Whatever the healthcare

Transcription

1 Need for tissue viability education for community children s nurses Whatever the healthcare setting, when treating children it is important that the care pathway is built around the child and their family to allow flexibility, responsiveness and integrated care. It is also vital to remember that services provided for children are different from those for adults (Young, 2006). Within this article, the word child will l be used as a broad term to represent esent all age groups, unless specific reference is made to a certain age group, namely: Premature: e: born before 37 weeks gestation Neonates: birth to one month Infants: one to 12 months Children: 12 months to 10 years Young people: 11 to 18 years. Suzanne Tandler, tissue viablity nurse, Worcestershire Health and Care NHS Trust Holistic wound management in children should focus on alleviating pain, reducing any emotional distress and minimising scarring (Bale and Jones, 2006) and throughout, good communication with both the child and their family is vital, as this underpins best practice in paediatric care (Bidgood and Arora, 2016). PRESSURE ULCERS Pressure ulcers predominantly occur over bony prominences such as the sacrum, heels, hips, shoulders and elbows, although can occur in other areas of the body (National Institute for Health and Care Excellence [NICE], 2014). Presentation in infants and children is more likely to occur in areas such as the occipital region or ears. Tissue damage may involve skin, subcutaneous tissue, deep fascia, muscle and bone (National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance [NPUAP/ EPUAP/PPPIA], 2014). Pressure is considered to be the major causative factor of pressure ulcers (Bhattacharya and Mishra, 2015). Blood vessels within the affected area are compressed and angulated out of their usual shape, meaning that blood is unable to flow through them normally. This restricts blood flow to the network of vascular and lymph vessels supplying oxygen and nutrients to the tissues leading to cell necrosis (Bhattacharya and Mishra, 2015). Prevalence The amount of empirical data regarding the prevalence of pressure ulcers in children is scarce. Following an extensive search of the literature, using EBSCO, CINAHL and Pubmed, the author found a limited number of studies (Baldwin, 2002; Groeneveld et al, 2004; Dixon and Ratcliff, 2005). Prevalence of pressure ulcers in the child population is predicted to be as high as 27.7% (Schluer et al, 2009). In earlier research, prevalence was estimated to be between 0.47 and 13.1% in hospitalised children, and up to 27% in intensive care units (Baharestani and Ratliff, 2007). Although it is recognised that the exact incidence of pressure ulceration is at present unknown, Ranade and Collins (2011) acknowledged that pressure ulcers in children do occur and have the potential to affect a child at any age and in any care setting Wound Care People Ltd Practice point A pressure ulcer is defined as localised damage to the skin caused by pressure, shear or a combination of these (National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance [NPUAP/ EPUAP/PPPIA], 2014). JCN 2017, Vol 31, 6 39

2 Children are vulnerable to an increased risk of pressure ulceration due to immature skin structure compared to adults. The skin, as an organ, continues to develop after birth, as outlined below (Parnham, 2012). Premature babies The skin is covered in vernix caseosa, a film covering made of water, protein and lipids which protects the skin from maceration and the development of the epidermis (White and Butcher, 2006) The stratum corneum is thinner and immature compared to fullterm babies (Jackson, 2008) Reduced, or absence of subcutaneous fat in premature babies results in the inability to regulate temperature and increases the risk of damage caused by trauma (Jackson, 2008) There is increased risk of transdermal water loss and absorption of topical products applied to the skin. Absorption is proportional to gestational age and can cause neonatal toxicity (Rutter, 1996). Neonates At birth, the skin s surface is virtually sterile. Subsequent skin colonisation may occur within two to seven days, depending on exposure to bacteria. This enables the stratum corneum to adapt and develop its barrier function (Jackson, 2008) Neonates have a reduced barrier function compared to adults, which increases absorption, infection risk and decreases skin sensitivity (White and Butcher, 2006) There is an increased risk of shear and skin stripping due to lack of fibrils ils that connect the epidermis to the dermis (White and Butcher, 2006). Infants The stratum corneum (outermost layer) is well defined, although remains thinner in comparison to adults and is therefore at increased risk of damage. Areas at risk of pressure ulcers Areas associated with pressure ulcer formation in children differ slightly to those of adults. As said, in children younger than 36 months, it is the occipital region that is at highest risk. It is the heaviest and biggest bony prominence (Baharestani and Ratliff, 2007), with less subcutaneous tissue and hair, thus increasing the risk of damage from shear due to increased head movements (Neidig et al, 1989). Other common areas at risk of pressure ulcers in children which relate to those in the adult population, include ear lobes and elbows (Groeneveld et al, 2004). Reassessment of risk is recommended if there is any change in the child or young person s condition (NICE, 2014). Following identification of risk, an appropriate care plan is advised with documentation and underpinning evidence for the interventions ntions being put in place. Children who have an increased risk of developing pressure ulcers are those in critical/intensive care units and those undergoing lengthy periods of surgery. This is mainly due to being in one position for an increased time and being immunocompromised (Wounds International, 2010). Children with orthopaedic conditions, such as external fixators or plaster casts, are at risk of device-acquired pressure ulcers, including those with exposure to prolonged use of nasal cannulae and continuous positive airway pressure (CPAP) (Murray et al, 2013). Children who have spinal injury and neurological impairment, or nutritional deficits are also at increased risk of pressure ulcer development (NICE, 2014). Generally, the same risk factors that apply to the adult population are applicable to children, although consideration should be given to differences in structure and fragility of the skin (Ranade and Collins, 2011). Risk assessment Healthcare professionals in the author s local trust use an approved children s pressure ulcer risk and intervention plan assessment tool, which has been selected by the Worcestershire Health and Care Trust (WHCT) paediatric team (WHCT, 2013). This tool is recommended to be undertaken on all children admitted onto the caseload, with regular reassessments depending ding upon circumstances. At a minimum, this is identified d as six monthly, or if there is any change in the child s condition. Also, the nationally rolled out SSKIN care bundle (NHS Midlands and East, 2012) is incorporated into the intervention plan. The implementation of the care bundle in the delivery of fundamental care in practice is recognised as an effective way of providing consistency in the provision of pressure ulcer preventative care (Ellis, 2016). Reassessment of risk is recommended if there is any change in the child or young person s condition (NICE, 2014). Following identification of risk, an appropriate care plan is advised with documentation and underpinning evidence for the interventions being put in place. und Care People Ltd WOUND ASSESSMENT AND MANAGEMENT Following the birth of a fullterm baby, the skin is only 60% thick in terms of the dermal and epidermal layers, in comparison to adult skin (Campbell and Practice point Children and their parents should be involved in their care. Thus, they need to be given accurate information so that they can understand the treatment options available (Department of Health [DH], 2003). Their views should always be considered. 40 JCN 2017, Vol 31, 6

3 Banta-Wright, 2000). The way in which wounds in children heal is comparative to adults, although due to the immaturity of the skin and its functional ability, wound management calls for increased caution from clinicians (Wounds UK, 2014). The types of wounds encountered in children tend to be traumatic wounds from lacerations, burns and road traffic accidents (Wounds UK, 2014). Chronic wounds/conditions experienced include pressure ulcers (including device-related), and epidermolysis bullosa (Wounds UK, 2014). Baharestani and Ratliff (2007) and King et al (2014) highlighted that, despite advances, the knowledge and evidence base for the management of wound care in children remains far behind its adult counterpart. Literature highlights the need for healthcare professionals to choose the most appropriate dressing to (Bahrestani and Ratliff, 2007): Encourage healing Reduce the risk of infection Minimise pain experienced. It is also important to consider a dressing s absorbent capacity and the patient s tolerance of adhesives, as dressings have been traditionally trialled on the adult population (Baharestani and Ratliff, 2007). As with adults, healthcare professionals need to ensure that dressing selection is done in relation to wound type, location, tissue type and that a moist wound healing environment is achieved (Campbell and Banta-Wright, 2000). PROVISION OF EDUCATION Evidence-based tissue viability is the responsibility of all healthcare professionals irrespective of the age group of the patient, whether preventing damage to the skin or treating a complex wound (Stephen-Haynes, 2013). However, as said, paediatric wound care lacks a comprehensive evidence base. Ashton and Price (2006) in a cross-sectional questionnaire emphasised that knowledge was Wou 32.14% 67.86% Figure 1. often sourced from colleagues and personal experience, with journals and courses preferred by specialist clinicians. Clinicians have a professional responsibility to ensure that they have the appropriate knowledge, skills and competency to carry out any specific duty/role (Nursing and Midwifery Council [NMC], 2015). Similarly, employers need to ensure that they provide adequate training and education to support safe and effective practice (NHS England, 2013). The author s trust thus decided to evaluate healthcare professionals knowledge and competence of paediatric wound care within the trust. As the author was newly appointed as TVN to the trust and had an interest in tissue viability in relation to children she undertook this task, which was also supported by the focus on achieving high quality care and experience for patients and building on compassion in practice (NHS England, 2016). Survey method An online survey was conducted to identify areas of educational need in relation to tissue viability. The survey was sent to 40 healthcare professionals who work within children s services to find out whether they felt confident and competent in the delivery of fundamental aspects of tissue viability. The survey covered: 6pR % 57.14% Figure 2. Ltd und Care People Ltd Ltd Pressure ulcer staging Completion of the approved children s pressure ulcer risk and intervention plan assessment tool Attendance to pressure ulcer prevention training Selection of advanced dressings from the local wound management formulary Completion of wound assessment and management documentation Attendance to wound management training. Survey results The response rate of the survey was 28 out of 40 (70%). From the clinicians who completed the survey, 18 (64%) were community children s nurses, five (17%) special school nurses, three (11%) residential short-break registered nurses and two (7%) residential shortbreak healthcare assistants. JCN 41

4 % 4.00% Figure 3. Do you feel confident and competent in the staging of pressure ulcers % 12.50% Figure 4. Do you feel confident and competent in the selection of dressings appropriate to wound type/classification from the wound management formulary. The survey illustrated that 68% of staff did not feel confident or competent in the staging of pressure ulcers using guidance from the EPUAP/NPUAP/PPPIA P/NPUAP/PPPI guidelines (Figure 1) ) (EPUAP/ NPUAP/PPPIA, PPPIA, 2014). While 43% of clinicians ns had attended a pressure ulcer update within months, 36% had never attended one to date. Although 70% said that they undertook a risk assessment for each child on their caseload, 57% said that they lacked confidence and did not feel competent in the selection of dressings appropriate to wound type from their local wound management formulary (Figure 2). However, 54% felt confident in completing wound assessment documentation, and 50% had attended a wound assessment and management update within months; 25% had never attended such an update. All survey questions were devised to identify clinician s educational need with regard to tissue viability. Following the implementation of a bespoke educational conference aimed at providing staff with an update on all key areas highlighted by the first survey, a second survey was undertaken to review the impact of the event. Of the 25 clinicians that completed the second survey, 24 (96%) felt confident/competent in the staging of pressure ulcers (Figure 3), and 19 (79%) completed a risk assessment. Twenty-one (88%) felt confident/competent in the selection of dressings appropriate to wound type/classification from the wound management formulary ry (Figure 4), and similarly, 21 (88%) felt competent/confident in the completion of the WHCT wound assessment documentation. n. DISCUSSION The majority of pressure ulcers are considered to be preventable. Despite the lack of empirical data, risk factors for pressure ulcer formation in children are comparable to adults however, the anatomical areas affected and skin structure differ. In the author s clinical opinion, this highlights the need for a different approach to assessment, treatment and management of pressure ulceration in children. The survey undertaken at the author s trust found that an alarming 68% of clinicians did not feel confident/competent in the staging of pressure ulcers. While 70% completed a pressure ulcer skin assessment intervention plan for each child, in the author s clinical opinion, the percentage should be 100%, as the reduction of avoidable pressure ulcers is a key national government target (NICE, 2014). It is therefore imperative that healthcare professionals are competent in the effective assessment of risk, prevention, treatment and management of pressure damage. As said, healthcare professionals should be accountable for ensuring that they have knowledge, skills and competency (NMC, 2015), yet 36% of clinicians in the survey had never attended a pressure ulcer risk assessment update. The implementation of a bespoke tissue viability conference resulted in an increase in the competency of clinicians in the staging of pressure ulcers from 68 to 96%. CONCLUSION The need for tissue viability education for clinicians who work with children was highlighted by the use of an online survey at the author s trust. This was followed by the implementation of a bespoke educational conference after which a second survey was carried out. Following the implementation of the conference an increase was seen in the competency and confidence of clinicians in the prevention, staging and assessment of pressure ulcers, as well as the assessment and management of wounds. An altered approach is required in the prevention of pressure ulcers in children due to difference in skin structure compared to adults, and healthcare professionals need to ensure that they have the knowledge and competence to provide care in relation to tissue viability, with employers providing appropriate education and training. JCN REFERENCES Ashton J, Price P (2006) Survey comparing clinicians wound healing knowledge and practice. Br J Nurs S Wound Care People Ltd Ltd Baharestani M, Ratliff CR (2007) Pressure ulcers in neonates and children: An NPUAP white paper. Adv Skin wound Care Baldwin KM (2002) Incidence and prevalence of pressure ulcers in children. Adv Skin Wound Care Remember... Parents are often the experts in their own child s care (Young, 2006). 42 JCN 2017, Vol 31, 6

5 Bale S, Jones V (2006) Wound Care Nursing. A patient-centred approach. Elsevier, London Bhattacharya S, Mishra RK (2015) Pressure ulcers: current understanding and newer modalities of treatment. Ind J Plast Surg 4 16 Bidgood S, Arora L (2016) Best practice in prescribing for paediatric food allergy. Nurse Prescribing Campbell JM, Banta-Wright SA (2000) Neonatal skin disorders: a review of selected dermatologic abnormalities. J Perinat Neonat Nurs Department of Health (2003) Getting the right start: national service framework for children, standard for hospital services. DH, London Dixon M, Ratliff C (2005) Pediatric pressure ulcer prevalence one hospital s experience. Ostomy Wound Management 44 6, Ellis M (2016) Understanding the latest guidance on pressure ulcer prevention. J Community Nurs Groeneveld A, Anderson M, Allen S, et al (2004) The prevalence of pressure ulcers in a tertiary care pediatric and adult hospital. 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