Pressure Ulcers in Neonatal Patients

Pressure Ulcers in Neonatal Patients
Rene Amaya, MD
Pediatric Specialists of Houston –
Infectious Disease/Wound Care
Objectives
 Review skin anatomy and understand why neonatal
skin is at increased risk for injury
 Define pressure ulcers and review the stages of
pressure ulcers in neonates
 Explain the serious legal nature of pressure ulcers and
how they are a recognized “Never Event”
 Examine current staging tools used to screen patients
for pressure ulcer development.
 Explain which factors among neonates place them at
risk for pressure ulcer development
 Address the potential for development of a neonatal
skin care teams
Functions of Skin
 Provides physical barrier to protect
underlying tissue and organs.
 Provides a key role in immune system
 Involved in temperature regulation
 Key role in sensory perception
Neonatal Skin vs Mature skin
Some critical differences
Structural differences
increase risk of trauma and infection
Neonatal Skin Differences
Epidermis
Fibrils
• Fibrils connect the
epidermis and dermis
• More widely spaced and
fewer in neonates than in
mature skin
• Diminished cohesion leaves
the neonate more susceptible
to injury from shear and
pressure forces
Dermis
Neonatal Skin Differences
 Stratum Corneum is
thinner in neonates
especially premature
infants
 Increases susceptibility to
infections and topical
agents
 Also predisposes to
excessive evaporative
heat and fluid loss
Stratum Corneum
Neonatal Skin Differences
 Dermis of newborn is
60% thinner than
than that of mature
skin
 Deficient in collagen
 Increases risk for
injury to underlying
tissues
Dermis
So what is a
pressure ulcer?
I thought these only
arose in the
elderly?
Definition
A pressure ulcer is localized injury to the skin and/or
underlying tissue usually over a bony prominence, as a result
of pressure, or pressure in combination with shear.
A number of contributing or confounding factors are also
associated with pressure ulcers – moisture, nutrition, tissue
perfusion, mobility and activity.
Tissue
Injury
Incidence and Prevalence
 The literature on the incidence and prevalence of
neonatal pressure ulcers remains limited.
 From pediatric data that does exist, most of the
studies have focused on populations considered
high-risk for pressure ulcers: NICU, PICU and Pedi
cardiac.
 Most available studies cite an incidence rate
ranging from 5% to 23% in neonatal patients.
 Regardless of the incidence, the goal should be
zero
Staging of Pressure Ulcers
Stage I
Stage II
Stage III
Stage IV
Suspected Deep Tissue Injury
Unstageable
Staging of Pressure Ulcers
 The staging of pressure ulcers as
defined by national guidelines
(NPUAP, CMS) allows for uniform
documentation and classification of
pressure ulcers by healthcare
professionals
 The staging of pressure ulcers reflects
the amount of tissue damage
Stage I: Non-blanchable erythema
 Intact skin with non-blanchable
redness of a localized area usually
over a bony prominence.
 Darkly pigmented skin may not
have visible blanching; its
color may differ from the
surrounding area.
 The area may be painful, firm, soft,
warmer or cooler as compared to
adjacent tissue.
 Category I may be difficult to
detect in individuals with dark skin
tones.
 May indicate “at risk” persons.
Stage II: Partial thickness
 Partial thickness loss of dermis
presenting as a shallow open
ulcer with a red pink wound
bed, without slough.
 May also present as an intact or
open/ruptured serum-filled or
sero-sanginous filled blister.
 Presents as a shiny or dry
shallow ulcer without slough or
bruising*. *Bruising indicates
deep tissue injury.
 This category should not be used
to describe skin tears, tape
burns, incontinence associated
dermatitis, maceration
or excoriation.
Stage III: Full thickness skin loss
 Full thickness tissue loss.
 Subcutaneous fat may be
visible but bone, tendon
or muscle are not
exposed.
 Slough may be present
but does not obscure the
depth of tissue loss.
 May include undermining
and tunneling.
 Bone/tendon is not visible
or directly palpable.
Stage IV: Full thickness tissue loss
 Full thickness tissue loss
with exposed bone,
tendon or muscle.
 Slough or eschar may be
present.
 Often includes
undermining and
tunneling.
 Category/Stage IV ulcers
can extend into muscle
and/or supporting
structures (e.g., fascia,
tendon or joint capsule)
making osteomyelitis
likely to occur.
Unstageable: Full thickness skin or tissue loss
– depth unknown
 Full thickness tissue loss in
which actual depth of
the ulcer is
completely obscured by
slough (yellow, tan, gray,
green or brown) and/or
eschar (tan, brown or
black) in the wound bed.
 Until enough slough
and/or eschar are
removed to expose the
base of the wound, the
true depth cannot be
determined; but it will
be either a
Category/Stage III or IV.
Suspected Deep Tissue Injury –
depth unknown
 Purple or maroon localized area of
discolored intact skin or bloodfilled blister due to damage of
underlying soft tissue from pressure
and/or shear.
 The area may be preceded by
tissue that is painful, firm, mushy,
boggy, warmer or cooler as
compared to adjacent tissue.
 Deep tissue injury may be difficult
to detect in individuals with dark
skin tones.
 Evolution may include a thin blister
over a dark wound bed. The
wound may further evolve and
become covered by thin eschar.
 Evolution may be rapid exposing
additional layers of tissue even
with optimal treatment.
Pressure Ulcers and
CMS/Medicare
 Pressure ulcers have
been classified as a NEVER-EVENT by
CMS
 Never-Events are defined as hospital associated problems
that can be prevented.
 Other examples of Never-Events include surgery on wrong
patient, surgery on wrong limb, foreign object left in pt
after surgery, infant discharged to the wrong person, ….
 Never-Events will NOT be reimbursed by insurance
 Never-Events must be reported and can lead to mistrust
by public.
Why bring a Decubitus Ulcer Lawsuit? It’s about exposing patient
neglect. Decubitus ulcers (or pressure sores) are preventable by good
care. Unfortunately, it is the most vulnerable patients who cannot
complain about the negligent care they receive. This is known as
nursing home abuse or hospital patient neglect. Patients get neglected
when nurses are understaffed and overworked. When nurses are too
busy, they ignore the most vulnerable patients, who in turn develop
bedsores. Because pressure sores are so preventable, decubitus
ulcer lawsuits may be valued in the hundreds of thousands of dollars.
Skin Assessment Scales
The key to keeping neonatal
pressure ulcer rates low lies in
reliable skin assessment scales
and identification of risk factors
associated with ulcer
development.
Skin Assessment Scales
 Skin assessment scales are tools that can be used to
identify patients at risk for pressure ulcers.
 Unfortunately, many of the recognized risk factors are not
captured by skin assessment scales.
 Nonetheless, NICU personnel should adopt and utilize
these tools to identify babies at risk early and this prevent
an ulcer from developing.
 Three pediatric skin assessment tools that have been
validated include the Braden Q Scale, Glamorgan Q
scale and the Neonatal Skin Risk Assessment Scale
(NSRAS).
Neonatal Skin Risk Assessment Scale
(NSRAS)
NSRAS
 NSRAS modeled after the Braden Scale, measures 6
subscales pertinent to neonates
 Reliability and validity testing of the NSRAS was performed
with 32 NICU patients (26-40 weeks of gestation)
 Using a cutoff score of 5, the sensitivity and specificity of
NSRAS was 83% and 81% respectively.
 Limitations of the NSRAS scale includes a small sample size,
the need for further clarification in subscales’ operational
definitions, and improved reliability.
NSRAS
Gestational Age
Mental Status
Mobility
Activity
Nutrition
Moisture
NSRAS
 Gestational Age
 < 28 weeks ………. > 38 weeks posterm
 Mental Status
 Unresponsive even to pain……… Alert and Active
 Mobility
 Completely immobile ….. Major changes in
position w/o assistance
NSRAS
 Activity
 Isolette under Saran wrap……………………….….Open Crib
 Nutrition
 NPO/TPN ………................... Bottle/Breast feeds every meal
 Moisture
 Skin constantly wet ………………………… Mostly dry/q24 hr
bedding change
NSRAS
A score of >13 should prompt the unit to monitor
carefully for signs of a pressure ulcer.
Initiatives to reduce the risk for acquiring a pressure
ulcer should to be started.
Risk factors for Neonatal Pressure Ulcers
 Identifying babies at risk for pressure ulcers is the key to their
prevention
 Among neonates and children, 50% of pressure ulcers are
equipment and device related (nasal prongs, CPAP masks,
tubing, lines, tracheostomy devices, O2 monitors and
bedding)
 Acutely ill and immobilized neonates are at high risk for
pressure injuries. Such patients are often nutritionally
challenged which directly affects skin integrity.
 Extremely premature infants less than 32 weeks
Risk Factors - Bedding
Risk Factors - Bedding
Risk Factors - Devices
Risk Factors - Devices
Risk Factors - Devices
Risk Factors - Devices
Risk Factors - Edema
Risk Factors – Extreme Preemie
Risk Factors – Hydrocephalus
Risk Factors - Hydrocephalous
NICU Pressure Ulcer Prevention
Team
 The goal of each institution is to reduce the incidence of
stage 2-4 pressure ulcers in neonates to 0%
 One intervention which has resulted in good success is the
creation of a Pressure Ulcer Prevention Team “PUP”
 Multidisciplinary teams composed of nursing staff,
respiratory care, nutrition specialists, NNP/Physicians whose
role includes frequent assessment with rounding and data
collection.
 Function to provide education, identify babies at risk and
initiate interventions to prevent PU from developing.
NICU Pressure Ulcer Prevention
Team
 Would provide proper reporting, staging and
documentation of pressure injuries
 Analyze trends to determine if a change in
equipment, bedding or procedures is necessary to
prevent additional PU from developing.
 Ensure that proper wound care intervention is
initiated if WC team is not available in the facility.
Summary
 Neonatal skin has unique properties which increase the
risk for trauma and injury
 Pressure ulcers arise on susceptible areas of the body due
to combination of pressure, moisture, immobility, shear
forces as well as direct injury from medical devices.
 Pressure ulcers are classified as Grades1-4 and also
include Unstagable and Suspected Deep Tissue Injury
 Pressure ulcers may have significant legal implications
that directly affect nurses and are considered a “Never
Event” by CMS/Medicare.
Summary
 Identifying babies at risk using various skin
assessment tools such as NSRAS can determine
which babies require close observation and
monitoring.
 Creating a multidisciplinary team to prevent
pressure ulcers from developing is one way
neonatal ICU’s lower rates to ZERO!
Thank You!
Dr. Rene Amaya
713-464-9776