Judy A. Gretz, RNC, MSN, DNPEmory 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

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:◦ Stratum basale (cellular generation layer)◦ Stratum spinosum◦ Stratum granulosum◦ Stratum lucidum◦ Stratum corneum (outermost layer & vital barrier

of skin)

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

Edema Blood flow reduced to epidermis Risk for injury

Appearance

Skin pH

Nutritional stores

Vulnerability to infection

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 environmentUse an objective scale to assess skin condition

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 < 50% body surface◦ 3 = visible erythema > 50% body surface

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

Primary cause of skin breakdown Minimize amount of adhesive contact Bonding agents increase risk of trauma

Mineral oil, emollients facilitate removal

Avoid toxic solvents

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

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

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

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

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

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?

YES

Goal 3: Significant?

YES

Goal 2: Significant?

NO

Goal 4: Significant?

NO

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

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

Disinfect prior to procedureCleanse thoroughly with waterApply 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

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

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.

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.