LUMPS, BUMPS AND RUMPS PEDIATRIC WOUND & SKIN CARE Shannon McCord, MS, RN, PC-PNP, CNS Director of Advanced Practice Providers & Clinical Nursing Support Services MaryAnne Lewis, BSN, RN, CWOCN Wound, Ostomy and Continence Nursing Ankhi Dutta, MD, MPH Assistant Professor Pediatric Infectious Diseases
PHYSIOLOGY: INFANTILE SKIN Weak epidermal/dermal bond Prone to skin tears Increased risk of infection Premature skin less able to prevent evaporation -fluid loss is more marked
GENERAL SKIN CARE Bath daily or QOD with neutral PH cleansers In hospital: disposable bathing products At home: Dove, Lever 2000, Cetaphil Shower wand Cross contamination: Do not re-use basin CHG bath for CVC patients Protect IV sites and tubing Caution with stomas
SKIN CONDITIONS RELATED TO OSTOMY AND CONTINENCE Dermatitis Epidermal skin injury
INCONTINENCE ASSOCIATED DIAPER DERMATITIS Wet skin: maceration, erosion, ulceration, fungus Change in acid mantle Acid mantle is vital in maintaining normal bacterial flora Friction and shear Epidermal damage and inflammation Gray, M. 2007 et.al. JWOCN, 34(2), 134
TREATMENT OF INCONTINENCE ASSOCIATED DIAPER DERMATITIS (IDD) Alleviate the cause Change diapers frequently, open to air, sunlight Decrease friction and irritating chemicals Moisture-wicking pads; limit incontinence pads/linens to one layer - reduces friction and interface pressure Cleansing Soft non-sterile wipes (Viva paper towels), barrier wipes, avoid baby wipes and products containing alcohol Cleansing foam, peri bottles & sprays may loosen stool & reduce friction/wiping of skin
DIAPER DERMATITIS TREATMENT Severe IDD EBP Guideline #2149: Cleanse Stoma powder or antifungal Protective skin barrier film Zinc or petrolatum based cream or ointment
PREVENTION & TREATMENT OF G TUBE DERMATITIS Goal is to keep skin clean, dry and protected Assess: skin, stoma, causes of intraabominal pressure (constipation, venting), tube size, adaptor size and stabilization Cleanse skin with soap and water Avoid hydrogen peroxide, alcohol and povidone - iodine and lotions/ointments No sting barrier or barrier cream/ointment Use foam dressing. Do NOT apply an occlusive gauze dressing Treat for fungal rash (2% miconazole ointment or Nystatin powder)
BASIC OSTOMY CARE AND TREATMENT DERMATITIS/CANDIDIASIS Care: Cleanse with soap and water Flat surface fill in scars with paste, avoid inguinal fold, umbilicus, scars Pattern: may need to cut wafer off center Dermatitis: Powder: stoma powder, or treat with antifungal powder if candidiasis Protective barrier film
SKIN INJURY: PERISTOMAL COMPLICATIONS Cleanse Protect and heal skin: no sting barrier, contact layer Pouch Limit pouch changes if possible Do not leave open to air as stool will cause further irritation and skin breakdown
WOUND MANAGEMENT PRINCIPLES Prevent and manage infection Cleanse wounds Debride Maintain moisture balance Eliminate Dead space Control odor Eliminate or minimize pain Protect wound and periwound
WOUND CLEANSING Goal: minimize disruption of wound surface while removing excess exudate/bacteria/debris. Normal saline is best Soap and water in home setting and for superficial wounds Avoid chemicals that inhibit granulation hydrogen peroxide, alcohol, povidone-iodine Contaminated/colonized wounds consider Dakins ¼ strength Optimal wound irrigation/cleansing: Pressure per square inch (PSI) of 8-15 Range 6-8 Normal Saline irrigation using a 35 cc syringe and 19 gauge needle will obtain this psi
Debridement WOUND MANAGEMENT PRINCIPLES Surgical Autolytic Enzymatic Mechanical: wet to dry Other modalities: Maggot therapy
DEBRIDEMENT
WOUND MANAGEMENT: MANAGE EXUDATE MOISTURE BALANCE Dry wound base & minimal exudate: Leads to desiccation and Slower Healing Dressing removal can be painful Add hydrogel or honey Use moist to moist saline gauze dressing Wet wound base & moderate/large exudate: Leads to macerated peri-wound Possible increase in wound size and Slower Healing Use absorptive dressing (alginate, hydrofiber, foam)
WOUND MANAGEMENT PRINCIPLES: ELIMINATE DEAD SPACE Pack wound to prevent fluid accumulation and abscess formation Hydro fiber ribbon or wound gel
WOUND MANAGEMENT PRINCIPLES: PROTECT WOUND Protect and maintain periwound skin integrity Avoid tape: net stretch bandage to secure dressings Picture frame with skin barrier Low adhesive, non- allergenic silicone tape Avoid latex products Non-adherent silicone dressings
A HOLISTIC APPROACH TO WOUND MANAGEMENT Pain management Consider developmental age in the plan of care engage patient in dressing change Consult Child Life Specialists Premedication for pain and anxiety Dressing selection and frequency Circulation Ambulate, compression (SCD), caution use of TED hose Increase cardiac output, anticoagulants, correct anemia Nutrition Labs: total protein, pre- albumin, Vit. C, A & Zinc Fluids prevent dehydration and edema Neuropathy lower extremities of spina bifida and diabetic patient Wear shoes, decrease pressure, change position, wheel chair evaluation
TEST YOUR KNOWLEDGE: WOUND MANAGEMENT PRINCIPLES What s you assessment What type of dressing would you use? To protect skin To provide moisture balance
TYPES OF WOUNDS Surgical Pressure Ulcer/Injury Infectious
SURGICAL WOUNDS NEGATIVE PRESSURE WOUND THERAPY (NPWT) Benefits of NPWT circulation Removes exudate Protects wound wound contraction Provides moist environment Dressing changes less pain, narcotics
NEGATIVE PRESSURE WOUND THERAPY Indications for NPWT therapy Surgical wounds dehiscence, amputation, post I& D Chronic wounds Pressure ulcers Osteomyelitis Acute wounds Fistulas Flaps/Grafts
NEGATIVE PRESSURE WOUND THERAPY FOAM DRESSING: 6 WEEKS
STERNAL WOUND: VAC
Pain: NEGATIVE PRESSURE WOUND THERAPY: SPECIAL CONSIDERATIONS Decreased dressing selection Change frequency Premedication Practical: compliance of dressing change regimen in the home and addition of nurse to assess wound in home setting
PEDIATRIC PRESSURE ULCER/INJURY PREVALENCE Location in children occipital, sacral, heels Hospitalized pediatric patients: 50% pressure ulcers are device related Non- critical 0.47%-13% Critical 20-27% Critical care & rehabilitation units 3.36 and 4.41 X more likely to acquire HAPI Complex care patients: up to 43% Adults: 9.2%-15% HAPI Risk: JWOCN Mar/Apr 2018
PRESSURE ULCERS
NEONATAL PRESSURE ULCER/INJURY RISK FACTORS Immature skin Thin, even gelatinous in very preterm May be dry in term infants Decreased epidermal-dermal cohesion Increased Trans-epidermal water loss (TEWL) Low birth weight or pre- term birth - Minimal subcutaneous tissue Neonatal Skin Condition Score Pre-term to 43 weeks PMA; Risk = >5
ASSESSING RISK OF PRESSURE ULCERS/INJURY Braden Scale 9 years to adult; Risk 18 or below Increased moisture Immobility Decreased sensory perception Friction/Shear Alteration in nutrition Braden Q 3 week to 8 years; Risk =/ > 16; Increased moisture Immobility Decreased sensory perception Friction/Shear Alteration in nutrition Alteration in tissue perfusion and oxygenation Braden Q D new 7 subscales plus medical devices
Edema RISK FACTORS IN PEDIATRIC ICU PATIENTS PRESSURE ULCERS Length of stay > 96 hours Increasing PEEP Not turned/turned by a low air loss bed Weight loss McCord, 2004
HOSPITAL ACQUIRED PRESSURE ULCER/INJURY (HAPI) VERSUS COMMUNITY ACQUIRED (POA) Community acquired: POA The presence of a pressure injury on admission to the facility as documented on the admission assessment or within 24 hours. Hospital Acquired A new pressure injury that developed after admission to the facility Development of Pressure injury: Stage 1-12-24hrs. Stage 2 in last 24 hrs. Stage 3, 4 at least 72 hrs. DTI intact purple skin - 48hrs. Blister formation - 72 hrs. ( NDNQI )
MEDICAL DEVICE RELATED PRESSURE ULCER/INJURY Localized injury to the skin or underlying tissue as a result of sustained pressure from a device Incidence rates as high as 50% Tissue injury typically mimics device shape Often seen in areas without adipose tissue
MEDICAL DEVICE RELATED INJURY PREVENTION Skin assessment upon admission, transfers, post op & 3D head to toe exams Prevention: use of pressure redistribution devices ; avoid blanket rolls Avoid use of positioning devices to reduce pressure Pad and rotate medical devices < HOB less than 30 degrees to reduce shear Turn and/or reposition patients every 1-2 hours, include head Evaluate bed surface
MUCOSAL MEMBRANE RELATED PRESSURE INJURY History of a medical device in use at the location of the injury. These ulcers are not staged.
INFECTIOUS WOUNDS
Systemic antibiotic therapy Culture draining wounds Prevent reoccurrences ABSCESS Bathing regimen to decrease colonization Bleach baths 1-2 tsp per gallon of water Dakin s solution - sodium hypochlorite ¼ strength Chlorhexidine baths Mupirocin in nares BID Do not share towels, washcloths, or razors Change underwear, clothes - wash daily in hot water
CASE STUDY 17 yr. male with H/O of stage III non-hodgkin's lymphoma ( now in remission for 3 years), poorly controlled Type II DM, BL chronic axillary ulcers 1/23/18 admitted with DKA requiring insulin drip Open wounds bilateral axilla, malodorous, moderate- heavy drainage, extremely painful Antimicrobials: multiple antibiotics over several months
HIDRADENITIS SUPPURATIVA HS, from the Greek hidros = sweat and aden = glands Usually starts between puberty and age 40 Painful chronic skin disease that develops when hair follicles become blocked and inflamed. Factors include hormones, metabolic syndrome, genetics, altered immune system Most common areas affected are intertriginous skin areas of the axillary, groin, perianal, perineal, and inframammary regions Not caused by an infection ( but can get superinfected) and not due to poor hygiene
TREATMENT BASED ON CLINICAL STAGING AND CONTROL OF CO-MORBIDITIES Stages of the Disease Stage 1 Abscess formation (single or multiple) without sinus tracts and cicatrization/scarring Stage II Recurrent abscesses with sinus tracts and scarring, single or multiple widely separated lesions Stage III Diffuse or almost diffuse involvement, or multiple interconnected sinus tracts and abscesses across the entire area Medical Management: Topical agents Oral antibiotics Hormonal therapy Immunosuppressant, and Immunomodulator therapy Wound care is crucial! Surgery for refractory cases
2018 RIGHT AXILLA February May
LEFT AXILLA 2018 February May
RIGHT AXILLA SURGICAL INTERVENTION
LEFT AXILLA SURGICAL INTERVENTION
CASE STUDY #2 3 yo. male Turkish refugee with hx. of recessive epidermolysis bullosa, failure to thrive, esophageal stricture (s/p balloon dilatation), iron deficiency anemia Hospitalized in January and again in March with MRSA bacteremia likely secondary to translocation from skin Multiple blistered/ crusted, open skin lesions on head, arms, legs, abdomen, back
Rare inherited disorders characterized by marked mechanical fragility of epithelial tissues with blistering and erosions following minor trauma Various genetic mutations associated 4 major categories based on the level of skin cleavage Common complications: Infections (Staph, GAS, GNR, Pseudomonas) Skin cancer Malnutrition and anemia EPIDERMOLYSIS BULLOSA
MANAGEMENT OF EB Skin and Wound care Prevention and treatment of infections Nutritional management **Multidisciplinary approach
CASE STUDY # 2: EPIDERMOLYSIS BULLOSA March 21 March 21 March 21
CASE STUDY #2 What would be your approach to this patient? What principles would you need to keep in mind? Cleansing Dressing Securement Patient involvement Pain management
CASE STUDY #2: EPIDERMOLYSIS BULLOSA March 27 March 28 April 3
SPECIAL CONSIDERATIONS March 28, 2018 April 3, 2018