Neonatal Skin Structure: Pressure Injury Staging Challenges
Ann Marie Nie, Deanna E. Johnson, Robyn C. Reed
Abstract
ABSTRACT GENERAL PURPOSE To review neonatal pressure injuries (PIs), including clinical features and challenges in evaluation and staging related to the unique anatomic features of preterm neonatal skin as well as the common sites and mechanisms of injury. TARGET AUDIENCE This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES After participating in this educational activity, the participant will: 1. Recognize the causes of PIs in preterm neonates. 2. Choose the outcomes of PIs in preterm neonates. 3. Distinguish the common characteristics of preterm neonates’ skin. 4. Summarize the challenges clinicians face when classifying the PIs of preterm neonates. OBJECTIVE To review neonatal pressure injuries (PIs), including clinical features and challenges in evaluation and staging related to the unique anatomic features of preterm neonatal skin, as well as the common sites and mechanisms of injury. METHODS A review of the literature and discussion of clinical experiences at a large children’s hospital. Specific topics include the nature and mechanism of PIs, histomorphometric features of skin development in preterm neonates and how these features inform bedside evaluation of PI, and experience-based observations of challenges in evaluating PIs in this vulnerable population. RESULTS Pressure injury staging in preterm neonates presents unique challenges: (1) The National Pressure Injury Advisory Panel PI staging model is based on visual identification of depth of injury, but because of the immaturity of the preterm neonate, skin lacks many of the visual cues present in adult PIs. Specific qualitative and quantitative differences in skin development impact the macroscopic appearance of skin at different gestational ages. (2) The most common cause of PIs in this population is related to noninvasive respiratory devices, but these injuries may be extremely small and difficult to evaluate visually. CONCLUSIONS The National Pressure Injury Advisory Panel staging system can be difficult to implement accurately in the neonatal population. Further study is warranted to determine whether an alternative staging system may provide more accurate and actionable information for this population.