Improving Neonatal Skin Care

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Improving Neonatal Skin Care

• Judy A. Gretz, RNC, MSN, DNP
• Emory University Emoryhealthcare

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Objectives

• During our time today we will
• Review the physiologic function and anatomy of
  the skin
• Explore the fragility and characteristics of
  neonatal skin
• Assess the newborns skin utilizing AWHONNs EBP
  Guidelines
• Compare sponge bathing to immersion bathing
• Discuss recommended skin care practices for
  prevention and treatment of skin issues

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Function of the Skin

• Barrier against infection
• Protection of internal organs
• Regulates insensible water loss
• Secretes electrolytes and water
• Provides tactile sensory input for sensations of
  touch, pressure, temperature, pain, and itch

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Anatomy of the Skin
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Stratum Corneum of Epidermis

• The Epidermis is subdivided into 5 layers (from
  deepest to most superficial layer
• Stratum basale (cellular generation layer)
• Stratum spinosum
• Stratum granulosum
• Stratum lucidum
• Stratum corneum (outermost layer vital barrier
  of skin)

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Underdeveloped Stratum Corneum

• Toxicity from topical agents
• Percutaneous absorption of neomycin has been
  reported to cause neural deafness
• Increased fluid, heat loss
• 10-20 layers of S.C. in the adult and term
  newborn
• Preterm infants have fewer layers of S.C.
• Traumatic injury
• Portal of entry for infection
• Diminished cohesion of dermis and epidermis
• make infant vulnerable to blistering and
  trauma, i.e adhesive removal

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Collagen Stability Decreased in Dermis

• Edema
• Blood flow
• reduced
• to epidermis
• Risk
• for injury

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Characteristics of Neonatal Skin

• Appearance
• Skin pH
• Nutritional
• stores
• Vulnerability
• to infection

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Goals of Neonatal Skin Care

• Reduce traumatic injury
• Prevent dryness
• Avoid exposure to toxins
• Minimize exposure to unnecessary substances
• Promote normal skin development

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Skin Assessment

• Assess skin surfaces head-to-toe daily
• Note risk factors in environment
• Use an objective scale to assess skin condition

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Neonatal Skin Condition Scale

• Dryness
• 1 normal, no dryness
• 2 dry skin, visible scaling
• 3 very dry skin, cracking/fissures
• Erythema
• 1 no evidence of erythema
• 2 visible erythema lt 50 body surface
• 3 visible erythema gt 50 body surface
• Breakdown
• 1 none
• 2 small localized areas
• 3 extensive

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Preventing Skin Breakdown

• Cotton surfaces, sheepskin
• Water or air mattress, gel pads
• Petrolatum-based emollient over groin, thigh
• Transparent dressings on knees, elbows

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Adhesives

• Primary cause of skin breakdown
• Minimize amount of adhesive contact
• Bonding agents increase risk of trauma
• Mineral oil, emollients facilitate removal
• Avoid toxic solvents

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Adhesive Products

• Hydrogel electrodes, strips
• Pectin barriers, hydrocolloid tapes
• Soft gauze wraps
• Transparent dressings
• Alcohol-free skin protectants

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Treatment of Skin Breakdown

• Culture, gram stain
• to identify colonization
• Use antifungal ointment if fungus cultured
• Monitor for systemic fungal infection
• Consider systemic antifungal treatment

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Treatment of Skin Breakdown

• Culture, gram stain
• to identify colonization
• Use antifungal ointment if fungus cultured
• Monitor for systemic fungal infection
• Consider systemic antifungal treatment

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Treatment of Skin Breakdown

• Flush with sterile water or ½ normal saline
• Cover with petrolatum ointment
• Use transparent dressings, hydrogel, hydrocolloid
  dressings in selected cases
• Disinfectant solutions injure healing tissue

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Transepidermal Water Loss

• Increased in premature infants lt30 weeks
• Select one of the following strategies
• High humidity (gt70 RH for 7 days)
• Transparent adhesive dressings
• Petrolatum-based emollient every 6 hrs

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Nutrition

• Zinc intake 400mcg/kg/day in premature infants
• Full-term infants need 100-200mcg/kg/day, more if
  surgery
• IV lipids 0.5g/kg/day prevents EFAD
• Adequate calories, protein intake needed

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Tub Bathing versus Sponge Bathing for the Term
Newborn

• The goals of this project were to
• 1. Determine whether tub bathing lowers a
  newborns axillary temperature significantly more
  or less than sponge bathing.
• 2. Determine whether or not there is a
  significant difference in umbilical cord healing
  between newborns who are tub bathed and those who
  are sponge bathed from 2-24 hours of birth.

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Goals Objectives cont.

• 3. Determine whether newborns that are tub
  bathed are more content during the bath than
  those who are sponge bathed.
• 4. Explore whether mothers of newborns who were
  tub bathed express more pleasure with the bath
  and are more confident regarding bathing on
  discharge than are mothers of newborns who are
  sponge bathed.

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Results
Goal 1 Significant? YES Goal 3 Significant? YES
Goal 2 Significant? NO Goal 4 Significant? NO
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First Bath

• Vital signs, temp
• stable 2 4 hours
• Antiseptic soaps
• not required
• Universal
• precautions
• Not necessary
• to remove all vernix

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Literature Synthesis

• No clinically significant heat loss when
  appropriate steps to preserve heat loss are
  taken.
• Infants and mothers more content with tub
  bathing.
• Flexible bathing time is acceptable and family
  choice is important.
• Babies may be safely bathed at the bedside.
• No difference in cord healing found.

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Umbilical Cord Care

• Cleanse cord during bathing
• Initial application of anti-microbial agents is
  debatable
• Routine isopropyl alcohol delays cord separation
• Educate about normal cord appearance

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Circumcision Care

• Disinfect prior to procedure
• Cleanse thoroughly with water
• Apply petrolatum-gauze dressings to site
• No proven benefit from antimicrobial ointments

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Diaper Dermatitis

• Urine makes skin moist, susceptible to injury
• Alkaline pH activates enzymes, bile salts in
  stools which cause breakdown
• Identify and treat underlying cause

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Diaper Dermatitis

• Use zinc oxide
• ointments
• Apply thick layer
• to prevent re-injury
• Use antifungal
• ointments for candida

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Using Evidence-Based Skin Care

• Improves skin condition for premature and
  full-term infants
• Protects skin during normal development
• Reduces exposure to toxic or sensitizing agents
• May have long-term benefits for skin

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Acknowledgements

• I would like to thank Juanita Davis, NNP-BC for
  sharing slides and information for this
  presentation today.
• I also would like to thank all of the unsung
  heroes at the bedside, no matter their title or
  discipline, who each and every day support the
  lives of the smallest humans on earth.
• Thank you

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Bibliography

• Anderson, G. C., Lane, A. E., Chang, H. (1995).
  Axillary Temperature in Transitional Newborn
  Infants Before and After Tub Bath. Applied
  Nursing Research, 8(3), 123-128.
• Bryanton, J., Walsh, D., Barrett, M., Gaudet,
  D. (2004). Tub Bathing Versus Traditional Sponge
  Bathing for the Newborn. JOGNN, 33(6), 704-712.
• Cole, J. G., Brissette, N. J., Lunardi, B.
  (1999). Tub Baths or Sponge Baths for Newborn
  Infants? Mother Baby Journal, 4(3), 39-43.

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Bibliography cont.

• Hardman, M.J., Moore, L., Ferguson, M. Byrne,
  C. (1999) Barrier Formation in the Human Fetus
  is Patterned. Journal of Investigative
  Dermatology, p1106-1113.
• Hardman, M.J. Byrne, C. (2003). Neonatal Skin
  Structure Function, Marcel Dekker Inc., USA.
• Lund, C. H., Osborne, J. W., Kuller, J., Lane, A.
  T., Lott, J. W., Raines, D. A. (2001).
  Neonatal Skin Care Clinical Outcomes of the
  AWHONN/NANN Evidence-Based Clinical Practice
  Guideline. JOGNN, 30(1), 41-51.