Ensuring the survival and health of newborns in Europe and ...
Evidence-Based Objectives Skin Care for Newborns...
Transcript of Evidence-Based Objectives Skin Care for Newborns...
Terrie Lockridge, MSN, RNC-NICwww.perinatalneonatalconsulting.comPacific NW Association of Neonatal Nurses, 2015 1
Evidence-Based Skin Care for Newborns
PNANN 2015
Terrie Lockridge, MSN, RNC-NICPerinatal Neonatal Consulting & Swedish Medical Center
Objectives
Discuss pertinent elements of national guidelines related to NB skin care
Identify areas in your setting that might be enhanced by use of guidelines
Format: basics of skin structure and function factors that influence skin integrity 2013 guidelines on neonatal skin care
The skin is largest organ in the body
Preterm skin makes up 13% of weight, versus 3% of adult
Skin integrity essential to survival
any break is
portal of entry
Basic Components of the Skin
Epidermis: barrier against toxins and bacteria, retains both heat and water exfoliating dead cells
Dermis: collagen and elastin fibers that provide strength and elasticity blood vessels and nerves 60% as thick as an adults
Subcutaneous tissue: insulation, shock absorption and calorie storage area fatty connective tissue
Factors that Influence Skin IntegritySkin pH
pH <5 offers bacteriocidal quality
acid mantle = barrier to microorganisms
term skin pH >6 at birth, <5 by 4 days
preterm “mantle”, pH<5
not until ~ month
with alkaline soap need
> hour to drop pH <5
Terrie Lockridge, MSN, RNC-NICwww.perinatalneonatalconsulting.comPacific NW Association of Neonatal Nurses, 2015 2
Factors that Influence Skin Integrity
Skin Maturation
fetal skin development
follows clear pattern
at term, barrier function similar to adult
preterm change from aquatic to aerobic conditions accelerates maturation
delayed in lower GA
Factors that Influence Skin Integrity
Stratum corneum less keratinized and thinner as GA decreases term 10-20 layers preterm 2-3 layers
Epidermis of preterms > 26 wks improved barrier function within several weeks delayed to 30-32 wks if < 26wks
Preterm skin permeable to toxins &TEWL Barrier function limited for first year
Factors that Influence Skin Integrity
Preterm Cohesion
epidermis & dermis linked by thin fibrils
stronger and more numerous with age
diminished cohesion between layers, at risk for epidermal stripping
bond between skin and
adhesives may be stronger
than bond between skin layers
2013Guidelines
Vernix
Bathing
Cord care
Circumcision care
Diaper dermatitis
Disinfectants
Adhesives
Skin breakdown
IV infiltrates
Emollients
TEW
Nutrition
Vernix: Nature’s Waterproofing
Decreases skin permeability and TEWL
Cleanses and moisturizes skin
Protects against infection
Reduces pH and creates “acid mantle”, inhibits growth of pathogenic bacteria
Temperature regulation
Bathing: General Considerations
Staff and family: hand washing with anti-bacterial cleanser prior to bathing
Community acquired infections
Tub disinfection
Terrie Lockridge, MSN, RNC-NICwww.perinatalneonatalconsulting.comPacific NW Association of Neonatal Nurses, 2015 3
First Bath
Once thermal and CR stability achieved
Goal: Remove unwanted soils (meconium, blood) and leave residual vernix intact
Universal precautions
Minimal amount of pH –neutral or slightly acidic cleanser to assist with removal of blood and amniotic fluid
Skin Cleansers
Cleansers with least irritating ingredients
Neutral or mildly acidic pH (5.5-7.0)
Preservatives with demonstrated safety in newborns
No antimicrobial soaps
Avoid soap-based products
Product Selection
No specific products
Minimal product use
Potential toxicity, especially if preterm
Avoid unnecessary exposure to chemicals
A benchmark investigation of industrial chemicals, pollutants and pesticides in umbilical cord blood Environmental Working Group, 2005
~200 chemicals detected per baby
Baby Care Products: Possible Sources of Infant Phthalate Exposure, Pediatrics, Feb’ 08
Infants may be absorbing phthalates through commonly used baby products
Authors recommend reducing exposure
Routine Bathing: Term Newborns
Bathing is not an innocuous procedure
Daily bath not clearly justified for NB
May bathe every few days “to remove debris and for general hygiene“
Shampoo X1-2/week
Immersion or swaddle
bathing preferred
over sponge bathing
Immersion Bathing
Stable infants
safely immersed
No increase in rate of
bacterial colonization or infection of cord
Immerse entire body (except head and face) with warm water (100.4ºF or 38 ºC)
Terrie Lockridge, MSN, RNC-NICwww.perinatalneonatalconsulting.comPacific NW Association of Neonatal Nurses, 2015 4
Swaddle Bathing Routine Bathing: Preterm Infants
Should not be bathed daily “The bathing schedule for preterm
infants should be based upon the infant’s physiologic condition and behavioral state”
Routine Bathing: Preterm < 32 Weeks
Vulnerable to disruption and toxicityfrom topically applied substances Water baths only during first week Warm sterile water if breakdown
Soft cloth, avoid rubbing Sponge baths stressful Swaddled or immersion
bathing preferable
Bathing and Temperature Control
After bath, dry/diaper baby
Double wrap in blankets with cap for head
Ten minutes later…dress the baby, change the cap and wrap in dry warm blankets
large drops in temp
noted 10 min post bath,
due to dampening of
clothing
Cord Care Cord potential port of
entry for invasive bacterial pathogens
Good hand hygiene to avoid community-acquired infections such as MRSA
Dry cord care leads to shorter separation times
Topical drying agents: no benefits on separation, colonization, or infection
Cleanse cord during first bath with water or cleanser of choice
Dry thoroughly with clean gauze
If soiled, clean with water and dry
Keep cord clean/dry outside diaper
Terrie Lockridge, MSN, RNC-NICwww.perinatalneonatalconsulting.comPacific NW Association of Neonatal Nurses, 2015 5
Educate Parents about Cord Care
Hand hygiene
Keep clean and dry
Moist, mucky appearance is normal
Redness, swelling and drainage abnormal
Allow cord to fall off
Disinfectant Dilemma
Evidence is insufficient to recommend a single product for all newborns.
Efficacy
Potential for toxicity
Skin irritation or breakdown
Disinfectants: The Competitors
Isopropyl alcohol
10% Povidone-iodine (PI)
Chlorihexidine gluconate (CHG)
Isopropyl alcohol
Drying to skin and is least effective
Avoid use as primary disinfectant
Don’t use to remove either CHG or PI
Chemical burns in preterms
Use to disinfect needleless connectors and other access ports, preventing BSI
Povidone iodine (PI)
10% aqueous solution
Single use products
Better than alcohol for skin disinfection
Apply and allow to dry for 30 sec
Remove completely after use
Risk of absorption: Elevated iodine levels and thyroid suppression
2% Chlorhexidine Gluconate (CHG)
Used in aqueous solutions and in combination with isopropyl alcohol
Bactericidal properties, effective against gram positive and negative organisms
Also binds to protein in stratum corneum, leaving residual bactericidal effect that is resistant to alcohol removal
Terrie Lockridge, MSN, RNC-NICwww.perinatalneonatalconsulting.comPacific NW Association of Neonatal Nurses, 2015 6
Meta-analysis of eight studies (n=4143 catheters) in adults determined CHG disinfection reduced BSI risk by 49%
But, current CDC guidelines indicate that there is insufficient evidence to make a recommendation about safety or efficacy of CHG products
in infants less than
two months of age
2% Chlorhexidine gluconate (CHG)
Per 2012 FDA regulations, some CHG/alcohol-containing products are now labeled: ”Use with care in preterm infants or in infants less than 2 months of age. These products may cause irritation or chemical burns”
NICU’s may use the
product “off label” as
indicated for disinfection
2% Chlorhexidine gluconate (CHG) Systemic toxicity not yet seen in NB’s
Local reactions to impregnated dressings
European use for ~ 30
years, increasingly in US
& Canada in recent years
Chemical burns in VLBW
Chlorhexidine Gluconate Options
2% Aqueous CHG, poured
onto applicators or 2X2’s
Chloraprep: 2% CHG in 70% isopropyl alcohol
2% Aqueous CHG
Chloraprep for larger infants, PI or 2% Aqueous CHG for infants < 1500 grams
10% PI for all NB’s, all procedures
Disinfectant Options: “Insufficient evidence to recommend a single product” Disinfectant Dilemma
All have potential to damage skin and interfere with tissue function
Disinfectants kill bacteria
Damage or destroy fibroblasts and keratinocytes in healing wounds
Limit time and area of exposure
Remove with sterile water or saline
Terrie Lockridge, MSN, RNC-NICwww.perinatalneonatalconsulting.comPacific NW Association of Neonatal Nurses, 2015 7
Adhesives
Primary cause of skin breakdown
Strips epidermis, disrupts barrier
Use sparingly
Double back tape
Avoid bonding agents, solvents, bandages after drawing labs
Adhesive Damage is Painful
Remove using water-soaked cotton balls, pull tape at low level, parallel to skin
petrolatum if re-taping not anticipated
Anetoderma: Atrophic patches of skin due to dermal thinning
Adhesive Options
Hydrogel electrodes
Semipermeable dressings
Allow skin to “breathe”
IV’s, PICC’s, NG/OG’s
and nasal cannulas
Stretchy gauze to secure electrodes, probes and limbs to armboards
“Tender grips” adhesive circles for NC
Pectin or Hydrocolloid Barriers
Shown to cause skin trauma equal to tape when removed at 24 hours
Absorbs moisture, molds well to skin surface, and prevents application of tape directly to face
Useful with ETT, NC
for extended periods
Silicone Based Adhesive Products
Shown to improve adherence to wounds, reduce discomfort during tape removal
Holds promise for new products that adhere, with minimal trauma upon removal
Mepitac: soft silicone layer that provides secure fixation but no epidermal stripping
Secure non-life
sustaining devices
Minimize Risk of Breakdown
Reposition medical devices Water/air/gel mattress Sheepskin/soft surfaces Transparent dressings
over bony prominences Petrolatum-based
ointments to groin/thigh of VLBW infants
Terrie Lockridge, MSN, RNC-NICwww.perinatalneonatalconsulting.comPacific NW Association of Neonatal Nurses, 2015 8
Skin Breakdown
Culture and treat if signs of bacterial or fungal infection
Cleanse affected area Sterile water/saline No disinfectants Debride, don’t scrub
Moistening tissue facilitates healing
“Moist Healing” Environments
Dressing: Occlusive, nonadherent, and provides moist healing that promotes rapid migration of epithelial cells and protects wound from further injury
Use hydrogel, transparent dressings and hydrocolloids and leave in place for extended periods (remoisten hydrogels)
Serous exudate often forms (leukocytes)
Wound care options
Transparent dressings (Tegaderm)
uninfected wounds
Hydrocolloid (Duoderm)
deep and/or uninfected wounds
absorbs exudate and acts as barrier
Wound care options
Hydrogel (Vigilon, Flexigel or Transgel)
infected wounds in conjunction with antifungals or antibacterials
Mepitel, Mepilex soft silicone dressing
Emollients
Products should be petrolatum-based, water miscible, no preservatives, perfumes and dyes
Unit dose or single patient use
May be used with photoRX/warmers
Terrie Lockridge, MSN, RNC-NICwww.perinatalneonatalconsulting.comPacific NW Association of Neonatal Nurses, 2015 9
Emollients Protect integrity of stratum corneum and
enhance barrier function
Restore skin integrity
Gentle application at first sign of dryness, fissures or flaking
Watch for signs of
systemic infections,
especially < 750 gms
Petrolatum-based ointments
For uninfected or infected lesions (after cleansing and application of antibacterials)
Improves healing, reduces skin growth of gram neg organisms, and decreases severity of dermatitis
Cautious use < 750 gms
Not for fungal lesions
Routine Emollient Use in VLBW
Early emollient studies showed no increase in colonization patterns (Lane & Drost, 1993, Nopper et al, 1996, Pabst et al, 1999)
RCT: Association between emollients used twice daily X2 wks and coagulase-negative S. epi in subset of infants < 750 grams. No difference in gram-negative bacterial or fungal infections Edwards et al, 2004
Emollients used to treat dry skin during RCT did not increase infection rates
Routine Emollient Use in VLBW
Benefits of emollient use for prevention of dermatitis and skin
breakdown should be weighed against risk of infection
Transepidermal Water Loss
Increased TEW and evaporative
heat loss in infants <30 wks
At 23-25 wks have TEWL X10 > term
Use a single method or combination of techniques to limit TEWL and heat loss
Need more fluids if TEWL not limited
Strategies to Reduce TEWL
Polyethylene wrap at birth
Supplemental conductive heat
Semipermeable transparent dressings
Polyethylene coverings or blankets
Terrie Lockridge, MSN, RNC-NICwww.perinatalneonatalconsulting.comPacific NW Association of Neonatal Nurses, 2015 10
Humidity: Reducing TEWL
TEWL depends on ambient
water vapor pressure
Raising ambient humidity increases water vapor pressure, and decreases fluid and heat loss via evaporation
Humidity 70 - 90% for first 7 days
After first week, gradually reduce to 50% until baby is 28 days old
Strategies to Reduce TEWL
Humidity Newer isolette designs include servo-
controlled humidification using sterile water sources, eliminates reservoir as source of contamination
Actively generated humidification systems don’t cause air-borne aerosols that could be contaminated with microorganisms
NICU Best Practice Committee
Swedish Medical Center
Evidence-Based Care of Diaper Dermatitis
Heimall, et al. 2012. Beginning at the Bottom: Evidence-Based Care of Diaper Dermatitis. MCN: American Journal of Maternal Child Nursing, 37(1), 10-16
Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN). 2013. Neonatal Skin Care: Evidence Based Clinical Practice Guideline, 3rd Ed
Diaper Dermatitis
Acute inflammatory reaction of the skin
First signs are erythema and mild scaling
If not treated promptly, can progress to painful excoriated or ulcerated lesions
Multifactorial etiology includes moisture, warmth, friction, urine and feces
DD: Multifactorial Etiology
Trapped moisture (urine) against skin
Increases pH of skin surface, limits ability to maintain normal microflora
Increases skin permeability
Vulnerable to damage from friction
Can activate fecal enzymes: irritants that can cause skin destruction
Terrie Lockridge, MSN, RNC-NICwww.perinatalneonatalconsulting.comPacific NW Association of Neonatal Nurses, 2015 11
DD: Multifactorial Etiology
Skin loses ability to act as barrier against irritants and microbes
As skin becomes damaged, microbes are more likely to cause inflammation
Can lead to development of secondary infections (bacterial or fungal)
Candida is often opportunistic invader when simple diaper rash is untreated
Common after antibiotic use
Beefy red skin
Oval/dotty lesions
scattered at edges
(satellite lesions)
Slightly raised
Often in skin folds
Skin may or may not be denuded
Diaper Dermatitis Hurts
Erythema indicates that epidermal layer has been damaged, and that the dermis (with sensory nerve endings) is exposed to air, urine and stool
Goal: Prevent DD whenever possible, using an evidence-based algorithm for every baby
Heimall, et al. 2012. Beginning at the Bottom: Evidence-Based Care of Diaper Dermatitis. MCN: American Journal of Maternal Child Nursing, 37(1), 10-16
Terrie Lockridge, MSN, RNC-NICwww.perinatalneonatalconsulting.comPacific NW Association of Neonatal Nurses, 2015 12
Concern about prevalence of DD
Incidence was 24% at onset of project
Numerous DD concoctions and “potions”
Treatment plan changed shift to shift
Interdisciplinary task force included wound ostomy continence nurse, nurse researcher, pharmacist, four CNS’s (NICU, surgery, oncology, chronic care)
Focus groups with ~ 50 bedside nurses
Reviewed national skin care guidelines, pharmacy and nursing list-serves
Consulted with topic experts and other pediatric hospitals about their practices
Complete literature search
Levels I-VII
Very few systematic reviews or RCT’s
Mostly nonrandomized trials, single descriptive studies, expert opinions
2012,Literature Search
Highest level evidence is unavailable
Consensus of lower levels of evidence around effective barriers
Literature supports that petrolatum and/or zinc oxide provide effective barriers against potential perineal skin irritants and maceration
Vaseline and Desitin
Choosing our Barrier Products
Environmental Working Group http://www.ewg.org/skindeep
Petrolatum: Vaseline
Minimal ingredients
Preventive measure
Zinc Oxide: Desitin Maximum Strength Paste (40% zinc oxide)
Highest concentration of zinc oxide
Shorter term used anticipated
Barrier Products Initial application to clean, dry skin
Prevent skin breakdown
Protect injured skin with thick layer of barrier product: “Icing on a cake”
Allows “moist healing”
environment (not wet)
to protect healing skin
Terrie Lockridge, MSN, RNC-NICwww.perinatalneonatalconsulting.comPacific NW Association of Neonatal Nurses, 2015 13
Less comfortable since it exposes dermal layer to air
Exposes healing tissue to re-injury from irritants like stool and urine
Prevents faster healing from moist wound healing environment
Diaper Changes & Barrier Products
Prevent breakdown
Protect healing skin
Remove only soiled layer
Cleanse gently and avoid rubbing product off, pat dry
Replace product prn to clean, dry skin
Parent teaching
Diaper Wipes
Some contained preservatives, alcohol, and perfumes that could irritate skin
Newer formulations with fewer additives reported to be well tolerated and mild
Soft cloth with water, or mild cleanser and water are also acceptable options
Frequent diaper changes (Q 1-3 hours during day and at least once during night)
Assessment: Intact SkinNo Erythema
Goal: Prevent skin breakdown
Treatment: Vaseline
Application Instructions: Apply thick layer of Vaseline over entire area to be protected (think “icing on cake”).
With Diaper Changes: Try to remove only stool Leave barrier of Vaseline on skin if possible Replace any Vaseline that came off.
Assessment: After All Meconium PassedHigh Risk for BreakdownIntact SkinWith or Without Erythema
Goal: Prevent skin breakdown, Provide barrier
Treatment: Desitin
Application Instructions: Apply thick layer of Desitin over entire area to be protected (think “icing on cake”).
With Diaper Changes: Try to remove only stool Leave barrier of Desitin on skin if possible Replace any Desitin that came off.
Terrie Lockridge, MSN, RNC-NICwww.perinatalneonatalconsulting.comPacific NW Association of Neonatal Nurses, 2015 14
Assessment: Intact SkinErythemaNo Candida
Goal: Prevent skin breakdown, Provide barrier
Treatment: Desitin
Application Instructions: Apply thick layer of Desitin over entire area to be protected (think “icing on cake”).
With Diaper Changes: Try to remove only stool. Leave barrier of Desitin on skin if possible Replace any Desitin that came off.
Assessment: Intact SkinErythemaCandida
Goal: Prevent skin breakdown, Treat candida, Provide barrier
Treatment: Antifungal Ointment, then Desitin
Application Instructions: Apply antifungal as ordered and cover with Desitin (“icing on cake”).
With Diaper Changes: Try to remove only stool.Leave barrier of Desitin on skin if possible
Scheduled Antifungal Doses: Gently remove any residual products to allow assessment of skin,then reapply both antifungal, then Desitin
Assessment: Denuded Skin*No Candida
Goal: Prevent further breakdown, Provide barrier
Treatment: Adapt Stoma Powder, then Desitin. If no improvement, use “sealing” technique
Application Instructions: Apply Adapt
powder to denuded areas. May use cotton
ball to spread evenly. Powder will stick to
open skin. Apply thick layer of Desitin on
top of powder.
Assessment: Denuded SkinNo Candida
Diaper changes: Try to remove only stool. Leave barrier on skin if possible. Replace product that came off. If skin showing: Replace Adapt powder, then Desitin. If powder showing: Replace Desitin
“Sealing Technique”: Apply Adapt powder as previously described, then dab on
No-Sting Barrier* to seal powder.
Allow to dry and repeat process.
Layer with Desitin
Assessment: Denuded Skin*Candida
Goal: Prevent further breakdown, Treat candida, Provide barrier
Treatment: Antifungal Powder, then Desitin. If no improvement, use “sealing” technique
Application Instructions: Apply antifungal powder to denuded areas. May use cotton
ball to spread evenly. Powder will stick to
open skin. Apply thick layer of Desitin on top
of powder.
* Denuded skin: Moist, open, oozing ulcerations
Assessment: Denuded SkinCandida
Diaper changes: Try to remove only stool. Leave barrier if possible. Replace product that came off. If skin showing: Replace antifungal powder, then Desitin. If powder showing: Replace Desitin
“Sealing Technique”: Apply antifungal powder as previously described, then dab on No-Sting Barrier* to seal powder. Allow to dry and repeat process. Layer with Desitin
(*No-Sting Barrier is for use in babies > 28 days, and can also be applied prior to application of any barrier products)