Impact of a specialized care program in the prevention and managing of skin integrity disorder in pediatric patients after open heart surgery

Abstract

Background

Patients undergoing cardiac surgery, particularly children, are at an increased risk of experiencing skin integrity disorders and pressure ulcers, attributed to the underlying disease and prolonged surgical durations. This study aims to examine the impact of a specialized care program on the incidence and advancement of skin integrity disorders in children aged 1 month to 6 years after open heart surgery.

Materials and methods

This quasi-experimental study, registered with the Iranian Registry of Clinical Trials (IRCT) under the identifier IRCT202008250458515N12 on November 11, 2020, involved 80 children admitted to the critical care unit of a teaching hospital. The participants were divided into two groups: an intervention group and a control group, each consisting of 40 children. The intervention group received targeted care program measures, while the control group followed standard care procedures. The risk of pressure ulcer development, incidence of skin damage, and pressure ulcer status were assessed and recorded using the Braden Q Scale and the Pressure Ulcer Scale for Healing (PUSH) both before the intervention and seven days after hospitalization.

Findings

The incidence of skin damage in the intervention group (45%) was significantly lower than that in the control group (62.5%) (P < 0.001). Additionally, the average scores for PUSH and Braden Q in the intervention group were 2.95 ± 0.67 and 27.48 ± 1.50, respectively, whereas in the control group, they were 5.70 ± 1.07 and 25.05 ± 2.22, respectively. These differences were statistically significant (P < 0.001).

Conclusion

According to the results, the designed focused care program can lead to the reduction of the risk of skin damage and the improvement in pressure ulcers; thus, it is recommended to be considered in the special care units.

Introduction

Skin integrity disorders, including pressure ulcers, are significant concerns in pediatric patients, particularly those undergoing cardiac surgery. In these vulnerable populations, the risk is exacerbated by prolonged immobility, invasive procedures, and the complexity of their medical conditions. Studies have shown that the incidence of pressure ulcers in pediatric intensive care units (ICUs) ranges from 7 to 27% [1, 2]. Limited available evidence suggests that the incidence of pressure injury in children with congenital heart disease (CHD) ranges from 16.9 to 18% [3, 4]. However, in pediatric patients undergoing cardiac surgery, the incidence can be as high as 4.75–50%, highlighting the increased risk in this specific group [5].

Despite advancements in healthcare, the prevalence of pressure ulcers remains high in pediatric heart surgery ICUs. For instance, a study by Rao et al. (2016) reported that 29.5% of children undergoing cardiac surgery developed pressure ulcers [6], and another study by Taghiloo et al. (2023) found that 4.75–53.4% (pooled prevalence 24.06%) of pediatric cardiac surgery patients experienced skin integrity disorders [7]. These numbers emphasize the critical need for effective prevention and management strategies.

Skin integrity disorders can be effectively averted through timely investigations and interventions in the initial phases of surgery, potentially preventing almost 95% of all skin injuries. Consequently, focusing on the prevention and management of these wounds can play a crucial role in reducing hospitalization duration and [8, 9]. Various methods for treating and caring for these wounds include frequent changes in the patient’s position, utilization of pressure-reducing equipment like mattresses, pillows, and heel protectors, ensuring proper nutrition, conducting thorough assessments to prevent skin damage, monitoring cases with urinary incontinence, applying dressings, ensuring adequate perfusion during surgery, using silicone mats on the operating room bed, employing laser therapy, and utilizing negative pressure wound therapy [10–13].

With technological advancements, novel care programs and equipment incorporating effective compounds such as sunflower extract, aloe vera, silver ion particles, and calcium alginate, alongside other treatments, have garnered widespread attention in the realm of wound healing management [14, 15]. Additionally, implementing a comprehensive skin care program involves strategies such as minimizing pressure on ankles and heels through pressure-reducing surfaces, cleaning and washing the skin after each defecation, applying skin moisturizing lotion, changing the patient’s diaper to reduce exposure to urine and feces, altering the patient’s position every two hours, using a pillow between the knees, utilizing special cushions to elevate the heel, and daily monitoring of bony prominences. These measures can significantly diminish the occurrence of pressure ulcers in patients admitted to special care units [16–19].

Furthermore, reducing the incidence of pressure ulcers in children hospitalized in special care units can be achieved by providing essential educational information through the Internet, participating in conferences focused on children’s skincare, and leveraging the experiences of nurses in understanding and addressing problems related to the prevention and treatment of pressure ulcers in pediatric patients. These interventions have the potential to decrease both the number of pressure ulcer cases and the length of hospital stays [3, 12].

Existing nursing care interventions in pediatric heart surgery ICUs have focused on measures such as frequent position changes, use of pressure-relieving devices, and skin assessments [20]. While these interventions have shown some efficacy, they are often inconsistently applied and lack a comprehensive approach. For example, Källman et al. (2022) highlighted that despite the use of pressure-relieving devices, the incidence of pressure ulcers remained significant in their study population [21]. Similarly, Gefen et al. (2022) found that moisture management and skin protection practices were not uniformly implemented, leading to varying outcomes in pressure ulcer prevention [22].

The limitations of existing programs are evident in their fragmented nature and the absence of a standardized, holistic care approach. Many interventions are reactive rather than proactive, addressing skin integrity issues after they have developed rather than preventing them. Moreover, the lack of specialized training for nurses in pediatric cardiac ICUs further exacerbates the problem [7].

Therefore, there is a pressing need for a targeted and systematic care program that integrates comprehensive preventive measures, continuous monitoring, and specialized training for healthcare providers. This study aims to address these gaps by evaluating the impact of a focused care program on the incidence and progression of skin integrity disorders in children after open-heart surgery, providing a model that can be adopted in pediatric heart surgery ICUs to improve patient outcomes and reduce the prevalence of pressure ulcers.

Methods

Study design

This study is a randomized controlled trial (RCT) designed to evaluate the impact of a targeted care program on skin integrity in pediatric patients undergoing open-heart surgery. The study adheres to the Consolidated Standards of Reporting Trials (CONSORT) guidelines to ensure transparency and reproducibility.

Setting and participants

This study adhered to a single-blind research protocol conducted at a center facility affiliated with Isfahan University of Medical Sciences, employing a quasi-experimental design. The design incorporated both intervention and control groups, integrating pre-test and post-test stages. Both participants and the statistician were blinded to the case. To ensure blinding and mitigate the researcher’s influence, equal time was allocated to both groups, and the researcher remained unaware of the allocation process. The target population comprised children aged one month to six years who had undergone corrective, restorative, or palliative heart surgery in the intensive care unit and operating room of the educational hospital.

Sampling & randomization

The sample size was estimated to be 40 cases per group considering the confidence level of 95%, the test power of 80%, and the estimated ratio of skin integrity disorders in the control and intervention groups (60% and 30% respectively) using the following formula:

Sampling was conducted using a convenience method, and upon meeting the entry criteria, samples were randomly assigned to the control and intervention groups using Random Allocation Software (RAS). the sampling was conducted in two stage: first, the control group was sampled, followed by the intervention group. Based on the software output, samples were either included in the study or not, and those included were all in the control group during the first stage and all in the intervention group during the second stage. A statistical colleague handled the randomization process to maintain blinding.

Inclusion & Exclusion CriteriaInclusion criteria encompassed children eligible for open heart surgery within the age range of one month to six years, absence of wounds in pressure areas, no history of skin disease or allergy to food and drugs, and no hemodynamic instability or respiratory distress syndrome. Exclusion criteria included the child’s death, manifestation of skin disease symptoms or drug-food allergy during the study, and the occurrence of grade 4 injuries.

Outcomes

The primary outcome is the incidence of pressure ulcers. Secondary outcomes include the the progression and healing of existing pressure ulcers.

Measurement of outcomes

• Pressure Ulcers: Measured using the Braden Q Scale, which assesses risk factors and the severity of pressure ulcers.

• Progression and Healing of Pressure Ulcers: Monitored using the Pressure Ulcer Scale for Healing (PUSH) tool, which tracks changes in ulcer size, exudate amount, and tissue type.

Data collection

Data collection occurred in 2020, with the researcher completing information on the first day of hospitalization and seven days after the initial questionnaire (post-intervention). A demographic questionnaire was utilized at baseline, covering age, weight, sex, height, preoperative hemoglobin level, and vascular access. Surgical information, such as operating room details (to investigate the operating room earth system and its relationship with burns during the operation), surgery duration, pump duration, aortic clamp duration, and inotrope consumption, was recorded. Post-surgery in the intensive care unit, information including intubation duration, intensive care unit hospitalization length, hemoglobin level (before admission and the last day), inotrope consumption, low blood pressure, and bleeding amount from drains in the first 24 h was collected. The Braden Q scale assessed the risk of pressure ulcers, while the PUSH scale was employed for patients with first-degree and higher ulcers to evaluate wound healing progress or skin damage deterioration, recording anatomical position, size, depth, number of wounds, and wound stage (Fig. 1).

Fig. 1.

Consort diagram

Validity and reliability of the tool

The Braden Q scale, employed as a risk assessment tool for predicting pressure ulcer development, consists of six primary subscales: “mobility,” “activity,” “sensory perception,” “friction force,” “nutrition,” and the crucial “tissue perfusion/oxygenation” subscale. The inclusion of the seventh scale is particularly significant for cases in the Pediatric Intensive Care Unit (PICU). This scale exhibits a sensitivity of 88% and specificity of 98%, indicating its robust predictive validity [23].

The PUSH scale, designed by the International Pressure Ulcer Counseling Association, incorporates three dimensions: wound surface, amount of exudate, and type of tissue, each scored independently. The wound surface score is determined by multiplying the length and width of the wound, ranging from 0 to 10. This tool has been confirmed as valid and reliable, with reported reliability ranging between 97% and 100% in various prospective studies [24, 25].

Specialized care administration

In the control group, nurses did not receive specific training on pressure ulcer management. Instead, routine interventions were implemented, including changing the patient’s position, managing moisture, and addressing nutritional needs. Skin protection products were used at the surgeon’s discretion, without a systematic approach for the prevention and treatment of skin injuries. The researcher observed and recorded the implementation of these interventions. On the first day, demographic and pre-operative information forms were completed, followed by the researcher’s observation and evaluation of the patient during and after the operation, with relevant information documented accordingly.

In contrast, the intervention group received specific training on the physiology and pathology of pressure ulcers, factors influencing their occurrence, and elements that increase the risk of pressure ulcers in children undergoing heart surgery. The training also emphasized effective communication and the proper transfer of patients between shifts(coordination between nurses). Additionally, a pre-operative scalp assessment was conducted, which involved cutting the child’s hair the day before the operation, with parental consent obtained. Upon the patient’s arrival in the intensive care unit (ICU) and after stabilizing vital signs, the researcher assessed the child’s skin and recorded the pressure ulcer risk score using the Braden Q scale. For a Braden Q score above 16, skin risk assessment continued once a day for seven days in the ICU, and for a score of 16 or less, it occurred twice a day. If a wound was observed, its stage was determined using a dressing tool, and characteristics were recorded based on the PUSH scale daily. The wound surface, amount of exudate, and tissue type were checked and scored separately. A systematic care program was implemented based on the wound stage, involving skin evaluation, distribution of pressure using pressure-reducing equipment (mattresses, pillows, and heel protectors), changing the patient’s head and body position, nutritional support, and moisture management. Dressings and skin protection products, such as spray, foam, and gel, were used according to the wound stage. Nutritional support aligned with pediatric ICU stress conditions, the nutrition parameter in the Braden Q tool, and assessments by a nutritionist and pediatric cardiologist. Ventilated patients received gastric or oral tube feeding, while non-ventilated patients were orally fed based on instructions and hemodynamic conditions.

To manage humidity, sheets and clothes were changed during each control shift and whenever wet, and the patient’s skin was promptly washed after each defecation. Movable medical equipment, like pressure control cuffs and pulse oximetry, were investigated as risk factors for skin damage, and their positions were changed every two hours. Care and prevention measures included using skin protection products, such as spray, foam dressing, and gel under various conditions:

1. For patients without skin redness, Linora spray (containing sunflower extract, aloe vera, and Centella asiatica extracts) was used upon the patient’s arrival in the operating room to prevent skin damage.

2. For first-degree injuries with healthy but red skin, Prontosan spray (betaine and polyhexanide) was applied for disinfection every eight hours after washing the skin, and lesion progress was evaluated at each shift.

3. For second- and third-degree injuries with old tissue or necrosis, Prontosan spray was used after washing the skin, and Askina debridement gel was applied to hydrate and moisturize the wound. Hydrogel adhesive dressing maintained wound moisture and facilitated necrotic tissue separation. The dressing remained on the wound for 48 to 72 h until tissue epithelialization. Dressings were observed and graded using a dressing tool, and repetition occurred if necessary. Secretion amount determined dressing changes during the shift; high secretion required more frequent changes, while low secretion indicated less frequent changes. Notably, fourth-degree injuries were not part of the intervention and fell under the supervision of the attending physician.

Implementation of care in the ward

To maintain the integrity of the intervention, strict procedures were followed within the ward:

• Dedicated Staffing: Only those healthcare professionals who successfully completed the specialized training were assigned to the intervention group. These trained professionals were scheduled in dedicated shifts to ensure that all aspects of care for the intervention group were administered exclusively by them. This ensured that no untrained staff inadvertently cared for patients in the intervention group.

• Separate Care Protocols: The ward implemented distinct care protocols for the control and intervention groups. These protocols were documented and monitored daily by a dedicated coordinator. The coordinator was responsible for ensuring that only trained personnel interacted with the intervention group patients and that the specific care guidelines were strictly followed.

• Monitoring and Quality Control: To further ensure compliance, the intervention group’s care was regularly audited by senior staff members who were not involved in direct patient care. This included reviewing patient records, observing care practices, and conducting random checks to verify that only trained staff were providing care.

Statistical analysis

Data were analyzed using SPSS, with descriptive statistics summarizing demographic and clinical characteristics. Chi-square tests compared the incidence of pressure ulcers and other skin integrity disorders between groups. Repeated-measures ANOVA and mixed ANOVA analyzed the progression and healing of pressure ulcers. Significance was set at p < 0.05.

Limitations

The study was constrained by the availability of only one Intensive Care Unit (ICU) for post-heart surgery sampling. This limitation introduces the potential for biases, underscoring the need for careful consideration in future studies. Additionally, a significant aspect that was overlooked at the outset was the daily reporting of the prevalence of skin integrity disorders. Such reporting could offer valuable insights into the effectiveness of the program’s implementation. Therefore, it is recommended that future studies place greater emphasis on this issue.

Findings

In the current study, the control group comprised 40 children, with 50% being boys and 50% girls, and an average age of 1.70 ± 0.36 years. The intervention group included 40 children, with 35% being boys and 65% girls, and an average age of 2.42 ± 0.37 years (p > 0.05). No significant differences were observed between the two groups in terms of other basic and clinical characteristics before and during surgery (p > 0.05). Furthermore, there were no significant differences between the groups in the average duration of intubation in the Intensive Care Unit (ICU) and Pediatric Intensive Care Unit (PICU) stay (P > 0.05) (Table 1).

Table 1.

Basic and clinical characteristics of children of the two groups

Variables		Intervention group	Control group	P- value
Gender	Boy	14(35%)	20(50%)	*0.17
	Girl	26(65%)	20(50%)
Age (year)		2.42 ± 0.37	1.70 ± 0.36	0.17**
Weight (kg)		12. 90 ± 1.90	10.31 ± 1.48	0.28**
Height (cm)		77.19 ± 56. 33	71 ± 19.80	0.16**
Hemoglobin level before surgery		13. 46 ± 1.53	14.02 ± 1.66	0.12**
Duration of operation (minutes)		250.56 ± 62.92	259.58 ± 54.15	0.50**
Pump duration (minutes)		91. 30 ± 33. 28	93. 18 ± 34.36	0.80**
Aortic clamp duration (minutes)		64.59 ± 26.13	74.68 ± 32.70	0.14**
Temperature during operation		31.45 ± 1.91	31.13 ± 1.49	0.41**
Location of CVC	Right subclavian	20(50%)	25(5/62%)	0.71*
	Right jugular	14(35%)	10(25%)
	Left subclavian	4(10%)	3(7.5%)
	Left jugular	2(5%)	2(5%)
	Milrinone	22(55%)	17(42.5%)
Duration of intubation in the intensive care unit (hours)		37.45 ± 14.08	33.83 ± 9.98	0.29**
Length of PICU stay (days)		6. 63 ± 3.57	6. 15 ± 2.40	0.49**

* Chi-square test, ** independent t-test

Additionally, the use of inotropes during surgery did not significantly differ between the two groups (P > 0.05). However, during hospitalization, the intervention group demonstrated a significantly higher use of milrinone compared to the control group (65% vs. 35%) (P = 0.03; Table 2).

Table 2.

Frequency of inotrope consumption during hospitalization

Inotrope consumption		Intervention group	Control group	P-value*
During operation	Adrenaline	13(32.5%)	11(27. 5%)	0. 63
	Dobutamine	3(7.5%)	1(2. 5%)	0. 31
	Dopamine	36(90%)	38(95%)	0. 34
	Levophed	0(0%)	2(5%)	0. 25
	Milrinone	22(55%)	17(42. 5%)	0. 26
During hospitalization	Adrenaline	15(37. 5%)	14(35%)	0. 82
	Dobutamine	1(2. 5%)	1(2.5%)	1
	Dopamine	40(100%)	39(97.5%)	0. 50
	Levophed	0(0%)	3(7.5%)	0. 12
	Milrinone	24(60%)	14(35%)	0. 03

Other parameters, such as mean arterial pressure (MAP), body temperature, and hemoglobin levels, showed no significant differences between the two groups from day one to day seven (P > 0.05) (Table 3).

Table 3.

The average values of MAP, body temperature, and hemoglobin levels of children during hospitalization

Parameters	Evaluation time	Intervention group	Control group	P-value
Mean arterial pressure (MAP)	First day of hospitalization	81. 15 ± 20. 47	83. 95 ± 17. 99	0.521*
	Second day of hospitalization	88. 54 ± 17. 53	89. 23 ± 15. 18	0.853*
	Third day of hospitalization	91. 74 ± 16. 25	95. 49 ± 12. 20	0.254*
	Fourth day of hospitalization	93. 94 ± 13. 95	97. 59 ± 8. 42	0.171*
	Fifth day of hospitalization	94. 57 ± 14. 66	97. 73 ± 7. 34	0.302*
	Sixth day of hospitalization	90. 61 ± 14. 03	96. 58 ± 8. 69	0.135*
	Seventh day of hospitalization	91. 62 ± 10. 94	96. 11 ± 8. 15	0.314*
		0.092**	0.121**	0.231***
Body temperature	First day of hospitalization	36. 84 ± 0. 30	36. 99 ± 0. 41	0.072*
	Second day of hospitalization	37. 40 ± 0. 41	37. 39 ± 0. 32	0.873*
	Third day of hospitalization	37. 40 ± 0. 39	37. 39 ± 0. 38	0.861*
	Fourth day of hospitalization	37. 25 ± 0. 28	37. 14 ± 0. 74	0412*
	Fifth day of hospitalization	37. 19 ± 0. 22	37. 22 ± 0. 27	0.573*
	Sixth day of hospitalization	37. 18 ± 0. 27	37. 12 ± 0. 26	0.494*
	Seventh day of hospitalization	37. 12 ± 0. 17	37. 15 ± 0. 17	0.660*
		0.745**	0.563**	0.642***
Hemoglobin	First day of hospitalization	12. 44 ± 2. 05	11. 81 ± 1. 99	0.163*
	Second day of hospitalization	12. 58 ± 1. 65	12. 62 ± 1. 96	0.921*
	Third day of hospitalization	12. 87 ± 1. 56	12. 50 ± 1. 26	0.243*
	Fourth day of hospitalization	13. 14 ± 1. 53	13. 03 ± 1. 04	0.720*
	Fifth day of hospitalization	12. 90 ± 1. 16	12. 95 ± 1. 15	0.853*
	Sixth day of hospitalization	12. 64 ± 1. 40	13. 01 ± 1. 21	0.392*
	Seventh day of hospitalization	12. 56 ± 0. 99	13. 04 ± 0. 95	0.223*
		0.193**	0.103**	0.364***

* Independent t-test

**Repeated measure

*** Mix ANOVA

The study also assessed the incidence of skin damage and the risk of pressure ulcers, as well as their recovery during the study period. The incidence of skin damage in the intervention group (45%) was significantly lower than in the control group (62.5%) (P = 0.04).

Moreover, there were no significant differences in the initial PUSH and Braden Q scale scores between the two groups (P > 0.05). However, on the last day of the study, the intervention group exhibited a significantly lower mean PUSH score (2.95 ± 0.67) compared to the control group (5.70 ± 1.07) (p = 0.02). Additionally, the recovery rate based on the last-day PUSH score in the intervention group (27.48 ± 1.50) was significantly higher than in the control group (25.05 ± 2.22) (p < 0.001). Notably, both the intervention (10.90 ± 4.89) and control (8.70 ± 4.16) groups showed significant recovery based on the PUSH score (p < 0.001). Based on the Braden Q scale score, the intervention group demonstrated a significant reduction in the risk of pressure ulcers (-1.08 ± 0.54; p = 0.03), while there was no significant difference in the control group (0.90 ± 0.67; p = 0.19) (Table 4).

Table 4.

The mean PUSH and Braden Q scores of children on the first and last day of the study between the two groups

Variables	Time	Intervention group	Control group	P-value
PUSH score	Baseline	4. 03 ± 0. 78	4. 80 ± 0. 68	0. 45**
	Seventh day of study	2. 95 ± 0. 67	5. 70 ± 1. 07	0. 02**
P-value		0. 03*	*0. 19	0. 001***
Braden Q score	Baseline	16. 58 ± 5. 10	16. 35 ± 4. 38	0. 83*
	Seventh day of study	27. 48 ± 1. 50	25. 05 ± 2. 22	0. 001**
P-value		< 0. 001	< 0. 001	0. 0001***

* paired t-test, ** independent t-test, *** covariance

Discussion

This study explored the impact of a care program on the occurrence and progression of skin integrity disorders in children aged one month to six years following open-heart surgery at an Isfahan Medical Sciences-affiliated hospital. The results indicated notable homogeneity between the control and intervention groups in terms of intervening variables and demographic characteristics, as a result of the random allocation process employed in the study.

The intervention group experienced a significantly lower frequency of skin damage (45%) compared to the control group (62.5%) (P < 0.05), underscoring the effectiveness of the care program in reducing post-surgical skin injuries. This finding aligns with prior research, which emphasizes that improving the quality of skin integrity protocols—through enhanced nursing knowledge, skill development, and modern equipment—can lead to a significant reduction in pressure ulcers and promote accelerated wound healing [14, 15].

Initially, there were no significant differences in PUSH and Braden Q scores between the intervention and control groups (P > 0.05). However, by the end of the study, the PUSH score in the intervention group was significantly lower than in the control group (P < 0.05), indicating improved wound healing. The Braden Q score also showed a significant decrease in the intervention group (P < 0.05), while the control group exhibited no significant changes (P > 0.05). These results highlight the positive impact of preventive care strategies. By the conclusion of the study, recovery rates, as gauged by the PUSH score, were significantly higher in the intervention group compared to the control group (P < 0.001), with the intervention group demonstrating a more pronounced improvement overall (P < 0.001). The findings contribute to the ongoing discourse on new and complementary therapeutic measures within standard pressure ulcer protocols. For example, previous studies have also evaluated innovative treatments, such as the use of olive oil, which significantly reduced first-degree pressure ulcers in ICU patients [26]. Rafiei et al. (2019) found that the application of henna led to a significant reduction in PUSH scores for patients with first-degree pressure ulcers [27]. Similarly, Mehrabani et al. (2012) indicated that honey dressings were more effective than hydrocolloid dressings, yielding significant improvements in healing as measured by changes in mean PUSH scores [28]. Kulik et al. (2019) reported a significantly higher average increase in the Braden Q score in the intervention group, concluding that the implementation of a standard skin care program, including skin assessment, pressure distribution using support surfaces, position change, nutritional support, moisture management, care, and prevention measures using skin protection products, can reduce the risk of pressure injury in patients with pressure ulcers [2].

n this study, we paid special attention to coordination among nurses and aimed to establish this coordination in caring for children who require special attention to prevent pressure ulcers. The collaboration of clinical nursing specialists in the diagnosis, prevention, and treatment of pressure ulcers in children, as well as the enhancement of nurses’ knowledge and cooperation in these areas, has been confirmed to improve the quality and speed of pressure ulcer treatment in children in other studies [14]. However, it should be noted that there is a need for precise tools to assess the level of coordination and its impact on pressure ulcer prevention.

An important challenge we faced in this study was the unavailability of specific guidelines for the prevention and treatment of pressure ulcers in these children, which is particularly necessary given their unique sensitivities. King et al. highlighted that although the lack of special evidence-based clinical guidelines for the prevention and management of skin problems and common wounds in infants and children patients undergoing open heart surgery is a barrier to providing appropriate care, the development of practical guidelines and the rational selection of dressings and specialized wound care products can assist wound care specialists dealing with children and infants in standardizing clinical procedures. They stated that using dressings, such as transparent film dressing made of polyurethane, accelerates the wound healing process [29]. additionally, Taghiloo et al. emphasized that special protocols are needed to decrease the prevalence of pressure injuries.

Conclusion

According to the findings of this study, the implementation of a specialized care program, encompassing patient skin assessment, pressure distribution using support surfaces, position changes, nutritional support, moisture management, and care and prevention measures employing skin protection products, can effectively reduce the incidence of skin damage and promote wound healing. The improvement in wound healing, as indicated by the PUSH scale, and the reduced risk of wound infection based on the Braden Q scale underscore the positive impact of such focused care programs.

In the realm of preventing and treating bedsores, the nursing team plays a crucial role by providing direct and continuous care. Therefore, employing a targeted care program in addressing these cases can be instrumental in minimizing pressure ulcers. Nurses, through risk identification and implementation of necessary protective measures, contribute significantly to maintaining the integrity of a patient’s skin, leading to a reduction in pressure ulcers.

In this context, programs focused on such care and corresponding training can be beneficial in enhancing the well-being of these children. However, it’s noteworthy that the designed program did not influence the length of hospitalization for these children, prompting the need for further research in this area.

Implications of Findings for Research, Education, and Practice:

Research: This study underscores the necessity for further exploration into the integration of comprehensive skin care programs with other elements of pediatric cardiac ICU care. Future research should delve into additional factors that may influence hospitalization duration and examine the long-term effects of targeted care programs on patient outcomes. Furthermore, investigating the cost-effectiveness and scalability of these interventions across various hospital settings is crucial.

Education: The findings highlight the critical need for specialized training for nurses working in pediatric cardiac ICUs. Incorporating evidence-based skin care practices into nursing education curricula can enhance nurses’ skills and knowledge, enabling them to effectively implement preventive measures and improve patient outcomes. Regular workshops and training sessions focused on the latest advancements in skin care and wound management should be made accessible to nursing staff.

Practice: The adoption of targeted care programs should be established as a standard practice in pediatric heart surgery ICUs. Hospitals need to develop protocols that encompass comprehensive skin assessments, regular position changes, and the utilization of pressure-relieving devices. Additionally, ensuring adequate nutritional support and moisture management should be integral components of patient care plans. Sustaining these programs necessitates continuous monitoring and evaluation to ensure compliance and assess their effectiveness.

Author contributions

M.M., A.Y., H.B., and F.K. all contributed to various aspects of the research, including design, implementation, result analysis, and manuscript writing.

Funding

This project was carried out with the financial support of the Nursing Care Research Center at Isfahan University of Medical Sciences.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. yazdannik@nm.mui.ac.ir.

Declarations

Ethics approval and consent to participate

The study will be conducted in accordance with the Declaration of Helsinki. This research received approval from the Ethics in Research committee of the Research and Technology Vice-Chancellor of Isfahan University of Medical Sciences, documented with the registration number IR.MUI.RESEARCH.REC.1398.227. Furthermore, it was registered with the Iranian Registry of Clinical Trials (IRCT) under the identifier IRCT202008250458515N12 on 11, 11, 2020. Following the referral to the hospital, the necessary ethics code was acquired, and coordination was established with the relevant authorities. Subsequently, a comprehensive explanation of the research methodology was provided to both the parents and children and written informed consent from the parents and verbal consent from the children was obtained. This trial was terminated in the event of unexpected adverse events, such as allergic reactions to the items used, deterioration of the patient’s condition, discovery of suitable treatment methods with a significant effect, budget limitations, or logistical challenges.

Consent for publication

Not Applicable.

Competing interests

The authors declare no competing interests.