankle have no subcutaneous (fat) tissue, so the wound is superficial. In areas with a large amount of fat, extremely deep wounds can develop. Bone and tendons are not visible or immediately palpable.

Category IV Loss of a complete tissue layer (muscle/bone visible)

Loss of a complete tissue layer with exposed bone, tendons or muscle. A fluidized wound deposit or necrotic scab may be present. There is usually undermining or tunnelling. The depth of the wound varies by body location. Decubitus can spread into the muscles and/or supporting structures (e.g., fascia, tendon or joint capsule) easily causing osteomyelitis or osteitis. Exposed bone or muscle tissue is visible and immediately palpable.

 





 DO

• Provide the child and family with understandable information about prevention, risks and treatment of pressure ulcers.
• Agree with child, parents and caregivers on roles and decide together on responsibilities related to pressure ulcer prevention/treatment including pain management, nutritional counselling, occupational therapy and physical therapy.
• In children at risk for pressure ulcers, inspect the entire skin daily with extra attention to high-risk sites (bone) and other pressure points.
• Prevent pressure ulcers by regularly applying alternating positions. 
• Use pressure-reducing mattresses.
• Protect the skin from humidity.
• Ensure good nutritional status. Enlist the help of a dietician for this, if necessary.

 










 DO

• Determine whether wound healing or symptom relief is the goal of treatment.
• Assess the wound for infection, pain, fragility, oedema, colour, odour, and deterioration.
• Clean the wound (especially for yellow or black wounds and/or odour issues) by flushing with tapwater once daily.
• Choose a wound dressing appropriate to the wound. Use the classification model in the WCS Wound Book (also available as an app) for this purpose, if necessary.
• Choose dressing materials that meet a wide range of requirements if more symptoms occur, such as odour, extreme exudate formation and bleeding tendency.
• Indicate rapidly occurring changes in the skin and respond to them promptly.
• If necessary, involve a (paediatric) physical therapist, occupational therapist, or medical device manufacturer in using assistive devices or making adjustments so that skin lesions are less stressed.
• Limit the smell of the wound by using: 
  • Antiseptic agents 
  • Topical metronidazole gel 
  • Antimicrobial dressings 
  • Charcoal dressings 
  • Use odour neutralizers such as cat litter or activated charcoal

 
 DO

• Evaluate the effect and side effects of the treatment instituted at the appropriate time, and adjust treatment as needed. Involve child and family in this process.