Skin Care Team in the Pediatric Intensive Care Unit: A Model for Excellence

Tracy Ann Pasek, Amanda Geyser, Maria Sidoni, Patricia Harris, Julia A. Warner, Ann Spence, Allison Trent, Libby Lazzaro, Julianne Balach, Alicia Bakota and Shana Weicheck
Crit Care Nurse 2008;28:125-135
© 2008 American Association of Critical-Care Nurses Published online http://www.cconline.org Personal use only. For copyright permission information: http://ccn.aacnjournals.org/cgi/external_ref?link_type=PERMISSIONDIRECT

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Critical Care Nurse is the official peer-reviewed clinical journal of the American Association of Critical-Care Nurses, published bi-monthly by The InnoVision Group 101 Columbia, Aliso Viejo, CA 92656. Telephone: (800) 899-1712, (949) 362-2050, ext. 532. Fax: (949) 362-2049. Copyright © 2008 by AACN. All rights reserved.

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BSN Patricia Harris. Concomitant pain and altered appearance are physical and emotional burdens for patients and families already experiencing stress associated with hospitalization in a pediatric intensive care unit (PICU). RN. BSN PRIME POINTS integrity predisposes patients to infection and poor outcomes. In infants and young children.aacnjournals. BSN. limited mobility. and leads evidencebased initiatives.4 Impaired perfusion. committed to a specific entity such as skin care enhances resource availability.1 Intact skin is a barrier to infection. Among the 7 groups of adverse events examined. Pressure ulcers are an important iatrogenic problem in health care with substantial financial costs. BSN Julianne Balach. CCRN Amanda Geyser. APRIL 2008 125 Downloaded from ccn. immunosuppression. 2. Cho et al4 reported that pressure ulcers had the greatest effect on length of stay.org by guest on June 6. RN. • Having a team he skin is the largest organ of the body and has many complex functions. 2012 . RN. RN. WOCN Libby Lazzaro. alteration in skin integrity predisposes patients to infection and poor outcomes.Pediatric Care Skin Care Team in the Pediatric Intensive Care Unit: A Model for Excellence Tracy Ann Pasek. Fifty-seven percent of all ulcers were detected during the http://ccn. BSN. Warner. Pressure ulcers have an incidence of 7% and a prevalence of 7% among acutely ill children. RN Alicia Bakota. pressure ulcers were the third most significant determinant of increased costs. CCTN Julia A. altered nutrition. unstable hemodynamic status. RN. RN. RN. RN. Immature bowel and bladder control and large heads are inevitable contributory risk factors specific to children. thus. with a 1. CCRN. CWOCN. and level of consciousness.3 In a study of adverse events. trains staff. • A pediatric skin care team provides expertise. pressure ulcers occur most often on the head and heels.84-fold increase in stay for patients with such ulcers. RN. BSN Maria Sidoni. No. after sepsis and pneumonia. and follow-through. mobility. promotes policy.aacnjournals. BSN Shana Weicheck.2. and medications contribute to T risk associated with altered skin integrity for critically ill children.5 Noonan et al3 reported a 27% incidence of pressure ulcers. RN. CWOCN. MSN. of which 32% of the more significant ulcers involved the head.org CRITICALCARENURSE Vol 28.5 The occurrence of pressure ulcers is associated with nutritional status. MS Allison Trent. communication. CFCN Ann Spence. • Alteration in skin • Pressure ulcers can almost double patients’ length of stay.

first skin assessment on the second day in the PICU. APRIL 2008 http://ccn. Corresponding author: Tracy Pasek. These devices are often placed when the patient is admitted to a PICU. The PICU skin care team is accountable to 2 hospital councils— a nurse skin care council made up of nurses from all inpatient care areas and a nurse practice council. Ann Spence was a performance improvement specialist and Allison Trent was a wound ostomy care nurse when this article was originally submitted for publication. Bedsores are considered an adverse health event. a recent consumer report7 from the Minnesota Department of Health includes an easy-to-read pie chart indicating that serious bedsores account for 43% of adverse health events. and follow-through. Pennsylvania. modest effort is directed at limiting the team’s size to approximately 8 nurses. For example. 101 Columbia. contact The InnoVision Group. children who are patients in a technology-rich environment such as a PICU may experience pressure ulcers early in hospitalization. the adverse effects of immobility and physiological instability on a patient’s skin do not discriminate by age or developmental level. At Children’s Hospital of Pittsburgh. Children’s Hospital of Pittsburgh.org Downloaded from ccn. This limitation increases the number of opportunities for nurses to lead and participate in rounds. and lead evidence-based initiatives. plans of care. (949) 362-2049.pasek@chp. communication. and masks for bilevel positive airway pressure (BiPAP). e-mail. Amanda Geyser and Julianne Balach are clinical leaders in the pediatric intensive care unit. Pittsburgh. Skin Care Rounds Skin care rounds take place each Tuesday morning. Two certified wound ostomy care nurses (CWOCNs) support the team as consultants. a team committed to a specific entity such as skin care enhances resource availability. PA 15213-2583 (e-mail: tracy. Warner are certified wound ostomy care nurses. Aliso Viejo. Nurses provide direct patient care. CCRN.aacnjournals. The team strives to maintain skin care as a top priority. conduct staff education. Purpose of a PICU Skin Care Team A PICU skin care team provides a core group with the expertise to provide care for patients with complex and variable skin care needs. Moreover.7 Health care providers’ assessment methods and prevention strategies are defined and described so that consumers are empowered to make safe health care decisions. Selection of new nurses for the skin care team is a joint effort between PICU leaders and nurses currently on the team. so tracking quality of care is imperative to prevent and identify problems. Alicia Bakota. Tracy Ann Pasek is an advanced practice nurse in the pediatric intensive care unit. 2012 .edu). Phone. Consumers are encouraged to learn about the law in relation to adverse health events and reporting. 3705 Fifth Ave. fax. consideration is given to having members representative of all shifts and of weekend staffing. Libby Lazzaro. skin care is a nursing research priority. Maria Sidoni.aacnjournals. Skin assessment findings. artificial airways. (800) 809-2273 or (949) 362-2050 (ext 532). This information is recorded by the night 126 CRITICALCARENURSE Vol 28. To purchase electronic or print reprints. a unitbased skin care team was established in the PICU.3 Indeed. RN. in Pennsylvania. Structure of the Skin Care Team The PICU skin care team is made up of professional staff nurses. Pittsburgh. Because expertise is primarily developed through direct patient care. An advanced practice nurse and clinical leader direct the team. augmenting skin care with comfort as another important team focus. CA 92656. and Braden Q scores (documented every 12 hours within the critical care service center) are routine components of the changeof-shift report (Table 1). promote policy. reprints@aacn. The advanced practice nurse has pain as a specialty. Pediatric Intensive Care Unit. Authors All authors are from Children’s Hospital of Pittsburgh. No. and Shana Weicheck are professional staff nurses in the pediatric intensive care unit.org. a large tertiary care hospital.8 Yet life-saving measures may preclude attention to less emergent skin and wound therapies in a critical care setting.org by guest on June 6.6 Moreover. Preparation begins with the clinical leader Monday night. thereby modeling excellence in skin care. Patricia Harris and Julia A.6 Noonan et al3 reported that more than 50% of medical devices that contributed to pressure-related skin injuries were pulse oximetry probes. 2. In a high-acuity unit with approximately 140 professional staff nurses. University of Pittsburgh Medical Center. Skinand wound-related initiatives involving prescribed medication require approval by the hospital’s pharmacy and therapeutics committee. Benchmark data are available to pediatric critical care nurses. The team members or “champions” proactively identify and avert potential adverse clinical outcomes. MSN.

or walks frequently severely limited or during day.aacnjournals. Bedfast Confined to bed Activity The degree of physical activity Sensory perception 1. chair. No apparent problem Friction: Occurs Spasticity. etc Dampness is detected every time patient is moved or turned Friction and shear 1. Occasionally moist 4. APRIL 2008 127 Downloaded from ccn. flinch. 2012 . Very moist 3. Chairfast 3. linen only changed at least 12 hours requires changing every 8 hours every 24 hours Intensity and duration of pressure Mobility The ability to change and control body position 1. Rarely moist Skin is often. contracture. or has sensory to be turned. Very limited 3. Very limited 3. but commands Cannot communicate cannot always Has no sensory discomfort except by communicate deficit that would moaning or restlessdiscomfort or need limit ability to feel ness.requiring Maintains relatively Maintains good frequent repositiongood position in position in bed or ing with maximum chair or bed most chair at all times assistance of the time but occasionally slides down Continued http://ccn. or agitation to maximum assisrequires minimum lift patient during a against support leads to almost tance in moving assistance position change. Completely limited The ability to Unresponsive (does respond in a not moan.org by guest on June 6. Completely immobile Does not make even slight changes in body or extremity position without assistance 1. always. or developmentally grasp) to painful appropriate way stimuli due to to pressure-related diminished level of discomfort consciousness or sedation. Constantly moist Skin is kept moist almost constantly by perspiration. No. Slightly limited 4. 2. but for Walks outside the nonexistent very short room at least twice Cannot bear own distances. Significant problem 2. Walks occasionally 4.aacnjournals. skin moves in bed and Shear: Occurs and friction without sliding probably slides to chair independently when skin and against sheets is some extent against and has sufficient adjacent bony impossible sheets. with or a day and inside weight and/or must without assistance room at least once be assisted into Spends majority of every 2 hours chair or wheelchair each shift in bed during waking hours or chair 2. but not Skin is occasionally Skin is usually dry. or other lift up completely across one down in bed or devices during move another chair. No limitations Makes occasional Makes frequent Makes major and slight changes in though slight frequent changes body or extremity changes in body or in position without position but unable extremity position assistance to completely turn independently self independently 2. requiring routine diaper Linen must be linen change every changes. Slightly limited 4. surface constant thrashing Complete lifting During a move. muscle strength to surface slide Frequently slides restraints. Potential problem 4. No impairment Responds only to Responds to verbal Responds to verbal painful stimuli commands. or or communicate has some sensory impairment that pain or discomfort impairment that limits the ability to limits ability to feel feel pain or pain or discomfort discomfort over half in 1 or 2 of body extremities Scoreb 2. moist moist. Problem 3.org CRITICALCARENURSE Vol 28. Requires moderate Moves freely or Able to completely when skin moves itching. drainage. Patient too young Ability to walk Walks occasionally to ambulate.Table 1 Braden Q scale used at Children’s Hospital of Pittsburgha Scoreb 2. urine. or has limited ability to feel pain over most of body surface Tolerance of the skin and supporting structure Moisture Degree to which skin is exposed to moisture 1.

For patients who are off the unit for operative or diagnostic procedures or whose condition is too unstable for a full skin assessment.40 be >2 seconds. a process that often consumes 3 to 4 hours. eats for more than 5 days.5 mg/dL and minerals for age minerals for age or Never refuses a meal or never eats a comor albumin <3 mg/dL eats more than Usually eats a total or rarely eats a plete meal. The schedule is determined in collaboration with the unit’s scheduling committee. <40 mm Hg <95%. Bedside nurses communicate valuable information. © Barbara Braden and Nancy Bergstrom. >95%. Rarely eats half of most meals of 4 or more complete meal and more than half of any Eats a total of 4 servings of meat generally eats only food offered servings of protein and dairy products about half of any Protein intake includes (meat. a member of the team returns later in the day to complete rounds. hemoglobin may be <95%. No. normal in newborn) or does may be <10 mg/dL.aacnjournals. capillary refill may seconds changes serum pH is <7. A skin care supply bag (Figure 1 and Table 5) is carried by the team to enhance product procurement for nurses and to minimize unnecessary. serum pH normal a b Adapted from Braden and Bergstrom9 and Curley et al. inadequate calories calories and most of every meal or albumin <2. Routinely conducting rounds early in the week yields consistency for PICU staff and provides the remainder of the week for follow-up of patients. dairy prodOccasionally eats food offered only 2 servings of ucts) each day between meals Protein intake includes meat or dairy products Occasionally will Does not only 3 servings of per day refuse a meal.org by guest on June 6. 1988. Busy nurses appreciate on-the-spot delivery of products.aacnjournals. APRIL 2008 http://ccn. Adequate 4.org Downloaded from ccn. not physiologically capillary refill may <10 mg/dL. The nurse who leads rounds is not assigned a patient for the first 4 hours of the Tuesday daylight shift (7 AM to 11 AM). nutrition. The team accomplishes a variety of work (Table 2). hemoglobin hemoglobin. clinical leader or charge nurse and is used by the skin care team during rounds the next morning. Normotensive. Very poor 2. Education of Nursing Staff The skin care team assumes responsibility for education of nursing staff. which calories for age intravenous fluids which provide provide adequate For example. arterial pressure <50 saturation may be oxygen saturation oxygen saturation mm Hg. The team cares for as many as 31 patients during rounds. Excellent oxygenation Hypotensive (mean Normotensive. Extremely compromised 2. process for “windowing” or 128 CRITICALCARENURSE Vol 28. but require supplmenmeat or dairy Takes fluids poorly will usually take a tation products per day Does not take a liquid supplement if Occasionally will dietary supplement offered take a dietary supplement Nutrition Usual food intake pattern Tissue perfusion and 1. Excellent Nothing by mouth Is on liquid diet or Is on tube feedings Is on a normal diet and/or maintained tube feedings/total or total parenteral providing adequate on clear liquids. Venues for such education include in-service training (eg. 2. Compromised 3. refer to Support Surface Selection Algorithm. Inadequate 3. Working with skin care supplies fosters familiarity with products. or parenteral nutrition. a fasciotomy dressing at 2 PM). either the professional staff nurse leader or the advanced practice nurse prepares an electronic summary and disseminates it to all PICU nurses (Table 3). At the conclusion of rounds. notify nurse on the unit-based skin care team. Keeping the bag stocked and monitoring expiration dates of supplies are tasks well suited to new team members.Table 1 Continued 1. Adequate 4. A member of the team asks to be called for complex dressing changes scheduled to happen during times other than rounds (eg. time-consuming trips to the supply room. 2012 . If total score is 15 or less. augmenting the team’s assessments. A full skin assessment includes but is not limited to the examinations listed in Table 4 as applicable. An 8-week schedule is posted to identify nurses to serve as rounds leaders. capillary refill <2 tolerate position be >2 seconds. oxygen Normotensive.10 with permission.

use of adhesive removers) Evaluate accuracy of documented Braden Q skin assessment scores Assist bedside nurse with diaper/incontinence garment and linen changes Weigh benefits and risks associated with treatments (eg. new products). applied prophylactic thick hydrocolloid dressing to bridge of nose and other mask pressure points Soft gel pillows and protective film barrier to heels added to plan of care Paged plastic surgeon. vacuum-assisted closure of wound. soft gel pillows. resulting in patient’s readmission to the unit with fulminant sepsis) Educate professional staff nurses Coordinate new product trials (eg. heels. APRIL 2008 129 Downloaded from ccn. trial of bilevel positive airway pressure planned for today. explaining how to operate a vacuum-assisted wound closure device). New PICU nurses are required to attend skin care rounds 1 time as part of a nurse residency program or orientation. coccyx Perineal and buttock region “picture framing” a site for central catheter insertion with transparent and hydrocolloid dressings). updates at monthly staff meetings (eg.Table 2 Role of the skin care team in the pediatric intensive care unit Assess each patient’s skin from head to toe Assist bedside nurse with repositioning and changes in therapeutic support surface Start/stop use of therapeutic support surfaces Procure skin care products for bedside nurses (eg. electronic management updates (reminders to document Braden Q scores). and blood pressure cuffs Skin surrounding and beneath electrocardiography patches Insertion sites of intravenous catheters Skin surrounding dressings for central catheters. including elbows. including skin beneath tracheostomy tube ties Insertion site for abdominal gastric tube Skin beneath splints. No. recommend dietary protein assessment for new nutrition-related occipital alopecia) Provide skin care education and positive reinforcement for self-care behaviors to family members Check current skin and wound care orders for accuracy and adherence Enter new or update existing skin and wound care orders via a computerized system Complete new and follow up on prior patient safety reports related to skin care Document skin impairment during monthly prevalence rounds Collaborate with preceptors to provide hands-on experience for new nurse orientees Collaborate with critical care service center disciplines to tackle wound-related legal dilemmas (eg. MD Table 4 Examination sites included in head-to-toe skin assessment Occiput Face near endotracheal tube tape and beneath a mask for bilevel positive airway pressure Nasogastric or orogastric tube insertion site Skin beneath a cervical collar Site of pulse oximetry probe Tracheostomy site. skin on clavicles clear beneath collar under potential pressure points. Less urgent http://ccn. and bedside education (eg.aacnjournals. sequential compression devices. necrotizing fasciitis) Prevent pain with dressing changes (eg. skin beneath transparent dressings for central catheters All pressure points. Stevens-Johnson syndrome.org CRITICALCARENURSE Vol 28.org by guest on June 6. dad requested additional information about sharp debridement (eschar excision performed with a surgical blade) Wound in right side of groin redressed and healthy tissue shown to parents Update on wound progress given to critical care medicine fellow Bed space 16.aacnjournals. methodological therapies for best approach to eschar debridement) Consult other services (eg. timing around preemptive analgesia. purchased vs rented low-air-loss mattress overlays) Table 3 Patient Example of a summary from skin care rounds 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 change Educated mom and dad about how to apply skin care products to diaper area Helped nurse change cervical collar. TP Bed space 22. dressing supplies) Direct and assist with complex dressing changes (eg. 2012 . long-term care facility repeatedly not following wound care discharge instructions. 2. AG Bed space 21.

Once the underlying causes of epidermal stripping and BiPAPrelated skin impairment were identified. Skin care may be the topic of monthly critical care evidence-based review clubs or journal clubs. APRIL 2008 http://ccn. the first Tuesday of each month. the incidence increased to a high of 19%. Data are submitted to the quality services department and reviewed as part of the hospital’s report card (Figure 3). and adapt to your unit’s needs) Dressing supplies (transparent. Both underuse of adhesive removers and the practice of taping devices (eg. absorptive) Sterile scissors Tape rolls. Skin impairment is recorded on prevalence day. a 130 CRITICALCARENURSE Vol 28.aacnjournals. or supplemental information is reserved for the PICU edition of a critical care newsletter11 (Figure 2). 2 quality indicators during fiscal year 2006 included prevention of epidermal stripping (skin tears) and prevention of BiPAP-related skin impairment (nose and other mask pressure points). BiPAP-related skin impairment had a prevalence of 5% during the first quarter. Performance Improvement Hospital-wide prevalence rounds occur monthly. adhesive. Educating physicians about support surface indications is a primary role of the hospital’s CWOCNs.org Downloaded from ccn. in the second quarter. nonadherent. urinary catheter tubing) directly to the skin instead of atop a hydrocolloid dressing were problems.Figure 1 Skin care supply bag. hydrocolloid. education initiatives and Table 5 Items in skin care supply bag (Specify quantity of each. hydrogel.org by guest on June 6. Epidermal stripping was brought to the team’s attention by an increased number of reports of events related to patient safety. 2012 . BiPAP skin impairment was proactively adopted as a process improvement indicator in anticipation of the high-census/high-acuity respiratory illness season.12 For the first time. They serve as a gauge for benchmarking against other hospitals of like size and acuity level. the incidence of epidermal stripping was 5%. but nurses on the skin care team also share in this responsibility.aacnjournals. small) Staple removers Nonprescriptive creams (in accordance with Children’s Hospital of Pittsburgh’s diaper dermatitis 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 Prescribed medications for diaper dermatitis and other skin and wound therapies are ordered via a computerized order entry system for providers. include list inside bag. 2. and adhesive removal products Tracheostomy ties Adhesive skin closures (large. No. During the first quarter. The prevalence form reflects new definitions from the National Pressure Ulcer Advisory Panel.

untreated osteomyelitis and wounds containing malignancy. The PICU Skin Care SKIN TEAR PREVENTION Remember to avoid securing Foley catheters to patients’ legs with clear adhesive dressings.A.com/ /upload/static/403753/ASWC_Br eakingNews_Feb07. Keep up the good work! THE END Figure 2 Pediatric intensive care unit (PICU) edition of critical care newsletter. This success was described at local conferences and was showcased as part of the nursing annual report of Children’s Hospital of Pittsburgh. The PICU skin care team is proactive and strategic. This is a culmination of over 5 years of work beginning with the identification of DTI in 2001. use of extracorporeal membrane oxygenation in a child). EA. When patients are not repositioned. The critical care service center has 4 low-air-loss beds. 2012 . This may result in skin impairment.The following contains peer review or other sensitive information and is therefore privileged and confidential. the ability to safely provide pressure redistribution for the patient. Reprinted with permission from Children’s Hospital of Pittsburgh. Skin care team members have a copy of this also.. is indicated for use with chronic open wounds (e.nursingcenter. Patients’ support surface requirements are communicated as a free text message in the computerized data system. as a result of pressure. Support surfaces are ordered preemptively if risk for pressure ulcers is anticipated (eg. Washington. Stage III or IV wounds. or pressure in combination with shear and/or friction. Included are the original 4 stages (I – IV) and 2 additional stages. placing patients on support surfaces depending on the evaluation of the patients’ risk for pressure ulcers. some pressure ulcers). General Skin Updates Thank you to the Clinical Leaders for improving communication. These beds are used only for critically ill patients and are ordered at the discretion of the team and the hospital’s CWOCNs. Skin care concerns and Braden Q Scores continue to be routinely integrated into patient hand-off. order numbers in the staff office.aacnjournals. the patient’s current risk score for pressure ulcers. Patients with scores of 15 or less on the Braden Q scale are considered at high risk for pressure ulcers (Table 1).aacnjournals.C. APRIL 2008 131 Downloaded from ccn. RN Press Release. Don’t miss it! Please see the list of the new skin care product FALSE The V. 2. A number of contributing or confounding factors are also associated with pressure ulcers. The 2 additional stages are deep tissue injury (DTI) and unstageable pressure ulcers.C. Ideally. TRUE or FALSE? The wound vacuum-assisted closure device (V. http://ccn. PICU Edition May 2007 Editor.C. frail skin. For several weeks. 12 hour skin assessments.g. New laminated copies of the Braden Q Scale have been placed in all of the bedside charts. 2003). acute & traumatic wounds. Tracy Pasek.A. Assessment of Support Surfaces A support surface is a bed. dehisced incisions) and flaps. Once a patient is at high risk. the significance of these factors is yet to be elucidated.13 Regardless of the support system used and recommended for a patient. IS YOUR PATIENT AT RISK FOR SKIN TEARS? Risk factors for skin tears include the likelihood for friction/ shear. February 2007 http://www. (Ayello. a PICU nurse notifies a nurse on the skin care team and decision making about selection of a support surface starts (Figure 4). followup is imperative.13 Selecting a mattress or seating surface on the basis of the assessment of a patient’s risk for pressure ulcers can be both efficacious and cost-effective. Contraindications include necrotic tissue with eschar. Pressure Ulcer Definition A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence. and significant existing comorbid diseases. At present.g. refined skin care standards resulted in elimination of these problems for the remaining quarters of fiscal year 2006. This skin impairment does not indicate failure of a support surface to prevent breakdown. The National Pressure Ulcer Advisory Panel (NPUAP) has redefined the definition of a pressure ulcer & the stages of pressure ulcers.13 Decisions related to support surfaces are made by nurses.) is contraindicated with chronic open Stage IV wounds.org CRITICALCARENURSE Vol 28. before starting continuous renal replacement therapy). No. Five random charts are being examined for practice associated with q. or seating surface that can decrease tissue interface pressure. advanced planning prevents patients in a highly unstable condition from being moved at less than optimal times. Pressure Ulcer Stages Revised by National Pressure Ulcer Advisory Panel. Click on the link above to read more. mattress. meshed grafts.htm Accessed 5/15/07 Team in collaboration with our CWOCN will keep you updated.org by guest on June 6. QUALITY FOCUS Braden Q Scores are being monitored weekly.13 The goal of a support surface is to remove localized pressure (pressure relief ) or to redistribute pressure evenly over the contact surface (pressure reduction). Instead. subacute wounds (e. Challenges include patients whose condition deteriorates too quickly to procure the best surface in time (eg. history of tape/ adherent dressings that were not removed with care. the PICU has been 100% compliant. pressure on bony prominences leads to skin impairment. Skin care education is planned for May’s staff meetings. D. dehydration. this redefinition of pressure ulcers & staging does not pose new or different practice implications at Children’s Hospital of Pittsburgh of UPMC. apply a hydrocolloid dressing to the skin and secure the Foley to the dressing. Assessment of a support surface includes determining the patient’s underlying medical condition and current medical status.

maximal turning as tolerated. F. Occasionally. For patients with multiple skin integrity problems.aacnjournals.Instructions: 1. Other Conditions (describe) Diaper Dermatitis Figure 3 Skin integrity prevalence form. Nurses on the skin care team. an overlay support surface was ordered for a solid-organ transplant recipient who had severe pain from rheumatoid arthritis. 2. and rigorous skin inspection can be offered to this patient until an appropriate support surface can be instituted safely. Complete one form for each patient with altered skin integrity. Once. Families’ requests may prevail. Ulcer Location (List only 1 ulcer per line using options in BOX F. 2. Perform a head-to-toe skin assessment for all patients on the unit. 2012 . Date: __________ Unit : ____________ Age: ______ Cost Center #: _____________ Gender: ___Male ____Female Number of patients assessed: ________ Medical Record Number: ________________ Patient’s current Braden Q score: ________ A. but her condition prevents using this procedure.org Downloaded from ccn. APRIL 2008 http://ccn. These situations are thoughtfully evaluated by the involved health care providers. Size L x W (square cm) Unable to stage 0-2 2-4 4-8 8-16 >16 0-2 D. 4. 3. 4. a patient’s family may ask that the patient be permitted to stay on a therapeutic surface for comfort when skin and wound condition no longer warrants such treatment. then the team must evaluate company delivery time in relation to the operating room admission and continuous renal replacement therapy goals. Maintenance with soft gel pillows. Pain rather than pressure redistribution was the primary indication for a support surface. This child requires a pressure redistribution support surface. If new surfaces must be rented. A patient who has undergone laryngotracheal reconstruction is expected from the operating room at 3 PM.org by guest on June 6. An oncology patient with unstable hemodynamic status is admitted to the PICU and requires emergent endotracheal intubation with eventual highfrequency oscillatory ventilation. Fax completed form(s) to X7097 WITHIN 24 HOURS OF PREVALENCE ROUNDS. CWOCNs. Influence and Future Work of the PICU Skin Care Team The skin care team had a primary role in developing the computerized 132 CRITICALCARENURSE Vol 28. Consider the following scenarios. Location) 1 2 3 4 5 6 Deep Tissue Injury (DTI) B. Complete patient & unit information on each. 2. 5. 5. Complete unit information only (see first line). Orders and charges are tracked by the CWOCNs via a computerized system. submit one form. Location 1 2 3 4 5 6 Head Elbows Upper Extremity (other) Torso Heels Lower Extremity (other) Skin Tear Chemical/Thermal Injury IV Infiltrate Surgical Wound G. Another PICU patient will be started on continuous renal replacement therapy at 1 PM. and physicians may order support surfaces. Depth (cm) 2-4 4-8 >8 E. No. Gentle education is provided to help patients and their families understand the indications for use of support surfaces. 3. Stage C. Her Braden Q score is 16.aacnjournals. The skin care team must evaluate current use of support surfaces and decide if other PICU patients can relinquish support surfaces or if new support surfaces must be rented. Where was ulcer acquired? Hospital Unit Community I II III IV 1. If there are no patients with altered skin integrity on Prevalence day. Reprinted with permission from Children’s Hospital of Pittsburgh. use additional forms if needed.

org by guest on June 6. buttocks. Generic names: Accucair Overlay. form for collection of data on skin impairment for the hospital (Figure 5). A digital camera has been purchased for the team to improve the tracking of wound healing by nurses and physicians. vibration. pressure redistribution for bariatric patients. continuous lateral rotation therapy: low air loss. mobile. APRIL 2008 133 Downloaded from ccn. antibiotics. The Advanced Burn Life-Saving course was offered to nurses at the hospital in 2006. air fluidized therapy: head elevation. which could include a combination of analgesics. Sheepskin. It is an electronic rendering of the current skin integrity prevalence form (Figure 3) and may be used in the future. PICU professional staff nurses reported that physicians’ orders did not include where to apply topical medications. http://ccn. low to floor for easy exit out of bed.aacnjournals. 2012 .Chemical paralysis/immobility with impaired gas exchange or actual pulmonary complications and/or for percussion/vibration No Yes V-Cue Total Care Sport Yes Burns or burnlike conditions Braden Q score 7-12 No Stage III and/or stage IV Braden Q score 7-15 No Limited mobility with multiple stage II and single stage III pressure ulcers Braden Q score 7-15 No Stage I or laryngotracheal reconstruction patients Braden Q score 16-20 No Low risk Braden Q score ≥21 No Patient with weight from 350-800 lb (150-350 kg) Yes Magnum II Yes Yes Yes Yes High exudating wound No Yes Full body No Clinitron CII No weight available Clinitron Rite-Hite Clinitron CII V-Cue Total Care Bed Hard Crib Flexicair Eclipse Accucair Overlay Yes Geomattress Pressure Guard II Hard Crib No Total Care Accucair Overlay Flexicair Eclipse Patient <30 lb or 15 kg Yes Pressure Guard II Geomattress. Figure 4 Algorithm for selection of support surfaces. Sheepskin Egg crate—acute care only No Daily reassessment 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 nurse and physician. In an effort to be prepared to manage patients with minor burns and burnlike skin conditions and to learn how to apply associated dressings. static alternating air: pressure redistribution. Magnum II. and so on) and is being considered for hospital-wide use. The team is working with surgical physicians to improve communication when caring for shared patients. Egg Crate. No. At any given time. Geomattress. A team member collaborated with a clinical pharmacy specialist and a clinical effectiveness specialist to develop an order set for topical medications for PICU patients. Having several PICU nurses who are certified in Advanced Burn Life-Saving is also in keeping with the hospital’s plan for disaster preparedness. rotation. Total Care. Pressure Guard II. Flexicair Eclipse. Clinitron Rite Hite. 5-zoned low-air-loss bed. 2. In 2006. This order set provides specific directions for the application of topical medications (eg. friction shear reduction. a critically ill child may have several topical medications ordered. steroids. antifungal medicines. static alternating air mattress. The skin care team currently manages mild cases of intravenous infiltration. and vasodilator ointments to promote wound healing. diaper dermatitis prescriptives. convoluted foam overlay 2-3 in (5-8 cm) in depth: prevention. Clinitron CII.aacnjournals. foam mattress overlay for infants <30 lb (<15 kg). heels. Reprinted with permission from Children’s Hospital of Pittsburgh. V-Cue. Total Care Sport. The PICU skin care team’s role with intravenous therapy is expanding. a surgical service manages severe cases. a “drop-down menu” listing face. Hard Crib. nurses on the PICU skin care team were among the first to attend. air fluidized therapy. The nurses collaborated with the hospital nurse intravenous team to lead hospital-wide education related to dressings at new intravenous cannulation sites.org CRITICALCARENURSE Vol 28. upgraded foam crib mattress: pressure redistribution. continuous airflow system. percussion. alternating air: pressure redistribution.

14 Last. weeping Figure 6 Clinical effectiveness guideline for prevention and treatment of diaper dermatitis. These records support nurses’ annual performance reviews and clinical advancement. pain.org Downloaded from ccn.aacnjournals. Reprinted with permission from Children’s Hospital of Pittsburgh. No. 2. discomfort Severe: Epidermal/dermal erosion. and Extra Protective Cream Notify unit’s skin care nurse Short gut syndrome Perineal cleanser/water and Pittsburgh Paste. A clinical effectiveness guideline for diaper dermatitis (Figure 6) is the result of a collaborative effort among CWOCNs and skin care nurses. reapply as needed • Reapply Aquaphor with each diaper change • Document skin plan of care Wet Nystatin powder* (antifungal agent) and Xenaderm ointment* (trypsin.15 Gray et al. 3M No Sting.17 Lund et al.16 Hoggarth et al.aacnjournals. 2012 . an agreement form is completed by all skin care nurses (Figure 7).5% whereas the national prevalence rate is 16% to 42%. The forms are kept on file with PICU leaders.19 Reprinted with permission from Children’s Hospital of Pittsburgh.18 and Lekan-Rutledge.org by guest on June 6. This guideline targets prevention rather than treatment. normal saline. Based on data from Agrawal and Sammeta. The hospital’s prevalence rate for diaper dermatitis for 2007 is 2. Extra Protective Cream Notify certified wound ostomy and continence nurse Mild: Blotchy erythema.14 Baharestani. balsam peru. and castor oil) Dry Nystatin ointment* (antifungal agent) Definitions of dermatitis Severe dermatitis Cleanse with normal saline and soak with Aveeno* (colloidal oatmeal 100%) twice a day or Domeboro’s* (aluminum acetate) compresses 3 times a day and Stomahesive powder (stoma adhesive protective powder). CCN No Mild dermatitis Perineal cleanser/water and Extra Protective Cream (zinc-based barrier) Diaper wipes. tenderness Moderate: Intense inflammation. * Physician’s order required. Aloe Vesta. Aquaphor* (petrolatum-based barrier ointment) or Infants >30 days old 3M No Sting (acrylate polymer film) Yes Skin intact No Yes Yes Moderate dermatitis Cleanse with water. APRIL 2008 http://ccn. mild erosion.Figure 5 Computerized form used to collect data on skin impairment. to assist with documentation of participation on the PICU skin care team and the hospital’s nurse skin care council.* (cholestyramine paste*) Yes Yeast present No Pull-through procedure Perineal cleanser/water and Ilex* (zinc-based paste) and Aquaphor* General guidelines • Do not remove Ilex. 134 CRITICALCARENURSE Vol 28.

Division of Health Policy. Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center. J Tissue Viability.4. Nurs Res. fulfill continuing education requirements). 2003:1-5.16(5):568-574. Attend the annual PICU Skin Care Team strategic planning meeting. 2008. new product trials. and medical costs. http://www. 2000. Agreement to Participate I agree to serve as a member of the PICU Skin Care Team for calendar year January 2008 thru December 2008. Kay Fischer. Nurs Res.g. 2007. Schindler. Palmer M. 1988. Bliss D. J Pediatr Nurs.org by guest on June 6. and Continence Nursing Secrets: Questions and Answers Reveal the Secrets to Successful WOC Care. http://ccn. containment devices. 3. Available online at www. d t To learn more about skin care in critically ill children. Fisher A. MSN. Curley MAQ.com//upload/static/403753 /ASWC_BreakingNews_Feb07. Sammeta V.g. Figure 7 Agreement form completed by all nurses on the skin care team. Minnesota Department of Health. eds.aacnjournals .emedicine. collect data. Bergstrom M.53(6):34-55. develop process improvement indicators). Braden Scale for predicting pressure ulcer risk. Accessed March 5. http://www.23(1):88-87.org and click “Respond to This Article” in either the full-text or PDF view of the article. Harrison MB. 2003. 2012 . Collect & fax monthly prevalence data if I round on prevalence day. Tickle S. Smith DG. Lekan-Rutledge D. Ermer-Seltun J. Published January 2008. Pediatr Crit Care Med. 7. 2001. Controlled. eLetters Now that you’ve read the article. Sprigle S. Urinary and Fecal Incontinence: Current Management Concepts. 5. and Linda Duncan in the American Journal of Critical Care. Kuhn. Gloria Lukasiewicz. Pressure sores in children: the acute hospital perspective. mortality. J Wound Ostomy Continence Nurs. 10. Dubuc DL. Actively participate in hospital Skin Care Council work (e. Ostomy Wound Manage. Anatomy and physiology of the skin. General Surgery and Dermatology). Noonan C. 2.bradenscale. Neonatal skin care: clinical outcomes of the AWHONN/NANN evidence-based clinical practice guideline. Waring M. Curley MAQ. Gray M. absorptive products. • References 1. APRIL 2008 135 Downloaded from ccn. Rossiter G. 2003. Accessed March 5. morbidity. Roberts KE. Geyer MJ. Pye H. Pasek T. Quigley SM. Evelyn M. National Pressure Ulcer Advisory Panel. Act as a positive role model and Skin Care Team ambassador to services with shared patients (e. Johnson C. 2. In: Baranoski S. 12. Assume active role with PICU Skin Care Team work (e. In: Milne CT. Write skin care summaries following weekly skin care rounds. Theresa A. Philadelphia. _________________________ _________________________ ___________ __________________________ Date __________ Date _________ 6.htm. Philadelphia. Kuller J.4(3):284-290. Appl Nurs Res.PDF. Consumer guide to adverse health events. Braden B.21(6):445-453. Just visit http://ccn. Advances in Skin and Wound Care eNews. Osborne JW. J Obstet Gynecol Neonat Nurs. Greenwood A.com/ped/topic2755 . Lane AT. Report information from these meetings to my manager and colleagues at scheduled PICU staff meetings. 2007. 19. Razmus IS. 2005. MO: Mosby Elsevier. Ming L. dren: a prevalence survey. Adhere to Children’s Hospital of Pittsburgh’s conference attendance guidelines when I attend skin-related continuing education offered outside the hospital. http://www. Ostomy. Wound Care Essentials: Practice Principles. create or contribute to an online discussion about this topic using eLetters. LQ.com/braden. Financial Disclosures None reported. 11. Print or store to folder? Critical care newsletter. Raines DA. Lott JW. Curley MA. Skin integrity in hospitalized infants and chil- 18. Baharestani MM.us/patientsafey /publications/consumerguide. Incontinenceassociated dermatitis: a consensus. Practice guidelines for the prediction and prevention of pressure ulcers: evaluating the evidence.aacnjournals. 9. Commit to provide monthly education to my colleagues. 2004:187212. Predicting pressure ulcer risk in pediatric patients: the Braden Q Scale. Cho SH. ed. Halpin-Landry J. clinical effectiveness specialist. 1996. 2006:309-339. 14. Willock J. Accessed March 5. 2007. Carnevale FA. positioning and support surfaces. 2008.pdf. 2003. Callaghan TA.34(1):45-54. Acknowledgments We are grateful to Janet Aradine.org CRITICALCARENURSE Vol 28. Accessed March 5. The effects of nurse staffing on adverse events. PA: Hanley & Belfus Inc.52:22-33. Plastic Surgery. In: Doughty DB.4(3):383-384. http://www . design data collection forms.51(12):30-42. either alone or with another PICU Skin Care Team nurse.g. Diaper dermatitis. Ketefian S. Pressure ulcers in pediatric critical care: examining the evidence. three-part trial to investigate the barrier function and skin hydration properties of six skin protectants. catheters. 17. Pressure ulcers in pediatric intensive care: incidence and associated factors. 2008. Agrawal R. NPUAP announces new pressure ulcer definition and staging.10(2):59-62. read “Skin Integrity in Critically Ill and Injured Children” by Christine A.nursingcenter. Hughes J.health. Crit Care Nurse. Seating. patient/ family education initiatives. Wells G. Wound. Wypij D. RN.state.aacnjournals. Adverse Health Events. No. Name (Please print) Signature Unit Manager signature 13. standards of care).9(1):9-17. Barkauskas VH.g. St Louis. PA: Lippincott Williams & Wilkins. 8. eds. Alexander J. 2006.org. Kennedy-Evans K.mn. 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.ajcconline. Pediatr Crit Care. 2003.30(1):41-51. Assume responsibility with my schedule to ensure I lead skin care rounds with regular frequency. Management of urinary incontinence: skin care. 15. Prince M. Quigley S. Doughty D. Brienza DM. Reprinted with permission from Children’s Hospital of Pittsburgh. 2008.52(2):71-79. An overview of neonatal and pediatric wound care knowledge and considerations. 2003. Ostomy Wound Manage. Lund CH.htm. Corbett. Published February 2007. Ayello EA. For those meetings I am unable to attend. Assume active role in skin-related PICU quality initiatives (e. Mikhailov. Hoggarth A. I will arrange to have another RN represent the PICU at the meeting. 16.