J Wound Ostomy Continence Nurs. 2014;41(3):219-221. Published by Lippincott Williams & Wilkins
CHALLENGES IN PRACTICE
Application of a Pectin Barrier for Medical Adhesive Skin Injury (Epidermal Stripping) in a Premature Infant Amanda O’Neil
Bette Schumacher
■ ABSTRACT BACKGROUND: Premature infants require, as part of their care, devices such as monitors and temperature probes to be attached to their skin. However, because of immaturity of the skin, they are especially vulnerable to medical adhesive-related skin injury. CASE: This case discusses the application of a hydrocolloid (pectin) barrier between the adhesive surface of a silver reflective patch covering thermistor probe and the neonate’s skin resulting in medical adhesive skin injury (epidermal stripping). CONCLUSIONS: The use of this pectin barrier proved to be a suitable surface to secure the temperature probe and avoid further medical adhesive-related skin injury. KEY WORDS: Premature infant, Skin barrier, Skin stripping
■ Introduction Because of advances in neonatal care, more immature infants are receiving care in neonatal intensive care units (NICUs). Immaturity influences multiple body systems including lungs, the gastrointestinal tract, and skin. Immature skin lacks connecting fibrils, layers of the stratum corneum, and collagen, which can increase the risk of medical adhesive-related skin injury associated with application and removal of the continuous monitoring equipment and adhesives.1 The immature skin of the premature infant is fragile and development of this organ is incomplete. The protective top layers of the epidermis, known as the stratum corneum, are often absent or sparse in the premature infant’s skin. These layers take weeks or months to develop fully.2,3 Premature infants often have fewer fibrils that connect the dermis to the epidermis. Skin injury, from adhesives from devices attached to the infant’s skin, can result when the bond between the adhesive and the epidermis is greater than the bond between the epidermis and the underlying dermis.1,3 Attachment of monitoring devices to the skin is
a routine part of care for immature infants. We describe a case of epidermal stripping that occurred after the removal of a device and a method to prevent it.
■ Case Presentation Baby boy Smith was born after a 24-week pregnancy. His mother had no prenatal care and initially presented for care in active labor. Prior to delivery, she received a single dose of an antibiotic and dexamethasone, a medication given to increase infant lung maturity. In addition, Apgar scores were calculated at 1 and 5 minutes. The Apgar scoring system is a screening tool to evaluate a newborn’s condition at birth and need for intervention.4 The following 5 variables are included: heart rate, respiratory effort, muscle tone, reflex irritability, and color. A numerical score of 0 to 2 is assigned in each category for a maximum score of 10; higher scores (≥7) are considered within normal range and lower scores indicate poorer overall condition. Baby boy Smith’s Apgar scores were 5 at 1 minute and 7 at 5 minutes; the score of 5 at birth was attributable to 1 point off for all variables, indicating the need for intervention. He was intubated at delivery and lung surfactant was administered in the delivery room via tracheal tube to alleviate breathing problems related to his immature lungs. His birth weight was 650 g (1 lb 6 oz). His appearance was typical for a very immature infant; he was observed to have a hairless body and smooth, red, wrinkly, nearly gelatinous skin. He required an isolette (incubator) type bed to regulate his temperature. Attached to his skin were 3 electrocardiography leads, an oxygen saturation Amanda O’Neil, RN, MS, Staff Nurse, and Nurse Practitioner Masters Student, Sanford USD Medical Center, Sioux Falls, South Dakota. Bette Schumacher, RN, MS, CPN, Clinical Nurse Specialist, Sanford USD Medical Center, Sioux Falls, South Dakota. The authors declare no conflict of interest. Correspondence: Bette Schumacher, RN, MS, CPN, Sanford USD Medical Center, Sioux Falls, SD 57110 (Bette.Schumacher@ SanfordHealth.org). DOI: 10.1097/WON.0000000000000029
Copyright © 2014 by the Wound, Ostomy and Continence Nurses Society™
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Copyright © 2014 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited.
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monitor, tape to secure the tracheal tube, and a reflective patch to cover a temperature probe. An umbilical catheter was stabilized on his abdomen. Baby Smith required full ventilator support, vasopressors, parenteral nutrition, and other medications. He did not tolerate handling and bathing was deferred. The reflective patch was removed after 8 days when he was more stable. A circular erythematous area approximately 1.5 cm in diameter was noted on his skin surface after patch removal, and epidermal tissue was noted on the reflective patch. The circular wounded surface had small pinpoint areas of bleeding with uniform redness over the entire area. Within his wound, an indentation corresponding to the size and location of the temperature probe was observed. Electrocardiography leads were removed and repositioned without evidence of skin damage. The electrocardiography leads used at out facility do not contain adhesive (Neotrode II, ConMed Corp, Utica, New York). Rather, their backing has thin hydrocolloid as the “glue” that attaches them to the infant’s chest. All subsequent applications of the temp probe for Baby Smith were done using the method described. No further episodes of epidermal stripping resulted for this infant. His injured area healed well without scar formation. No other injuries were noted to his skin under the area of the probe. Based on the experiences with Baby Smith, we have implemented a change in practice to prevent epidermal stripping with these fragile infants.
■ Discussion Full-term infants are unable to create heat by shivering like adults do. The primary mechanism to generate heat is called nonshivering thermogenesis5; this process breaks down a special type of fat (brown fat) that produces heat. Therefore, because immature infants lack brown fat, they require a neutral thermal environment that requires minimal oxygen and calories in order to maintain body temperature.6 Neonatal intensive care units use special incubator-type beds to maintain a neutral thermal environment.5 Temperature probes are commonly used in NICUs nationwide in incubator-type beds and warmers. They measure skin temperature and act as feedback mechanism to regulate the infant’s body temperature. The probe is usually covered with a silver reflective patch, enabling it to measure the heat of the infant’s skin rather than the temperature of the heat source. The surface of the reflective patch is attached to the premature infant’s skin via an adhesive. Placement of the probe is important because of its influence on the accuracy of skin temperature measurement. It should be secured at or about the costal margin of the chest, midway between the xiphoid and the navel, about the right upper quadrant of the abdomen. The temperature probe does need to be repositioned to provide a complete skin assessment and when bathing the infant. In addition, these fragile infants should not lie on probes,
■ May/June 2014
intravenous tubing, or other wires, as these can cause device-related pressure ulcers.
Skin Care in the Premature Infant Allwood7 reviewed the literature and concluded that research focusing on skin care in premature infants is sparse. Allwood discussed two studies by Lund and colleagues,3,8 which remain the most comprehensive studies to date. In addition, a lack of published studies on the effects of topical agents on neonatal skin, particularly adequately sized randomized controlled trials, has been noted.2,7 Use of pectin barriers to protect the skin of premature infants was first described by Dollison and Bestrand.9 Although this practice is also recommended by Lund, universal adoption of this practice is lacking.7 Protecting the epidermis from medical adhesive skin damage can be facilitated through the use of a barrier product. Morris and colleagues10 examined dressings with soft silicone adhesive technology for pediatric patients. A product option they described (Mepilex, Mölnlycke Health Care, Norcross, Georgia) also might be used for the purpose described in this case study. We did not trial the silicone adhesive dressings for this purpose, as a pectin product (DuoDERM Signal by ConvaTec) was readily available and more familiar to us (Figure 1). Pectin barriers (Hollihesive, Hollister, Libertyville, Illinois; Duoderm, Step 1 Using a thin barrier wafer product, trace the silver temperature relective patch and cut it out.
Step 2 Cut a slit up middle of barrier circle patch that is about the size of the temperature probe.
Step 3 Place the barrier circle patch on infant. Step 4 Place the temperature probe in the slit. Step 5 Place the silver reflective temperature patch over top of barrier circle patch and probe. Use the thinnest reflector patch available.
Change barrier and temp patches every 7 days. Document date to be changed in kardex. You may also write the date to be changed on the temp patch itself. Finished Product! FIGURE 1. Application of a pectin barrier.
Copyright © 2014 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited.
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J WOCN ■ Volume 41/Number 3 ConvaTec/Bristol-Myers Squibb Co, Princeton, New Jersey) are available in a variety of sizes and thicknesses. These dressings are made from a layer of gel-forming material attached to a semipermeable film or foam backing. Some are designed for specific areas of the body such as the adult sacrum or heel. Some thinner dressings have tapered edges that make them less likely to wrinkle or roll up at the edges. These thinner products may also be semitransparent allowing the nurse to see the skin without the need to remove the dressing. Placing a thin barrier product underneath the area of the adhesive lessens stripping as bonding between the skin and the adhesive is prevented.7,9 The thin barrier pectin product allows direct contact of the temperature probe to the skin when cut as illustrated in Figure 1. However, care must be taken to alternate the position of the temperature probe, reflective cover, and barrier product to prevent the pressure injuries from the temperature probe. Our nursing protocol permits leaving the patch and probe in place for up to 1 week. Nurses may reposition the probe and patch if the baby’s temperature is not reading well. This innovative practice impacted nursing practice throughout our facility via a process of Shared Governance. Our nursing practice council maintains an online information site that is accessible to all the nursing staff. Electronic instructions and pictures were posted to the site. Information was shared at unit meetings. In addition, we collaborated with Education Council to provide bathroom posters: “Potty Ponders” as well as “Just in time” education for those nurses who admitted babies to the NICU.
■ Summary The case discussed in this “Challenges in Practice” column illustrated the use of a thin hydrocolloid product to protect the skin from an adhesive surface required for placement of a thermistor probe. After implementation of this practice change, we no longer noted skin stripping due to patch application and removal for this infant or others. Rotation of the site of the temperature probe is important
O’Neil and Schumacher
221
to be able to assess all of the skin, as well as to prevent pressure injuries. Adapting a hydrocolloid product in the fashion demonstrated by us is not recommended to secure life-sustaining equipment, such as an endotracheal tube, as other devices are available designed specifically for this purpose.11
■ References 1. McNichol L, Lund C, Rosen T, Gray M. Medical adhesives and patient safety: state of the science. Consensus statements for the assessment, prevention, and treatment of adhesive-related skin injuries. J Wound Ostomy Continence Nurs. 2013;40:365380. 2. Blume-Peytavi U, Hauser M, Stamatas GN, Pathirana D, Garcia Bartels N. Skin care practices for newborns and infants: review of the clinical evidence for best practices. Pediatr Dermatol. 2012;29(1):1-14. 3. Lund C, Kuller J, Lane A, Lott JW, Raines DA. Neonatal skin care: the scientific basis for practice. Neonatal Netw. 1999;19(4): 15-26. 4. Rubarth L. The Apgar score: simple yet complex. Neonatal Netw. 2012;31(3):169-176. 5. Knobel R, Holditch-Davis D. Thermoregulation and heat loss prevention after birth and during neonatal intensive-care unit stabilization of extremely low-birthweight infants. Adv Neo Care. 2009;10:S7-S14. 6. Baumgart S. Iatrogenic hyperthermia and hypothermia in the neonate. Clin Perinatol. 2008;35:183-197. 7. Allwood M. Skin care guidelines for infants aged 23-30 weeks’ gestation: a review of literature. Neonatal Paediatr Child Health Nurs. 2011;14(1):20-27. 8. Lund CH, Osborne JW, Kuller J, Lane AT, Lott JW, Raines DA. Neonatal skin care: clinical outcomes of the AWHONN/NANN evidence-based clinical practice guideline. Association of Women’s Health, Obstetric and Neonatal Nurses and the National Association of Neonatal Nurses. J Obstet Gynecol Neonatal Nurs. 2001;30:41-51. 9. Dollison EJ, Bestrand J. Adhesive tape vs. pectin based barrier use in preterm infants. Neonatal Netw. 1995;14:35-39. 10. Morris C, Emsley P, Marland E, Meuleneire F, White R. Use of wound dressings with soft silicone adhesive technology. Paediatr Nurs. 2009;21(3):38-43. 11. McLean S, Kirchhoff KT, Kriynovich J, VonDerAhe L. Three methods of securing endotracheal tubes in neonates: comparison. Neonatal Netw. 1992;11:17-20.
Copyright © 2014 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited.
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CHALLENGES IN PRACTICE
Application of a Pectin Barrier for Medical Adhesive Skin Injury (Epidermal Stripping) in a Premature Infant Amanda O’Neil
Bette Schumacher
■ ABSTRACT BACKGROUND: Premature infants require, as part of their care, devices such as monitors and temperature probes to be attached to their skin. However, because of immaturity of the skin, they are especially vulnerable to medical adhesive-related skin injury. CASE: This case discusses the application of a hydrocolloid (pectin) barrier between the adhesive surface of a silver reflective patch covering thermistor probe and the neonate’s skin resulting in medical adhesive skin injury (epidermal stripping). CONCLUSIONS: The use of this pectin barrier proved to be a suitable surface to secure the temperature probe and avoid further medical adhesive-related skin injury. KEY WORDS: Premature infant, Skin barrier, Skin stripping
■ Introduction Because of advances in neonatal care, more immature infants are receiving care in neonatal intensive care units (NICUs). Immaturity influences multiple body systems including lungs, the gastrointestinal tract, and skin. Immature skin lacks connecting fibrils, layers of the stratum corneum, and collagen, which can increase the risk of medical adhesive-related skin injury associated with application and removal of the continuous monitoring equipment and adhesives.1 The immature skin of the premature infant is fragile and development of this organ is incomplete. The protective top layers of the epidermis, known as the stratum corneum, are often absent or sparse in the premature infant’s skin. These layers take weeks or months to develop fully.2,3 Premature infants often have fewer fibrils that connect the dermis to the epidermis. Skin injury, from adhesives from devices attached to the infant’s skin, can result when the bond between the adhesive and the epidermis is greater than the bond between the epidermis and the underlying dermis.1,3 Attachment of monitoring devices to the skin is
a routine part of care for immature infants. We describe a case of epidermal stripping that occurred after the removal of a device and a method to prevent it.
■ Case Presentation Baby boy Smith was born after a 24-week pregnancy. His mother had no prenatal care and initially presented for care in active labor. Prior to delivery, she received a single dose of an antibiotic and dexamethasone, a medication given to increase infant lung maturity. In addition, Apgar scores were calculated at 1 and 5 minutes. The Apgar scoring system is a screening tool to evaluate a newborn’s condition at birth and need for intervention.4 The following 5 variables are included: heart rate, respiratory effort, muscle tone, reflex irritability, and color. A numerical score of 0 to 2 is assigned in each category for a maximum score of 10; higher scores (≥7) are considered within normal range and lower scores indicate poorer overall condition. Baby boy Smith’s Apgar scores were 5 at 1 minute and 7 at 5 minutes; the score of 5 at birth was attributable to 1 point off for all variables, indicating the need for intervention. He was intubated at delivery and lung surfactant was administered in the delivery room via tracheal tube to alleviate breathing problems related to his immature lungs. His birth weight was 650 g (1 lb 6 oz). His appearance was typical for a very immature infant; he was observed to have a hairless body and smooth, red, wrinkly, nearly gelatinous skin. He required an isolette (incubator) type bed to regulate his temperature. Attached to his skin were 3 electrocardiography leads, an oxygen saturation Amanda O’Neil, RN, MS, Staff Nurse, and Nurse Practitioner Masters Student, Sanford USD Medical Center, Sioux Falls, South Dakota. Bette Schumacher, RN, MS, CPN, Clinical Nurse Specialist, Sanford USD Medical Center, Sioux Falls, South Dakota. The authors declare no conflict of interest. Correspondence: Bette Schumacher, RN, MS, CPN, Sanford USD Medical Center, Sioux Falls, SD 57110 (Bette.Schumacher@ SanfordHealth.org). DOI: 10.1097/WON.0000000000000029
Copyright © 2014 by the Wound, Ostomy and Continence Nurses Society™
J WOCN
■ May/June 2014 219
Copyright © 2014 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited.
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monitor, tape to secure the tracheal tube, and a reflective patch to cover a temperature probe. An umbilical catheter was stabilized on his abdomen. Baby Smith required full ventilator support, vasopressors, parenteral nutrition, and other medications. He did not tolerate handling and bathing was deferred. The reflective patch was removed after 8 days when he was more stable. A circular erythematous area approximately 1.5 cm in diameter was noted on his skin surface after patch removal, and epidermal tissue was noted on the reflective patch. The circular wounded surface had small pinpoint areas of bleeding with uniform redness over the entire area. Within his wound, an indentation corresponding to the size and location of the temperature probe was observed. Electrocardiography leads were removed and repositioned without evidence of skin damage. The electrocardiography leads used at out facility do not contain adhesive (Neotrode II, ConMed Corp, Utica, New York). Rather, their backing has thin hydrocolloid as the “glue” that attaches them to the infant’s chest. All subsequent applications of the temp probe for Baby Smith were done using the method described. No further episodes of epidermal stripping resulted for this infant. His injured area healed well without scar formation. No other injuries were noted to his skin under the area of the probe. Based on the experiences with Baby Smith, we have implemented a change in practice to prevent epidermal stripping with these fragile infants.
■ Discussion Full-term infants are unable to create heat by shivering like adults do. The primary mechanism to generate heat is called nonshivering thermogenesis5; this process breaks down a special type of fat (brown fat) that produces heat. Therefore, because immature infants lack brown fat, they require a neutral thermal environment that requires minimal oxygen and calories in order to maintain body temperature.6 Neonatal intensive care units use special incubator-type beds to maintain a neutral thermal environment.5 Temperature probes are commonly used in NICUs nationwide in incubator-type beds and warmers. They measure skin temperature and act as feedback mechanism to regulate the infant’s body temperature. The probe is usually covered with a silver reflective patch, enabling it to measure the heat of the infant’s skin rather than the temperature of the heat source. The surface of the reflective patch is attached to the premature infant’s skin via an adhesive. Placement of the probe is important because of its influence on the accuracy of skin temperature measurement. It should be secured at or about the costal margin of the chest, midway between the xiphoid and the navel, about the right upper quadrant of the abdomen. The temperature probe does need to be repositioned to provide a complete skin assessment and when bathing the infant. In addition, these fragile infants should not lie on probes,
■ May/June 2014
intravenous tubing, or other wires, as these can cause device-related pressure ulcers.
Skin Care in the Premature Infant Allwood7 reviewed the literature and concluded that research focusing on skin care in premature infants is sparse. Allwood discussed two studies by Lund and colleagues,3,8 which remain the most comprehensive studies to date. In addition, a lack of published studies on the effects of topical agents on neonatal skin, particularly adequately sized randomized controlled trials, has been noted.2,7 Use of pectin barriers to protect the skin of premature infants was first described by Dollison and Bestrand.9 Although this practice is also recommended by Lund, universal adoption of this practice is lacking.7 Protecting the epidermis from medical adhesive skin damage can be facilitated through the use of a barrier product. Morris and colleagues10 examined dressings with soft silicone adhesive technology for pediatric patients. A product option they described (Mepilex, Mölnlycke Health Care, Norcross, Georgia) also might be used for the purpose described in this case study. We did not trial the silicone adhesive dressings for this purpose, as a pectin product (DuoDERM Signal by ConvaTec) was readily available and more familiar to us (Figure 1). Pectin barriers (Hollihesive, Hollister, Libertyville, Illinois; Duoderm, Step 1 Using a thin barrier wafer product, trace the silver temperature relective patch and cut it out.
Step 2 Cut a slit up middle of barrier circle patch that is about the size of the temperature probe.
Step 3 Place the barrier circle patch on infant. Step 4 Place the temperature probe in the slit. Step 5 Place the silver reflective temperature patch over top of barrier circle patch and probe. Use the thinnest reflector patch available.
Change barrier and temp patches every 7 days. Document date to be changed in kardex. You may also write the date to be changed on the temp patch itself. Finished Product! FIGURE 1. Application of a pectin barrier.
Copyright © 2014 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited.
JWOCN-D-13-00072.indd 220
4/28/14 7:42 AM
J WOCN ■ Volume 41/Number 3 ConvaTec/Bristol-Myers Squibb Co, Princeton, New Jersey) are available in a variety of sizes and thicknesses. These dressings are made from a layer of gel-forming material attached to a semipermeable film or foam backing. Some are designed for specific areas of the body such as the adult sacrum or heel. Some thinner dressings have tapered edges that make them less likely to wrinkle or roll up at the edges. These thinner products may also be semitransparent allowing the nurse to see the skin without the need to remove the dressing. Placing a thin barrier product underneath the area of the adhesive lessens stripping as bonding between the skin and the adhesive is prevented.7,9 The thin barrier pectin product allows direct contact of the temperature probe to the skin when cut as illustrated in Figure 1. However, care must be taken to alternate the position of the temperature probe, reflective cover, and barrier product to prevent the pressure injuries from the temperature probe. Our nursing protocol permits leaving the patch and probe in place for up to 1 week. Nurses may reposition the probe and patch if the baby’s temperature is not reading well. This innovative practice impacted nursing practice throughout our facility via a process of Shared Governance. Our nursing practice council maintains an online information site that is accessible to all the nursing staff. Electronic instructions and pictures were posted to the site. Information was shared at unit meetings. In addition, we collaborated with Education Council to provide bathroom posters: “Potty Ponders” as well as “Just in time” education for those nurses who admitted babies to the NICU.
■ Summary The case discussed in this “Challenges in Practice” column illustrated the use of a thin hydrocolloid product to protect the skin from an adhesive surface required for placement of a thermistor probe. After implementation of this practice change, we no longer noted skin stripping due to patch application and removal for this infant or others. Rotation of the site of the temperature probe is important
O’Neil and Schumacher
221
to be able to assess all of the skin, as well as to prevent pressure injuries. Adapting a hydrocolloid product in the fashion demonstrated by us is not recommended to secure life-sustaining equipment, such as an endotracheal tube, as other devices are available designed specifically for this purpose.11
■ References 1. McNichol L, Lund C, Rosen T, Gray M. Medical adhesives and patient safety: state of the science. Consensus statements for the assessment, prevention, and treatment of adhesive-related skin injuries. J Wound Ostomy Continence Nurs. 2013;40:365380. 2. Blume-Peytavi U, Hauser M, Stamatas GN, Pathirana D, Garcia Bartels N. Skin care practices for newborns and infants: review of the clinical evidence for best practices. Pediatr Dermatol. 2012;29(1):1-14. 3. Lund C, Kuller J, Lane A, Lott JW, Raines DA. Neonatal skin care: the scientific basis for practice. Neonatal Netw. 1999;19(4): 15-26. 4. Rubarth L. The Apgar score: simple yet complex. Neonatal Netw. 2012;31(3):169-176. 5. Knobel R, Holditch-Davis D. Thermoregulation and heat loss prevention after birth and during neonatal intensive-care unit stabilization of extremely low-birthweight infants. Adv Neo Care. 2009;10:S7-S14. 6. Baumgart S. Iatrogenic hyperthermia and hypothermia in the neonate. Clin Perinatol. 2008;35:183-197. 7. Allwood M. Skin care guidelines for infants aged 23-30 weeks’ gestation: a review of literature. Neonatal Paediatr Child Health Nurs. 2011;14(1):20-27. 8. Lund CH, Osborne JW, Kuller J, Lane AT, Lott JW, Raines DA. Neonatal skin care: clinical outcomes of the AWHONN/NANN evidence-based clinical practice guideline. Association of Women’s Health, Obstetric and Neonatal Nurses and the National Association of Neonatal Nurses. J Obstet Gynecol Neonatal Nurs. 2001;30:41-51. 9. Dollison EJ, Bestrand J. Adhesive tape vs. pectin based barrier use in preterm infants. Neonatal Netw. 1995;14:35-39. 10. Morris C, Emsley P, Marland E, Meuleneire F, White R. Use of wound dressings with soft silicone adhesive technology. Paediatr Nurs. 2009;21(3):38-43. 11. McLean S, Kirchhoff KT, Kriynovich J, VonDerAhe L. Three methods of securing endotracheal tubes in neonates: comparison. Neonatal Netw. 1992;11:17-20.
Copyright © 2014 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited.
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