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Pediatric Skin Care Management Protocol

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Pediatric Skin Care Management Protocol

Protocol and Procedures Page 1 of 10

    ________________________________________________________________________ SKIN CARE MANAGEMENT, Management of the Pediatric Patient Requiring…

    Key Words: wound, pressure ulcer, skin care, preventive skin care, specialty bed, overlay.

1. Indications for Use

    1.1. This protocol applies to all pediatric patients except NICU patients.

    1.1.1. For NICU patients, see: Skin Care Management of the NICU Patient

    http://dermatlas.med.jhmi.edu/ppp/NEONATAL%20INTENSIVE%20CARE%2FNI

    CU%20SKIN%203%2D02%2Edoc

2. Responsibility

    2.1. The RN is responsible for:

    2.1.1 Skin Assessment including Braden Q Score on admission and daily (See

     Appendix A).

     2.1.1.1 Assessments and Braden Scores should be completed each shift for

    patients with scores < 22.

    2.1.1. Writing a nursing order for topical protectants, as appropriate, to be used in a

    preventative manner. Refer to Medication Administration Policy for

    guidelines. (See Also Appendix B).

    2.1.2. Ordering a pressure-reducing device as appropriate (See Appendix C).

    2.1.3. Notifying Pediatric Wound Care Specialist (Beeper - #4-WUND or #4 9863)

    of any patients requiring in depth assessment or specialized products.

    2.1.4. Obtaining Nurse Manager Approval for rental beds as appropriate (See

    Specialty Overlay/Bed Protocol).

    http://www.insidehopkinsmedicine.org/nursing/cnp/bed_poster.pdf

    2.2. The authorized prescriber is responsible for:

    2.2.1. Writing orders for appropriate skin care or wound management products not

    available with a nursing order.

    2.2.2. Writing orders for any Specialty beds or overlays that are rental products and

    not available with a nursing order.

    2.2.2.1. An order to discontinue the rental product must be written if the product

    is discontinued prior to discharge.

    2.3. The Wound Care Specialist is responsible for:

    2.3.1. Consultation for skin and wounds that have not improved after

    implementation of the protocol(s).

    2.3.2. Consultation and management of any stage III-IV wounds, fistulas, or other

    complex wounds.

    2.3.3. Approval of requests for Specialty Beds, as appropriate.

    2.3.4. Recommendations for wound care and general skin care management issues

    as requested by medical or nursing staff.

3. Patient Care Management

    3.1. Assessment

Original: August 2003 Approved Department of Pediatrics

    Revised: Aug 2004, April, 2007 The Johns Hopkins Hospital

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Protocol and Procedures Page 2 of 10

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    3.1.1. Assess patients on admission and daily using the Braden Q Risk Assessment

    Scale and other criteria outlined in this protocol.

    3.1.1.1. The Braden Q scale is a method of determining a pediatric patient’s

    risk for skin breakdown/development of pressure ulcers. Lower scores

    indicate higher risk.

    3.1.1.2. Assess the patient’s risk for skin breakdown in terms of:

    ? Mobility (ability to change and control body position)

    ? Activity (degree of physical activity)

    ? Sensory perception (ability to respond in a developmentally

    appropriate way to pressure-related discomfort)

    ? Moisture (degree to which skin is exposed to moisture)

    ? Friction-Shear (adverse response to exposure of skin to support

    surfaces, either movement against surface or sliding across surface)

    ? Nutrition (usual food intake pattern)

    ? Tissue Perfusion and Oxygenation

    3.1.2. Patient should also be assessed for the presence of:

    3.1.2.1. Intactness of skin

    3.1.2.1.1. For non-intact skin including pressure ulcers or dehisced wounds,

    implement the Wound Care Protocol

    http://www.insidehopkinsmedicine.org/nursing/cnp/398wound.html

    3.1.2.2. Presence or history of Spina Bifida

    3.1.2.2.1. Implement Pediatric Spina Bifida Protocol

    http://dermatlas.med.jhmi.edu/ppp/PEDS%20GENERAL%20CARE%2FPED

    S%20Spina%20Bifida%20Protocol%205%2D99%2Edoc

3.2. Interventions

    3.2.1. Provide Skin Care Interventions as indicated in Appendix C.

    3.1.1.1 Other products and interventions may be availablecontact wound

    care specialists if above interventions are insufficient.

    3.1.2 Provide pt/family/caregiver education on skin care as appropriate.

    4 Reportable Conditions

4.1 Notify authorized prescriber of :

    4.1.1 Changes in condition of skin including:

    4.1.1.1 Non-blanchable erythema over pressure points.

    4.1.1.2 Signs of skin breakdown.

    4.1.1.3 If any ulceration develops.

    4.1.1.4 Change in suture line integrity, drainage, or erythema in post-

    operative patients.

5 Documentation

Original: August 2003 Approved Department of Pediatrics

    Revised: Aug 2004, April, 2007 The Johns Hopkins Hospital

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Protocol and Procedures Page 3 of 10

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    5.1 Braden Q Risk Assessment score on nursing daily flowsheet or in Eclipsys in

    ICU at least daily or more frequently, as appropriate.

    5.2 Use of pressure reducing products on nursing daily flowsheet or in Eclipsys in

    ICU.

    5.3 Turning schedule on nursing daily flowsheet or in Eclipsys in ICU.

    5.4 Patient/family teaching on Patient Teaching Plan.

6 See also:

    6.1 Management of Patients Requiring Wound Care.

    6.2 Use of Pressure Relieving/Reducing Specialty Overlay/Bed.

    6.3 Pediatric Spina Bifida Protocol

7. References

    Ball, J. and Bindler, R. (1999). Spina Bifida. Pediatric Nursing. (2nd edition). Appleton

     and Lang, 785-788.

    Curley M.A., Quigley, S. M., & Lin, M. (2003). Pressure ulcers in pediatric intensive

     care: Incidence and associated factors. Pediatric Critical Care Medicine, 4(3). 284-290.

    Quigley, S. M. and Curley, M.A.Q. (1996). ―Skin Integrity in the Pediatric Population:

     Preventing and Managing Pressure Ulcers.‖ JSPN. Vol. 1, No. 1. April-June, pp. 7- 18.

    U.S. Department of Health and Human Services (AHCPR #95-0652), December, 1994.

     Treatment of Pressure Ulcers. Clinical Practice Guidelines, Num. 15.

    thWong. (2003). Nursing Care of Infants and Children. (7 edition). Mosby, 1121- 1127.

8. Reviewed By:

    Kim McIltrot RN, BSN, MSN Pediatric Wound Care Specialist

    Cathy Garger RN, BSN Pediatric Standards of Care

Original: August 2003 Approved Department of Pediatrics

    Revised: Aug 2004, April, 2007 The Johns Hopkins Hospital

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Protocol and Procedures Page 4 of 10

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    Appendix A

    The Braden Q Scale Quigley, S.M. & Curley, M.A.Q. (1996). Skin integrity in the pediatric population: Preventing and managing pressure ulcers. Journal of the Society of Pediatric Nursing , 1, 7-18.

    Intensity and Duration of Pressure Score

     1. Completely immobile: 2. Very Limited: 3. Slightly Limited: 4. No Limitations: Mobility Does not make even slight Makes occasional slight changes Makes frequent though slight Makes major and frequent The ability to change or changes in body or in body or extremity position but changes in body or extremity changes in position without control body position extremity position without unable to completely turn self position independently. assistance. assistance. independently. 4. All patients too young to 2. Chair fast: 1. Bedfast: 3. Walks Occasionally: ambulate OR walks Confined to bed Ability to walk severely limited Walks occasionally during day, Activity frequently: Walks outside the or nonexistent. Cannot bear own but for very short distances, with The degree of physical room at least twice a day and weight and/or must be assisted in or without assistance. Spends activity inside room at least once every to chair or wheelchair. majority of each shift in bed or 2 hours during waking hours. chair. Sensory Perception 1. Completely Limited: 2. Very Limited: 3. Slightly Limited: 4. No Impairment: The ability to respond in Unresponsive (does not Responds only to painful stimuli. Responds to verbal commands, Responds to verbal commands. a developmentally moan, flinch, or grasp) to Cannot communicate discomfort but cannot always communicate Has no sensory deficit, which appropriate way to painful stimuli, due to except by moaning or restlessness discomfort or need to be turned limits ability to feel or pressure-related diminished level of OR has sensory impairment OR has some sensory impairment communicate pain or discomfort consciousness or sedation which limits the ability to feel which limits ability to feel pain or discomfort. OR limited ability to feel pain or discomfort over ? of discomfort in 1 or 2 extremities. pain over most of body body. surface.

    Tolerance of the Skin and Supporting Structure 1. Constantly Moist: 2. Very Moist: 3. Occasionally Moist: 4. Rarely Moist: Moisture Skin is moist almost Skin is often, but not always Skin is occasionally moist, Skin is usually dry, Degree to which skin is constantly by perspiration, moist. Linen must be changed at requiring linen change every 12 routine diaper changes, exposed to moisture urine, drainage, etc. least every 8 hours. hours. linen only requires changing Dampness is detected every every 24 hours. time patient is moved or turned. 1. Significant Problem: Friction - Shear 2. Problem: 3. Potential Problem: 4. No Apparent Problem: Friction: occurs when Spasticity, contracture, Requires moderate to maximum Moves feebly or requires Able to completely lift skin moves against itching or agitation leads to assistance in moving. Complete minimum assistance. During a during a position change; support surfaces almost constant thrashing lifting without sliding against move skin slides to some extent Moves independently and has Shear: occurs when skin and friction. sheets is impossible. Frequently against sheets, chair, restraints, or sufficient muscle strength to and adjacent bony surface slides down in bed or chair, other devices. Maintains good lift up completely during slide across one another requiring frequent repositioning position in chair or bed most of move. Maintains good with maximum assistance. the time but occasionally slides position in bed or chair at all down. times. 1. Very Poor: 2. Inadequate: 3. Adequate: 4. Excellent: NPO and/or maintained on Is on liquid diet or tube Is on tube feedings or TPN, which Is on a normal diet providing clear liquids, or IVs for feedings/TPN which provide provide adequate calories and adequate calories for age. For Nutrition more than 5 days OR inadequate calories and minerals minerals for age OR eats over example: eats/drinks most of Usual food intake pattern Albumin <2.5 mg/dl OR for age OR Albumin <3 mg/dl half of most meals. Eats a total of every meal/feeding. Never Never eats a complete meal. OR rarely eats a complete meal 4 servings of protein (meat, dairy refuses a meal. Usually eats a Rarely eats more than ? of and generally eats only about ? products) each day. Occasionally total of 4 or more servings of any food offered. Protein of any food offered. Protein will refuse a meal, but will meat and diary products. intake is only 2 servings of intake includes only 3 servings of usually take a supplement if Occasionally eats between meat or dairy products per meat or dairy products per day. offered. meals. Does not require day. Takes fluids poorly. Occasionally will take a dietary supplementation. Does not take a liquid supplement. dietary supplement. 1. Extremely 2. Compromised: 3. Adequate: 4. Excellent: Tissue Perfusion and Normotensive; Normotensive; Normotensive, Compromised: Oxygenation Hypotensive (MAP Oxygen saturation may be <95 % Oxygen saturation may be <95 % Oxygen saturation >95%; <50mmHg; <40 in a OR hemoglobin may be < 10 OR hemoglobin may be < 10 Normal Hemoglobin ; & newborn) OR the patient mg/dl OR capillary refill may mg/dl OR capillary refill may Capillary refill < 2 seconds. does not physiologically be > 2 seconds; be > 2 seconds; tolerate position changes. Serum pH is < 7.40. Serum pH is normal. Total:

Original: August 2003 Approved Department of Pediatrics

    Revised: Aug 2004, April, 2007 The Johns Hopkins Hospital

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Protocol and Procedures Page 5 of 10

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    Appendix B

    Alphabetical List of Skin Care Products

    NOTE: Items from PMM# can be ordered at any time, items from Pharmacy will require Nursing or

    Physician order. (4/07)

    Item Size Source/ESI # Comments

    A & D Ointment Foil pack PMM# #5849 RN Order Accuzyme 30 gr tube Pharmacy MD Order

    Nonformulary form

    required Acticoat 4 X 4 PMM #20101

     4 X 8 PMM #20201

     8 X 16 PMM #20301

     16 X 16 PMM #20401

     4 X 48 PMM #20501 Adaptic 3 X 3 PMM # 1696 Adaptic 3 X 3 (3 pieces/pkg) PMM #6198 Air Shoe Boot One Size PMM #23726

     Liner PMM #23727 Alginate Kaltostat Rope packing (5/box) PMM #25499 Alginate Kaltostat Sheet 3 X 4 (10/box) PMM #25506 Baby Lotion (J & J) 1 oz PMM #35088 Baby Shampoo 1 oz PMM #3949 Baby Bath 1 oz PMM #24305 Bacitracin 15 gm tube Pharmacy MD Order Bactroban 15 gm tube Pharmacy MD Order Butt Paste Pharmacy compound Pharmacy MD Order Cloropactin 2 gms to be mixed in 1 L Pharmacy MD Order Coloplast Critic Pharmacy Aid clear ointment

    Coloplast Critic Pharmacy Aid clear AF

    ointment

    Coloplast Gentle PMM #87134 Rain

    Coloplast Bedside PMM # 87137 Care Foam

    Coloplast Extra Care PMM # 87139 Lotion

    Coloplast Sween PMM # 87140

    24 Cream

    Comfort Bath Disposable washcloths PMM #2288 Comfort Shampoo in Disposable cap PMM #27121 a Cap

    Comfort Shield Perineal care disposable PMM #27120

    washcloths

Original: August 2003 Approved Department of Pediatrics

    Revised: Aug 2004, April, 2007 The Johns Hopkins Hospital

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Protocol and Procedures Page 6 of 10

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    Appendix B (con’t)

    Alphabetical List of Skin Care Products Item Size Source/ESI # Comments Condom catheter Convatec Perineal/ PMM # 6070 Skin Cleanser

    Dense Foam 5 inch depth 18 X 18‖ PMM # 38566 May substitute for Cushion eggcrate but only for

    small areas Desitin Pharmacy RN Order Duoderm regular 4 X 4 box of 5 dressings PMM #2108 CGF

    Duoderm regular 6 X 6 box of 5 dressings PMM #4261 CGF

    Duoderm regular 8 X 8 box of 3 dressings PMM #1687 CGF

    Duoderm Extra thin 4 X 4 box of 10 dressings PMM #3274

    EPC/ Triple Care 3.25 oz tube PMM #20409 Cream

    Eucerin Cream Pharmacy RN Order Exudry Fecal incontinence bag

    Gaymar Sof-care One size PMM #3273 Overlay

    Gaymar Sof-care One size Seat Cushion PMM #38566

     Cover PMM #38572 Greer’s Goo 60 gm jar (compound) Pharmacy MD Order Hydrogel Duoderm, 30 gm tube or box of 3 PMM #20578 sterile tubes

    Hydrogel Duoderm, 7 oz. spray bottle PMM #4757 nonsterile

    Ilex Barrier Cream Pharmacy MD Order/ Non-

    formulary Iodoform packing ? X yds PMM #4657 strips

    Iodoform packing ? X yds PMM #4656 strips

    Iodoform packing 1 X yds PMM #4655 strips

    Iodoform packing 2 X yds PMM #2080 strips

Original: August 2003 Approved Department of Pediatrics

    Revised: Aug 2004, April, 2007 The Johns Hopkins Hospital

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Protocol and Procedures Page 7 of 10

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    Appendix B (con’t)

    Alphabetical List of Skin Care Products

    Item Size Source/ESI # Comments Karaya Powder Pharmacy RN Order Multipodus Boot Med PMM #33486

    Lg PMM #33487 Myconizole cream Pharmacy MD Order 2%

    Nu gauze packing ? X 5 yds PMM #4658 strips

    Nu gauze packing ? X 5 yds PMM #2079 strips

    Nu gauze packing 1 X 5 yds PMM #4659 strips

    Nu gauze packing 2 X 5 yds PMM #4660 strips

    Nystatin cream 15 gm Pharmacy MD Order Nystatin ointment 15 gm Pharmacy MD Order Sorbaview Primapore dressing 2 X 3 PMM #20436 Primapore dressing 6 X 3 PMM #5915 Primapore dressing 13.75 X 4.75 PMM #5914 Sensicare Barrier 4 oz tube PMM #32890 Stocked on some Cream units Sensicare Perineal/ 4 oz spray bottle PMM #6070 Stocked on some Peri-Wash Skin units Cleanser Spray

    Silvadene 50 gm jar Pharmacy MD Order

    400 gm jar

    Sween Baby 3 oz PMM #5187 Powder/Corn Starch

    Telfa 3 X 8 PMM #4998 Triple Care/EPC 3.25 oz tube PMM #20409 Vaseline 5 gm peel pack PMM #1182 Wound Wash 16 oz spray PMM #11177 Xeroform 1 X 8 PMM #1526 Xeroform 5 X 9 PMM #1525 Zinc Oxide Pharmacy RN Order

Original: August 2003 Approved Department of Pediatrics

    Revised: Aug 2004, April, 2007 The Johns Hopkins Hospital

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Protocol and Procedures Page 8 of 10

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    Appendix C

    Skin Care Interventions

    Goal And Specific Product/Action Comments Category of Intervention (* = MD Order required)

     Pressure Relief:

    ? Encourage maximum mobility Immobility Issues

    ? Encourage patients to shift and

    redistribute weight frequently

    ? Establish schedule for position changes

    individualized for pt.

     (Minimum Q 2 hrs.)

    Pressure Relief Devices ? Use pressure reducing cushion in chair ? Especially true for

    (NO ring/doughnut types) spina bifida

    o Limit time in chair to < 1 hr intervals patients

    o If > 1 hr in chair, establish weight

    shift schedule for Q 30 min.

    ? Protect heels:

    o Elevate heels off of bed

    o Air Shu and Liner (bedrest, no

    standing)

    o Multi Podus boot (short transfers,

    may stand short time)

    ? Prevent excess bedding pressure on

    toes

    Mattress/Overlay/Specialty ? Use (at the minimum) Gaymar SofCare ? Gaymar Overlays Bed overlay for ALL spina bifida pts. for and Sof-care

    prevention of skin breakdown cushions can be

    ? If Specialty Bed may be indicated, ordered through

    refer to Specialty Bed Protocol. PMM#:

     ? Overlay ESI # 3273

    Cushion ESI #38566

     Friction/Shear Reduction:

    Use drawsheet or cloth underpad to

    lift pt ? Keep HOB elevated <30

    o if possible

    ? Gatch bed at knee to prevent sliding, if

    appropriate

Moisture Exposure

Original: August 2003 Approved Department of Pediatrics

    Revised: Aug 2004, April, 2007 The Johns Hopkins Hospital

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Protocol and Procedures Page 9 of 10

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    Appendix C (con’t)

    Skin Care Interventions

    Basic Nursing Care Minimize prolonged contact with Interventions moisture.

    ? For Intact, normal, or ? Wash with warm water (soap optional)

    red skin or use:

    o J & J baby bath/baby shampoo

    o Gentle Rain Extra Mild

    o Comfort Bath disposable washcloths

    o Comfort Shield Perineal Care

    disposable washcloths

    o Comfort Shampoo in a Cap

    o Sensicare Perineal/Skin Cleanser

    Spray

    o Coloplast Bedside- Care foam

    ? Apply protective barrier of choice:

    o A & D Ointment

    o Coloplast Critcaid Clear

    o Zinc Oxide

    ? Use incontinence devices as

    appropriate:

    o Diapers

    o Fecal incontinence bag

    o Condom catheter

    ? For Open, denuded skin ? Wash as above ? Periwash may sting

    ? Apply barrier: raw areas.

    o Sensicare barrier cream OR ? If cream not

    o Coloplast Critcaid Clear OR adhering to skin,

    Butt paste apply light dusting

    of Karaya Powder

    to skin first.

    ? For Fungal rash ? Wash as above If unsure of rash

    ? Apply Coloplast Critcaid Clear etiology, request Derm

    Antifungal (AF) Consult.

    ? Apply ointment, powder, or cream such For female patients,

    as Nystatin or Myconizole Cream 2% assess for vaginal

    yeast infection. ? For Fungal rash with ? Wash as above If no improvement

    denuded skin ? Apply Coloplast Critcaid Clear after 3 days, request

    Antifungal (AF) Derm Consult

    ? Apply Nystatin powder and cover with

    Sensicare

    ? Apply Greer’s Goo or Triple Cream

Original: August 2003 Approved Department of Pediatrics

    Revised: Aug 2004, April, 2007 The Johns Hopkins Hospital

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Protocol and Procedures Page 10 of 10

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Moisture Replacement:

    ? Intact, dry skin ? See above for basic skin care

    ? Apply lotion immediately after bath

    while skin moist:

    o Use J & J Baby Lotion OR

    o Dawn Mist Hand & Body Lotion

    ? Apply Eucerin Cream (for extra dry

    skin)

    ? Apply topical protectants/emollients to

    prevent cracking of dry skin

     Nutrition Support:

     ? Maximize protein, calorie, and vitamin ? Involve dietician as

    intake approp.

    Refer to Wound Care Protocol Pressure Ulcer

    Treatment:

Original: August 2003 Approved Department of Pediatrics

    Revised: Aug 2004, April, 2007 The Johns Hopkins Hospital

    ________________________________________________________________________

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