Transcript Improving Neonatal Skin Care - Emory University Department of

Judy A. Gretz, RNC, MSN, DNP
Emory University & Emoryhealthcare
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 newborn’s skin utilizing AWHONN’s EBP
Guidelines
 Compare sponge bathing to immersion bathing
 Discuss recommended skin care practices for
prevention and treatment of skin issues
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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
The Epidermis is subdivided into 5 layers (from
deepest to most superficial layer:
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Stratum
Stratum
Stratum
Stratum
basale (cellular generation layer)
spinosum
granulosum
lucidum
◦ Stratum corneum (outermost layer & vital barrier of skin)
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Toxicity from topical agents
◦ Percutaneous absorption of neomycin has been
reported to cause neural deafness
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Increased fluid, heat loss
◦ 10-20 layers of S.C. in the adult and term newborn
◦ Preterm infants have fewer layers of S.C.
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Traumatic injury
Portal of entry for infection
◦ Diminished cohesion of dermis and epidermis
make infant vulnerable to blistering and trauma, i.e
adhesive removal
Edema
 Blood flow
reduced
to epidermis
 Risk
for injury
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Appearance
Skin pH
Nutritional
stores
Vulnerability
to infection
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Reduce traumatic injury
Prevent dryness
Avoid exposure to toxins
Minimize exposure to unnecessary
substances
Promote normal skin development
 Assess
skin surfaces head-to-toe
daily
 Note risk factors in environment
 Use an objective scale to assess
skin condition
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Dryness
◦ 1 = normal, no dryness
◦ 2 = dry skin, visible scaling
◦ 3 = very dry skin, cracking/fissures
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Erythema
◦ 1 = no evidence of erythema
◦ 2 = visible erythema < 50% body surface
◦ 3 = visible erythema > 50% body surface
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Breakdown
◦ 1 = none
◦ 2 = small localized areas
◦ 3 = extensive
Cotton surfaces, sheepskin
 Water or air mattress, gel pads
 Petrolatum-based emollient over
groin, thigh
 Transparent dressings on knees,
elbows
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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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Hydrogel electrodes, strips
 Pectin barriers, hydrocolloid tapes
 Soft gauze wraps
 Transparent dressings
 Alcohol-free skin protectants
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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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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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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
Increased in premature infants <30
weeks
 Select one of the following strategies:
◦ High humidity (>70% RH for 7 days)
◦ Transparent adhesive dressings
◦ Petrolatum-based emollient every 6
hrs
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Zinc intake 400mcg/kg/day in
premature infants
 Full-term infants need 100200mcg/kg/day, more if surgery
 IV lipids 0.5g/kg/day prevents EFAD
 Adequate calories, protein intake
needed
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The goals of this project were to:
1. Determine whether tub bathing lowers a
newborn’s 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.
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.
Goal 1: Significant?
Goal 3: Significant?
YES
YES
Goal 2: Significant?
Goal 4: Significant?
NO
NO
Vital signs, temp
stable 2 – 4 hours
 Antiseptic soaps
not required
 Universal
precautions
 Not necessary
to remove all vernix
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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.
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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 Disinfect
prior to procedure
 Cleanse thoroughly with water
 Apply petrolatum-gauze
dressings to site
 No proven benefit from
antimicrobial ointments
 Urine
makes skin moist,
susceptible to injury
 Alkaline pH activates enzymes,
bile salts in stools which cause
breakdown
 Identify and treat underlying
cause
•Use zinc oxide
ointments
•Apply thick layer
to prevent re-injury
•Use antifungal
ointments for candida
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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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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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), 704712.
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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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.