Pressure ulcers are due to compression of the skin over a bony area which compromises the blood supply to cells with resulting tissue injury and ulcer formation.

Not only is this a physical concern, but the psychological needs of the young client is a component of care. Youth are particularly concerned with appearance, and skin breakdown causes an altered body image, leading to anxiety or depression. They may also be concerned that their overall health is deteriorating.

 
Risk factors are well known (e.g., edema, immobility, poor nutrition), but even mildly paraplegic or partially insensate persons have a high rate of breakdown. Those at higher risk also have very dry skin, history of atopic conditions, or skin wet from secretions or diapers. Shear injury is a risk related to immobility when a child cannot reposition himself or cannot be easily turned- the skin is stationary but underlying tissue shifts. The result is reduced blood supply to the skin.

The Braden Scale for early identification of relative risk for pressure ulcers has six components: sensory perception, skin moisture, activity, mobility, friction and shear, and nutritional status. It is less helpful for assessing children so a modified version (Braden Q Scale) is being evaluated.

Daily care includes inspection of all bony prominences, especially the coccyx, occiput, and heels for areas that are blanched, red, or blistered. Pressure ulcers are staged (National Pressure Ulcer Advisory Panel, 1992) as follows: I (nonblanchable redness of intact skin); II (superficial abrasion, blister or shallow crater); III (full thickness skin loss including subcutaneous tissue but not into the facsia); and IV (extensive damage to tissue and possibly muscle, bone, tendons or joint capsules).
A model nursing care plan was offered with the case study with multiple goals addressing skin integrity: accurate assessment, family and child knowledge about skin care, control of moisture and irritants, positioning, nutrition, body image, and hopeful outlook related to the primary condition.

(Pallija G et al. Skin care of the pediatric patient. J Pediatr Nurs 1999;14(2):80-87)

Comment: For the school care plan, teachers cannot assume that skin breakdown is the responsibility of the parent, nurse and therapists. Frequent observation for signs of pressure and prevention-minded positioning are critical. The child's body image and psychological aspects of skin breakdown are important features of an Individual Healthcare Plan for school. -J.O.