Exploring the Effects of Wound Dressings and Patient Positioning on Skin Integrity in a Pediatric Burn Facility
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Index: Ostomy Wound Manage. 2007;53(6):67-74.
An estimated one to two million Americans suffer burn injuries each year; of these, approximately 70,000 require hospitalization.1 Burns that require surgical interventions not only cause physical trauma but also have a heavy emotional toll. The scars, both physical and emotional, will impact the patient forever – it has been found for example that facial burns have a significant impact on recovery of both the child and the parents.2
Medical science has made astounding advances in sepsis management and wound coverage in the burn population. These advances include artificial skin substitutes, cultured skin, advanced antibiotics, early diagnosis of infection, and medications that decrease the pain related to donor sites. The pediatric population (average age 8 years, range 1 month to 21 years) with acute burns treated at the authors’ 30-bed urban hospital are followed in the outpatient setting until they are 21 years of age and, as has been reported elsewhere, even patients with total body surface area burns of 80% and greater are living and thriving.3 The lengthy relationship between patients and the authors’ small hospital offers a unique opportunity for insight into the complications burn survivors face such as itching, keloids, and pressure ulcer formation.
The National Pressure Ulcer Advisory Panel defines pressure ulcers as localized areas of tissue necrosis that develop when soft tissue is compressed between a bony prominence and an external surface for a prolonged period of time.4 Although pressure ulcers are most often seen in long-term care facilities or in the critically ill adult patient,5 they are not well documented. However, the incidence and prevalence of pressure ulcers in pediatric patients have been shown to be between 7% and 27% and 0.47% and 6.5%, respectively.6
To assess pressure ulcer risk, facilities most frequently employ the Braden Scale, the most utilized validated pressure area risk assessment tool7; however, this scale is not widely used in burn patients. A multicenter study is currently underway to explore a validated risk assessment tool for the pediatric patient that includes burn as well as spinal cord injuries.8 When burn patients are evaluated using the Braden Scale, they routinely fall into the highest risk category due to the nature of their injury and the need for surgical intervention (skin grafting of patients with third-degree burns). For example, at the authors’ facility, patients undergo surgery in stages on two separate days. The first stage involves excision of the burn wound down to a viable wound base (defined as tissue with an adequate blood supply). In the second stage, donor site skin is harvested and applied to the wound base. After excision and grafting, the wounds are covered with wet postoperative dressings that are irrigated every 2 hours with alternating solutions (double antibiotic and sulfamylon). During the next 5 to 7 days, patients are pharmacologically sedated to manage pain and promote immobility to improve graft take. The affected areas also are splinted or the patient is positioned to achieve optimal limb immobilization to promote graft adherence – eg, if the back requires grafting, a patient can be placed prone for 5 to 7 days. Dressings are changed on postoperative day 1 or 2 and again on postoperative day 5.