Planning wound assessments and dressing changes

Providing assistance with skin care and wounds for infants and children requires planning. Premature infants need a great deal of undisturbed sleep for growth and development. The components of care of the premature infant, such as vital signs, blood draws, diaper changes, and feedings, are scheduled, when possible, to be done together at specific intervals so that the infant can sleep undisturbed for 3 to 6 hours at a time. Wound care, stoma pouch changes, and gastrostomy site care are best timed to occur during the infant’s other care. This requires some advance planning with the nurse responsible for the infant.

Scheduled visits with the parent and/or the nurse when they are providing wound care for toddlers and older children are important to limit interruptions in the child’s routine and to demonstrate respect for the needs of the child, the parent, and the nurse. Waking a sick irritable child who recently (or finally) fell asleep ignores the child’s need for sleep and complicates the staff’s workload by requiring them to settle the child again. On the other hand, the parent or nurse may be eager to have the child’s wound or skin evaluated, and they may be quite willing to wake the child. Or the child may have already been asleep for several hours, and waking him or her will not pose a problem. Although nurse colleagues will be appreciative of assistance from an experienced wound/ostomy nurse, they also will be protective of the developmental needs of the child and will appreciate the effort of health care providers who respect the infant’s needs for sleep. Coordinating schedules with the staff results in the best possible patient care.

Before making a decision on a dressing, it is advantageous to confer with any medical and surgical services involved with the patient’s care. The most appropriate dressing may be one that remains in place for several days. However, if other services (e.g., infectious disease, orthopedics, or neurosurgery) need to assess the wound and will remove the dressing, it may be best, at least temporarily, to use a dressing that is easily removed with minimal discomfort. After everyone involved has evaluated the wound, a dressing that minimizes the frequency of dressing changes should be used.

Minimize dressing change frequency

Dressing changes often are painful, and the experience can be quite traumatic for a child. Children endure many painful experiences during an illness or injury that cannot be mitigated. However, nurses can alter the pain experienced during dressing changes by choosing advanced wound care products that reduce the frequency of dressing changes and by selecting methods of securing dressings that eliminate or limit the use of adhesive tape. Box 36-2 lists a summary of issues to consider when selecting and securing dressings for pediatric use.

Although some colleagues will not appreciate the advantage of high-tech dressings over gauze for wound healing, most can be convinced of the advantage, to everyone involved, of minimizing the frequency of dressing changes. Alginates and fiber gel-forming dressings are safe and effective for wound care in children and significantly decrease the number of dressing changes. Decreasing the frequency of dressing changes from three times per day to once per day or every other day by using a hydrofiber instead of gauze reduces the stress on the child, parents, and staff. When dressings must be changed more often than once per day, dressings should be secured with wraps or flexible tube netting to reduce stress, pain, and the time associated with tape removal (Clinical Example 36-1).

Hydrocolloids do not require frequent dressing changes and are effectively used over eschar, intravenous infiltrates, pressure ulcers, and other small lesions that require protection and/or autolysis. Extra-thin hydrocolloid wafers conform to small body parts, such as heels, wrists, and elbows, and they can be left in place for 5 to 7 days. The key to successful use of hydrocolloid dressings is education, as the tendency is to change this dressing too often (daily or twice daily). If the wound requires more frequent dressing changes, a different dressing should be selected.

Hydrocolloid dressings can be used to frame a wound that requires frequent dressing changes. By positioning hydrocolloid strips on two or all four sides of the wound, tape can be attached to the hydrocolloid and crossed over the dressing. During dressing changes the hydrocolloid is left in place; the hydrocolloid framing the wound changed every 4 to 5 days as it loosens (Clinical Example 36-2).

Limit or eliminate use of adhesives

The method chosen to secure the dressing is extremely important. Children do not like having tape removed. Because skin irritation and tears can occur even when paper tape is used, dressings should be secured with gauze wraps, elastic wraps, self-adhesive wraps, or flexible tube net dressing whenever possible. Two- and three-inch wide conforming gauze is more effective than bulky loose weave gauze (e.g., Kerlix) on the extremities of smaller children. The conforming gauze can be taped to itself, thereby avoiding use of tape on the skin. Flexible tube net can be used to secure a dressing on the extremities of active children. It also performs well around the abdomen or chest of an infant or child to hold abdominal dressings, gastrostomy tubes, and central lines (Clinical Example 36-3).

Flexible net dressings need to be cut long enough to be effective; as they stretch, they decrease in length, roll, and fail to conform to the abdomen. For example, the distance on an infant’s abdomen from below the nipples to several inches below the gastrostomy is about 4 to 6 inches. However, once stretched over the abdomen, a 4- to 6-inch piece will become 3 to 4 inches and will not cover the area adequately to secure the dressing. Flexible net dressing should be cut twice the length needed, so for this infant 8 to 10 inches is needed (Figure 36-1).

FIGURE 36-1 Flexible net dressing used to secure wound dressings.

Elastic wraps and self-adhesive wraps are other options for securing dressings without tape. However, elastic wraps must be applied carefully when used to secure dressings to avoid applying unintended compression.

With the activity typical of infants and children, securing percutaneous tubes and drains is critical to maintain their proper position and to prevent peritubular skin breakdown. Again, flexible tube net dressing is invaluable for stabilizing central lines and gastrostomy tubes. The Hollister vertical drain/tube attachment device (Hollister, Inc., Libertyville, Ill., USA) can also be used to secure percutaneous tubes. This dressing encircles the tube site and has a locking ring that secures the tube perpendicular to the skin where the tube exits the tract. Because the percutaneous tube is kept erect at the skin level rather than lying against the skin, the risk of developing a device-related pressure ulcer along the tract is eliminated. For smaller abdomens the paper tape ring from the hydrocolloid portion of the attachment device can be removed. The vertical drain/tube attachment device can be left in place for 5 to 7 days.

The Grip-Lok (Zefon International, Ocala, Fla., USA) is another option for securing percutaneous tubes; however, it should be used cautiously because the tube often slips through the locking tape, creating traction on the tube. This problem can go unnoticed because the dressing of the locking system may not have moved. A pressure ulcer can develop along the tract, or the tube is at risk of being dislodged because it is no longer secured. Tubes are often stabilized more securely by applying a transparent film dressing to cover more of the tube. However, tubes secured by transparent film dressings must be moved every day to prevent development of a device-related pressure ulcer under the tape or along the tract.

Securing dressings in the burned child is particularly challenging because of the burn location and because children are so active. Toddlers are at high risk for sustaining burns to their chest, arms, face, hands, and abdomen as they begin exploring their environment. Burns to the hand are common, especially in cold climates and in homes with radiator heat. Toddlers need their hands to explore and are frustrated when their hands are wrapped. Application of a dressing that they cannot remove is challenging. Unaffected thumbs should be kept out of the dressing whenever possible. Gauze can be wrapped around the wrist to prevent the child from pulling off the dressing. Flexible tube net dressing or socks over the hand will help keep the dressing in place. Flexible net dressing is also useful for securing dressings on an extremity, the abdomen, and the chest. Although self-adhering wraps take more time to apply and remove, they are quite difficult for children to remove and therefore are very effective when the dressing does not need to be changed frequently (Clinical Example 36-3).

At times, use of tape or adhesive products may be unavoidable. Removing tape from a child’s skin often proves challenging. Although adhesive removers are used in children’s hospitals, they have not been tested for safety on children. When used, they should be washed off the child’s skin as soon as possible to minimize the child’s exposure to the chemicals in the product.

Adhesive removers can also be avoided by teaching nurses, caregivers, and patients a few key techniques for adhesive removal. This may seem unwarranted because nurses remove tape all the time. However, nurses often are not familiar with the techniques for tape removal that are less painful and damaging to the skin. A skin barrier wafer should be removed by pushing down gently on the skin just in front of the wafer. Tape should be rolled back while the same gentle pressure is applied on the skin just in front of the tape. Transparent film dressings can be removed by stretching them while keeping them horizontal to the skin. By about the age of 4 years, children can learn how to remove tape and ostomy pouch and may be more cooperative if they are allowed to help.

Prevent/treat wound infections

The skin provides a physical barrier to the invasion of microorganisms. This physical barrier is compromised by surgery, trauma, percutaneous tubes, and chronic wounds. The first line of defense against bacterial invasion, infection, and antimicrobial resistance is to keep the wound clean and covered. Most small cuts, surgical incisions on healthy children, and gastrostomy tube sites require no more than routine washing and a cover dressing. Topical antibiotic ointments should not be used routinely because indiscriminate use of topical and systemic antibiotics contributes to the growth of antibiotic-resistant organisms and use of topical antibiotics can lead to delayed hypersensitivity reactions, superinfections, resistance, and contact allergies (White et al, 2006). Specifically, mupirocin or polymyxin may promote the growth of gram-negative bacteria, and polymyxin has an unacceptably high rate of contact sensitization (Darmstadt and Dinulos, 2000). Therefore, topical antibiotic ointments should be used sparingly or not at all on wounds that have limited risk for becoming infected. Topical antibiotics are not an appropriate treatment option for colonized or infected wounds. Systemic antibiotics are warranted when bacterial infection or cellulitis is present.

Silver-based antimicrobial dressings can be used to inhibit bacterial growth and progression of bacterial penetration. As described in Chapter 16, silver binds to proteins in the cell wall (resulting in rupture of the wall), to bacterial enzymes and proteins (preventing them from performing their function and leading to cell death), and to bacterial cell DNA (interfering with cell division and preventing replication). This ability to bind to multiple sites results in an antimicrobial effect on a wide variety of microorganisms, including aerobic, anaerobic, gram-negative, and gram-positive bacteria, yeast, filamentous fungi, and viruses. This explains why resistance to silver is a rare occurrence (Ovington, 2004; Tomaselli, 2006). Silver is effective for treatment of mild wound infections. It is not indicted for cellulitis because it is effective only on superficial pathogens and not on those that have penetrated into the wound bed (Tomaselli, 2006). A variety of wound care products containing silver are available. Because some silver dressings cannot be mixed with normal saline, the wound should be cleaned with water and, if indicated, the dressing moistened with water. Evidence showing that silver dressings have no negative systemic or local effects is limited. Therefore, silver dressing should be used judiciously, for 2 to 4 weeks, until more research is available (Clinical Example 36-4) (Stotts, 2007).

Control pain

Large pieces of dressings are often aggressively packed in a wound, particularly after an incision and drainage of an abscess is performed in the emergency room or operating room. Removal of the packing when the child is awake is challenging. Packing often dries out and becomes adherent to the wound surface. Wetting the dressing before removing it will decrease discomfort. Wound packing is not well tolerated by children, is difficult for parents to do, and is generally not necessary. A dressing tucked in just far enough to keep the skin edges open and allow the wound to drain often is sufficient. A cotton-tipped applicator is helpful for gently tucking the dressing in the wound.

ELMA (eutectic mixture of local anesthetics) and cream for topical anesthesia can be used safely on neonates and children prior to painful procedures. The use of EMLA in premature infants of gestational age less than 37 weeks needs further study (Lillieborg, 2004). Features of development such as how a child of a particular age thinks, what they fear, and how they learn are pertinent to helping children cope with procedures like dressing changes (Table 36-1).

TABLE 36-1 Features of Development that Are Pertinent to Helping Children Cope with Procedures