Pressure Injuries

Pressure injuries, also known as bedsores or pressure ulcers, occur when skin presses or rubs against a harder surface such as a bed, chair, or medical device. This can occur when children stay in the same position for too long or when medical equipment puts pressure on skin. When skin presses against a harder surface, the pressure reduces blood flow to the area. This weakens and damages the skin.

In early stages, pressure injuries may appear as red, discolored, or dark patches on the skin. At later stages, the skin may break open resulting in blisters or open sores.

Causes of pressure injuries

Pressure injuries are often caused by lying in bed or sitting in a chair or wheelchair without regularly changing positions. In children, the most common cause of pressure injuries is medical equipment that pushes against the skin such as:

• Masks
• Catheters
• Blood pressure cuffs
• Surgical wraps 
• IV lines
• Orthotic devices

Children are at highest risk for bedsores when they:

• Are unable to change positions without help
• Have trouble holding themselves up due to illness, weakness, or young age (infants)
• Have weakened or dry skin
• Have decreased sensation or feeling in the skin
• Have damp skin from urine, sweat, or other fluids
• Toss or turn in bed
• Eat less than normal or have poor nutrition
• Have low body weight
• Have low blood pressure, low blood counts, or less oxygen in their blood
• Take certain medications such as steroids which can cause skin to be thin and weak

Preventing pressure injuries

Prevention and care of pressure injuries is very important. At first sign of a pressure injury, remove the pressure from the area to protect the skin from further damage. Sores can become infected, especially in children with weak immune systems from cancer treatments. Untreated, they can even extend deep into the skin and expose muscle or bone.

There are some simple ways to lower the risk for pressure injuries.

Check the skin.

The child’s skin should be checked regularly by the medical team and family caregivers. The medical team can teach caregivers how to examine skin thoroughly and what skin changes to look for.

Parents should be experts on their child’s skin. Check the skin every day. Remove clothing including socks, pajamas, underwear, diapers, and any other coverings to examine the skin underneath. Many children and teens do not speak up about sores until they have severe discomfort. Children might also be embarrassed and try to avoid being checked in certain areas.

Check the whole body, especially bony areas such as:

• Back of the head – This is the most common place for pressure injuries in children. 
• Shoulders
• Elbows
• Hip
• Buttocks
• Tailbone
• Feet including heels, ankles, and bottoms of feet

Pay special attention to places where medical devices might press on skin. These areas should be checked twice a day.

Keep an eye out for redness or dark areas, blisters, and sores. Early signs of pressure injuries can be especially hard to see on darker skin. Pay careful attention to places that the child says are even slightly sore or tender. Pressure injuries can be open or closed sores. Let the care team know about any changes in the skin’s appearance.

Change position.

The best way to prevent pressure injuries is to change position often. Have children sit, stand, or walk as much as possible. If the child needs to stay in bed, a caregiver or member of the care team should help the child change position every 2 hours. Children in a wheelchair should adjust position every hour.

Cushions can be used to keep pressure off the bony parts of the body. Be sure to talk to the care team about what is best to use. Some types of cushions may make pressure worse. 

Tips for repositioning a child in bed:

• Alternate positions. When the child is lying down, change position by switching sides of the body (right, left, back), and keep track of what side is due at the next change.
• Get someone to help. Two people should always help turn a child.
• Never slide or drag the child across a bed. Use a sheet to lift the child all the way off the bed before placing in the new position. 
• Use the whole hand when holding a child up. If the child needs to be held, use the palm of the hand. Using just the fingers increase the risk of pressure injuries.
• Use proper bedding and pillows. Ask a care team member what kind of cushions, pillows, and sheets to use, and how to place them under the child’s body. 
• Watch for sliding. Raising the head of the bed too high can cause the child to slide down and put stress on the skin.

Protect the skin.

Taking good care of the skin may reduce the chance for pressure injury and lower the risk for infection if a sore does occur.

• Keep skin clean. Use mild soaps. Don’t scrub or rub the skin. Gently pat or dab to dry.
• Keep skin dry. Clean the skin right away and change diapers or undergarments if the child wets or has a bowel movement. Diapers or absorbent pads can help keep urine, sweat, and other fluid off the skin.
• Report rashes or diarrhea. Notify a care team member if the child develops skin irritation or has diarrhea.
• Moisturize dry skin. After baths and cleanup, use a fragrance-free moisturizer recommended by the care team.
• Avoid rubbing or scratching the skin. Treat skin gently to keep skin from breaking open.
• Eat healthy. Good nutrition is important for healing.
• Watch for things that might injure the skin. Avoid tight clothes or clothes that have buttons or zippers that press into skin. Keep clothes and sheets smooth and free from wrinkles. Make sure that wheelchairs and orthotic devices fit well and don’t rub the skin.

In some cases, the care team might recommend preventive dressings or bandages to take pressure off bony parts of the body.

Tell the care team if you see any sign of a pressure injury. Pressure injuries are easier to treat when they are caught early.

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