SKIN ASSESSMENT - IN IN THE HE NEWBORN INF INFANT August, D L - PowerPoint PPT Presentation

SKIN ASSESSMENT - IN IN THE HE NEWBORN INF INFANT August, D L PhD Ca Candid idate NNCA CA, October 2016 Th The Townsvi vill lle Hosp spit ital l and Healt lth Se Servic vice 1

ACKNOWLEDGMENTS Patients/Families, Neonatal Unit Staff, Health & Wellbeing Service Group FUNDING • Mona Kendall Association • Parker Health Care & Australian College of Neonatal Nurses • The Townsville Research Trust Fund • Graduate Research School of James Cook University Karen New, Robin Ray, Yoga Kandasamy & Liza Edmonds 2

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Neonate/newb Measurements orn outcomes of skin health Objectives 4

THE GOAL 5

Creatinine Kidneys Urine output Minute/Tidal volumes Lungs Oxygenation Evaluate Heart rate, Perfusion Heart Echocardiogram, Electrocardiogram Visual assessment Skin Trans Epidermal Water Loss, pH HEALTH, FUNCTIONALITY & MATURITY 7

TEWL-Trans Epidermal Water Loss Skin Visual assessment TEWL Hey, Wu, Farnroff (1970) Rutter and Hull (1979) g/m 2 of water loss various gestational ages • • 4hours, 4 days, 3 weeks of life • 18 anatomical sites • Abdomen highest water loss <30 weeks • Thermoregulation & volume of fluid losses Harpin & Rutter (1983), Kalia et al. (1998) • TEWL, term ≤ adult  mature Lund & Kuller (1997) • Tape removal sites •  TEWL (pectin & plastic) EVALUATION OF HEALTH 8

TEWL & More Skin Visual assessment Skin health Hoeger et al. (2002) • pH, skin desquamation, stratum corneum hydration, surface texture (n=202, term) • 3 day, 4 weeks, 12 weeks , 4 anatomical sites • Differences in skin apparent in first 3 months Nikolovski & Stamatas (2008) • 124 infants (3-12 months) • water holding properties & transport differed Fluhr et al. (2010) • Doppler measure for perfusion • TEWL term ≠ preterm ≠ < 25 weeks • < 25 weeks (longer development) • (2014) electron microscope • Low surface acid   stratum corneum cohesion EVALUATION OF HEALTH 9

TEWL, pH Skin Visual assessment Lund et al. (2001, 2004) NSCS – Neonatal Skin Condition Score Lund et al. (1986) Dryness- Intact 1- normal, no dry skin 2- dry skin, visible scaling Dry/flaky 3- very dry, cracking/fissures Erythema- Reddened 1- no erythema Excoriated 2- visible erythema < 50% of body surface 3- visible erythema > 50% of body surface Breakdown/excoriation 1- none evident 2- small localized areas 3- extensive Perfect score = 3, worst score =9 68.7%-85.4% (intrarater) and 65.9%- 89% (interrater) 10

TEWL Skin Visual assessment Vi Visscher M. . A Practic ical l Meth thod for or Ra Rapid Measurement of of Skin Skin Con Condit ition. Newborn and and Inf Infant Nurs ursing Revie iews. . 12//2014;14(4):147-152. 12// 152. 11

SKIN INTEGRITY INTERVENTIONS Humidity Moisture Agents Cleansing Prevention of harm 12

SKIN INTEGRITY INTERVENTIONS Darmstadt et al. (2005) Lund et al. (2001) Prospective evaluation of skin care bundle & Aquaphor  Sunflower seed oil Bangladesh outcomes • Nosocomial infection Oils Emollients • No increased rates of infection Cooke (2011) Conner et al. (2003)- Cochrane Review UK Infant Massage & Oil for skin care Moisture Agents Ointment & Emollients for preterm skin • (2014) Protocol for trial >37 weeks • Aquaphor and Eucerin Danby et al. (2013) • Paraffin - TEWL • Skin conditions improved (TEWL) Olive oil  Sunflower seed oil UK • Coagulase Negative Staph increased • Adults, 4 weeks Cleansing • TEWL loss = tape stripping •  Stratum C. thickness Salam et al. (2015) RCT • Low alcohol % Nangia et al. (2015) RCT •  Povidone- • ‘Gentle’ Coconut oil and control for colonization Pakistan • iodine Odorless/colorless • 751gm- 1499g India • • Chlorhexdine Amount • TEWL, skin swabs, skin condition score (antimicrobial) without  infection •  Contact time 13

SKIN INTEGRITY INTERVENTIONS <30 weeks 60-80 % Emollients Humidity Wean day 7 & Length of Time stop at day14 Moisture Agents Born <25 weeks keep 4 weeks Cleansing Prevention of harm Example Text 14

Pressure Epidermal Dermatologic Collodion Stripping Iatrogenic Dermatitis Infection Scalded Skin Burn Genetic Epidermolysis bullosa Extravasation Benign Delivery/Birth Erythema Toxicum Injuries

Frequency & Severity 16

DEPTH REDNESS

SKIN INJURIES Pressure Epidermal Skin Injuries Stripping Dermatitis Burn Extravasation Delivery/Birth Injuries

SKIN INJURIES Pressure DERMATITIS Epidermal Skin Injuries Stripping Dermatitis Burn BURNS Extravasation Delivery/Birth Injuries

Pressure Epidermal Skin Injuries Stripping Dermatitis Burn Extravasation Delivery/Birth Injuries

Walk lker et t al. l. (2 (2009) n= 43, extremely preterm infants n= 44, matched term controls Follow up at 11 years 20 mild scaring 11 Moderate procedural investigation 12 Scars from surgery Li Li et t al. l. (2 (2015) Differences in thermal sensitively but not mechanical sensitivity n=11 13.9 ± 4.6 years (born 25.6 ± 1.6 weeks) Nasal deformities: • Nostril asymmetry • Collumellar asymmetry (septum) • Nasal tip deviation • Airway obstruction OUTCOMES 21

Newman (201 (2014) Yon ong (200 Fischer (200 Fi (2005) (2005) Günlemez (2014) n=78 (<1500 gm) Collins (2014) n=89 (28.7 ±2.3- 29.7 ± n=420/989 n= 179 n= 35, mask 2.5 weeks) n= 87 Silicone gel n= 132 (<32 weeks) Pressure Ulcer Advisory n= 21, prong n= 92 control n= 67 HHF + whiskers n=12/41 (29%) mask Panel Staging- n= 22, rotation n= 65 NCPAP n= 17/48 (35%) prongs Injury control – 13 (14.9%) 3 stages (stage 4 not NSCS- Lund (2004) n= 32 whiskers Injury gel- 4 (4.3%) used) • Length of time of CPAP n= 33 cannualaide • Necrosis higher in control Rotation group had • Born < 1500grams (OR (adjusted odds ratio best skin scores 0-Normal Bleeding 2.28, 95% CI 1.43 to 1.04; 95% Cl 1.01- • Risks included days on 1-Pink/ red Crusting 3.64) 1.07; p = 0.003) CPAP (p<0.001) 2- bleeding/ulcer/scab • Excoriated Nasal CPAP was used > • No statistical • Current gestational 3-skin tear Necrosis 5 days (OR 5.36, 95% difference between age (p=0.006) • CI 3.82 to 7.52) HHF + whiskers= less gestational age or use • Unit was >14 days (OR injury in 7 days post of mask/ prongs 1.67, 95% CI 1.22 to extubation • 2.28) No difference in trauma scores • Trauma score 2.8 (SD 5.7) or 11.7 (SD 12.5), p <0.001 Nasal Prongs vs. Masks & role of layers • Wiskers 14.4 (SD 12.5) or Cannualaide 9.5 (SD 7.3), p=0.006 22

Janata et al. (2010) Fischer et al. (2010)

Doll Dollis ison an and Bec Beckstr trand Lund et al Lu al. 1995 1995 1997 1997 Case control- Control site vs. pectin vs. adhesive 3 adhesives: plastic, pectin, gel 4/20 R pectin vs. Pectin and plastic 13/20 R tape significantly worse 3/20 E tape measurements 20 neonates 30 neonates (28-33 weeks) (26- 40 weeks) I- intact/moist D- dry Irritation/Stripping scales R- red intact +TDWL and colorimeter E- excoriated measurements Lund et al 1986

DEPTH REDNESS

NEONATAL SKIN AUDIT 2010-2012 26

Neonatal Skin audit cohort No injury occurred n=170 2 years: 247 patients Mean birth weight : 1155g 1155g (range (r e 445-2678g, SD SD 620g) g) Injuries occ Inju occurred Gestation: 28 28 wee eeks n= 77 n= 77 (range 22-41 weeks, SD (r D 4.1 .1) (10 (107 inj njurie ies) n=18 n=19 n=24 n= 34 Stage 1 St Stage 2 St Stage 3 St St Stage 4 Strippin St ing Temperature Airway n= n=32 n= 41 n= 41 n= 15 n= 15 n= 3 n= n= 16 n= 16 Vascular catheters & saturation Unknown devices probes 27

PROSPECTIVE (DAILY REPORTS OVER 9 MONTHS) Multiple Injury Rate 46.1 .1% 32 32 weeks (23 (23- 1960 g 115 41.4) 41. Media ian 32 32 [28 28- 33.9 .9% (60 600-4460g) 36] 36] wee eeks 39 39 In Injuries Observational Birth weight & Gestational Age Injury Information 28

Weeks of of Age 1st 2nd Older Week Week Stages 1-4 16 2 9 Stripping 6 4 1 2 nd Injury 9 2 7 PILOT OUTCOMES 29

Skin Assessment for measureable outcomes 3 https://catatoniccomic.wordpress.com/tag/cartoon/ 0

OUTCOMES 31