Thorough and frequent skin assessment is an effective tool for early identification of hospital-acquired pressure injuries. With the ever-increasing number of responsibilities placed on nurses, skin assessment may not always be a priority. In a pediatric hospital, there may be even more challenges to completing a thorough head-to-toe skin assessment each shift. Young patients and their parents or caregivers may not understand the need for skin assessment and may refuse. In adolescent and teenage patients, thorough evaluation of bony prominences requires assessment of areas that may make patients timid or embarrassed, so skin assessment may be deferred. Additionally, pressure injury risk factors vary greatly from neonates to older teens, as this patient population includes a wide range of patient sizes and mobility levels. Medical devices are also an important cause of pressure injuries in pediatric patients and must be considered when performing a thorough skin assessment. 

Simulation has been shown to be a useful educational tool among nurses and other healthcare clinicians, resulting in higher skill acquisition than traditional teaching methods.¹ Low-level fidelity simulation involves noncomputerized anatomical models, such as mannequins, used to provide a more lifelike educational experience. 

Looking at One Simulation Design

This article describes the development of a Wound Ostomy Continence (WOC) Nurse-led skin assessment simulation incorporated into a comprehensive hospital-wide pressure injury prevention program at a 300-bed academic, pediatric hospital in Birmingham, Alabama. Some additional assessment-focused components of the pressure injury prevention program include weekly skin surveillance and weekly WOC Nurse rounding on inpatient units identified as “high-risk,” which include intensive care, pulmonary, and rehabilitation units.

The target audience for the skin assessment simulation included staff nurses and clinical assistants in all inpatient hospital units excluding behavioral health. Nurses attended the simulation in small groups, with a maximum of 10 participants in each group. The following questions distributed before and after the simulation with 1-5 Likert scale assessed nurses’ comfort with skin assessment and basic knowledge of pressure injury prevention:

1. How would you rate your knowledge of pressure injury prevention measures?

2. How comfortable are you with performing a head-to-toe skin assessment on an alert teenager?

3. How would you rate your knowledge of what to do when you find a pressure injury?

4. Considering all aspects of patient care, how would you rate the importance of skin assessment and pressure injury prevention?  
   

The simulation included two non-computerized mannequins: an infant mannequin and an adult-size “teenager.” The design of the simulation was intended as a “scavenger hunt” in which nurses assessed the mannequins and were asked to identify at least 10 findings that were incongruous with pressure injury prevention. The findings were listed on a white board and then discussed as a group. Barriers to assessment, including patient or parent refusal and discomfort with assessing areas like the gluteal cleft in teenagers were also discussed. Experienced nurses leading the simulation were able to provide examples of dialogue to help newer nurses communicate the need for thorough skin assessment to patients and their caregivers. 

The following elements were incorporated into the simulation, based on an analysis of pressure injury etiology as well as common findings at this organization. 

On the infant mannequin:

• Incorrect padding placed under patient’s tracheostomy flange

• Long length of elastic bandage wrapped tightly around infant’s arm covering a peripheral IV

• Fluidized positioner flattened with multiple layers of linen under patient

• Roll of linen directly under infant, on top of the fluidized positioner

• Needle caps in the patient’s bed

• Sock and circumferential tape in place on ankle to secure pulse oximeter on foot

• Silicone bordered foam dressing on occiput 

• Pressure injury sticker added under trach ties on posterior neck

On the teenage mannequin:

• Head of bed elevated to 45 degrees

• Heels not floated off the bed

• Low air loss/alternating mattress unplugged and deflated

• Two diapers on the patient

• 4-5 layers of linen on the bed under patient

• Fluidized positioner in use with specialty mattress

• No padding under a peripheral IV

• No padding under cervical collar or noninvasive ventilation mask

• Pressure injury sticker on coccyx

Fig. 1: This photo shows an example of an infant mannequin like that used in the simulation.

Results

Over a period of about 9 months, more than 800 nurses and clinical assistants attended the skin assessment simulation. Results of the survey indicated an increase in knowledge of pressure injury prevention measures and an increase in comfort level with skin assessment. In the year following addition of the skin assessment simulation to the hospital’s pressure injury prevention program, hospital-acquired serious harm pressure injuries (Stage 3, Stage 4, and Unstageable) decreased by 69% and respiratory device-related pressure injuries decreased by 10%. Although the significant decrease in hospital-acquired pressure injuries cannot be attributed solely to the addition of the skin assessment simulation, the simulation was found to be a beneficial component of a comprehensive pressure injury prevention program. 

Reference

1. Bliss DZ, Becker AJ, Gurvich OV. et al. Projected augmented reality (P-AR) for enhancing nursing education about pressure injury: a pilot evaluation study. J Wound Ostomy Continence Nurs. 2022;49(2):128-136. DOI: 10.1097/WON.0000000000000858