Neonatal Skin Care

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Neonatal Skin Care Prepared by: LCDR Belinda Rand, RN, RNC

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Neonatal Skin Care. Prepared by: LCDR Belinda Rand, RN, RNC. Objectives. Name three functions of the skin. Describe two ways in which the skin of a newborn or preterm infant differs from that of an adult. Identify three factors that affect the appearance of the neonate’s skin. - PowerPoint PPT Presentation

Transcript of Neonatal Skin Care

Page 1: Neonatal Skin Care

Neonatal Skin Care

Prepared by: LCDR Belinda Rand, RN, RNC

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Objectives Name three functions of the skin. Describe two ways in which the skin of a newborn or preterm

infant differs from that of an adult. Identify three factors that affect the appearance of the

neonate’s skin. Identify two nursing interventions that provide protection for

the preterm infant’s skin. Recognize three common skin lesions that are normal

variations in the newborn infant. Describe their appearance and treatment, if any.

Describe three common vascular lesions in the neonate, their appearance, and appropriate treatment.

Identify two syndromes associated with vascular lesions.

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Clinical Significance Careful assessment of the skin is an important element of the

neonatal physical examination. The appearance of the skin gives the nurse important clues regarding the gestational age, nutritional status, function of organs such as the heart and liver, and the presence of cutaneous or systemic disease. It is important for the RN to be familiar with normal variances in the skin of the newborn infant, as well as those variances that signify disease.

Proper care of the neonate’s skin can directly affect mortality and morbidity, especially in the preterm infant. The skin is the first line of defense against infection. Proper skin care can protect the integrity of the skin and prevent breakdown.

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Anatomy and Physiology of the skin Three main layers

Epidermis: outermost layer, which functions as a barrier from outside penetration.

Dermis: directly under the epidermis, 2 to 4 cm thick at birth. Contains blood vessels and nerves that carry sensation; heat,

touch, pain, and pressure, sweat glands and hair shafts. Collagen and elastic fibers that connect the epidermis and dermis, and provide the skin with the ability to stretch and return to normal shape.

Subcutaneous layer: fatty tissue functions as insulation, protection of internal organs, and calorie storage.

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Layers and Structures of Human Skin

Insert Figure here

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Functions of the Skin

Physical Protection Mechanical

provides a protective barrier against transepidermal water loss and eternal invasions.

Process of sloughing prevents colonization of the skin surface by bacteria and other organisms.

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Functions of the Skin

Physical Protection Chemical/ bacterial

Acidic surface (pH) defends against bacteria and microorganisms

Production of melanin protects against damage from UV light radiation.

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Functions of the Skin

Heat Regulation

Production and evaporation of sweat. Dilatation and constriction of blood vessels. Insulation of body by subcutaneous fat.

Sense Perception

Heat, touch, pain, and pressure.

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Differences in Newborn & Preterm Skin

Basic structure is same as that of the adult

The less mature the infant, the less mature is the functioning of the skin.

The earlier the age, the more thin and gelatinous is the skin. Gradual maturing; however, at 4 wks of age a 25 wk infant has twice the transepidermal water loss as a term infant.

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Differences in Newborn & Preterm Skin

Subcutaneous fat is accumulated predominantly during the third trimester…. Preterm babies have little fat resulting in

decreased ability to maintain body temp and blood glucose levels.

Brown fat (for temp regulation) begins to differentiate in the 7th month of gestation.

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Differences in Newborn & Preterm Skin

Newborn skin is thinner and more permeable. Infants, esp. preterm, quickly absorbs

topically applied meds and chemicals. Allows for greater insensible water loss in

the preterm infant.

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Differences in Newborn & Preterm Skin

Fewer fibrils connect the dermis and epidermis, & they are more fragile than that of an adult.

Risk of injury from tape, monitor, and handling is increased.

Ex. Removal of the outermost layer of the dermis with removal of tape or electrodes.

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Differences in Newborn & Preterm Skin

Sweat glands are present at birth, but full functioning is not present until 2nd/3rd year of life. Newborn has limited ability to tolerate

excessive heat. Vasodilatation to increased heat loss can

result in hypotension and dehydration, which is attributed to increased insensible water loss.

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Care of Newborn Skin

Term Newborn Initial bath with water and a mild soap. Soaps containing hexachlorophene have

been shown to be absorbed through the skin. Don’t use.

Bacteriostatic soap safety has not been established. Use with caution, rinse completely.

Parents may want to give the first bath.

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Care of Newborn Skin

Term Infant Need a stable body temp to bathe Infant

(>36.5 C) When stable it is advisable to bathe infant to reduce caregiver’s exposure to blood-borne pathogens.

Vernix is good! The vernix caseosa contains large amounts of fats, which protect and insulates the skin, should not be scrubbed off with bath.

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Care of Newborn Skin Term Infant

Routine use of emollients is not recommended. Creams and lotions contain perfumes and are drying and can irritate the skin.

Some products can change the pH of the skin and decrease bacteriostatic properties.

Avoid puncturing skin when suspicious of maternal infection.

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Care of Preterm Skin

Preterm infant Keep skin clean with water, mild non

alkaline soap may be used. Handle infant gently and minimally to

avoid trauma. Need infrequent bathing to avoid

Excessive drying of the skin Avoid over stimulation, Stress and fatigue

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Care of Preterm Skin Preterm Infants

Minimize the use of tape, removing tape can strip the epidermis.

Transparent adhesive dressings can be used for wounds, abrasions, to secure IV’s etc.

Safety of adhesive solvents is uncertain, cotton balls soaked with warm water can be used.

Increased permeability of the skin allows for absorption of some meds and products; alcohol and betadine; can lead to chemical burns. Wash off well with water.

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Care of Preterm Skin Preterm Skin

Emollient creams, free of preservatives and perfumes may be of benefit by decreasing transepidermal water loss and skin breakdown when cracking, excessive dryness, or fissures are present.

Tent with warm mist may protect the skin and decrease insensible water loss in the very low birth weight infant.

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Assessment of Newborn Infant Skin

Factors affecting the appearance of the skin

Gestational age Postnatal age Nutritional status and hydration Racial origin Type and amount of available light Hemoglobin and bilirubin levels Environmental temperatures Oxygenation status

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Assessment of Skin

Definitions to describe skin lesions Macule; pigmented, flat spot that is

visible but not palpable. Papule; solid, elevated, palpable lesion,

with distinct borders > 1 cm in size Plaque; solid, elevated, palpable lesion,

with distinct borders > 2 cm in size Nodule; a solid lesion, elevated with

depth, up to 2 cm in size

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Assessment of Skin Definitions

Tumor; solid lesion, elevated with depth > 2 cm is size.

Vesicle; elevated lesion or blister filled with serous fluid and < 1 cm in diameter.

Bulla; fluid filled lesion larger that 1 cm. Pustule; a vesicle filled with cloudy or purulent

fluid. Petechiae; subepidermal hemorrhages, pinpoint

in size, that do not blanch.

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Assessment of Skin

Definitions Ecchymosis; a large area of

subepidermal hemorrhage. Wheal; area of edema in the upper

dermis, creating a palpable, slightly raised lesion.

Ulcer; erosion of skin with damage of the epidermis into the dermis. Will leave a scar after healing.

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Common Skin Lesions

Normal variations in newborn skin Cutis marmorata

Bluish mottling or marbling effect of skin Physiologic response to chilling caused by

dilation of capillaries Disappears when infant is rewarmed May be sign of stress or overstimulation in

newborn.

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Common Skin Lesions

Normal Variations Erythema toxicum (Newborn Rash)

Small white or yellow pustules surrounded by an erythematous base (redness caused by a histamine release)

Differential Diagnosis; may resemble a staphylococcal infection, (confirmed by a smear of aspirated pustules showing increased eosinophils).

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Common Skin Lesions

Normal Variations Milia

Multiple yellow or pearly white papules about 1mm in size; “inclusion cysts”, usually on brow, cheeks, and nose.

Observed in about 40% of newborn infants. No treatment needed, resolve

spontaneously during the first few weeks after birth.

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Common Skin Lesions

Normal Variations Epstein pearls

Oral counterpart of facial milia. Can be seen on the midline of palate or on the alveolar ridges.

Occurs in approx 60% of neonates. No treatment needed.

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Lesions from Trauma

Forceps marks Red or bruised areas seen over the

cheek, scalp, for face of infant following forceps delivery.

On assessment look for underlying tissue damage or other signs of birth trauma; scalp abrasions, fractured clavicles, or facial palsy.

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Lesions from Trauma

Scalp Lacerations May occur during delivery, with

placement of scalp electrodes, or fetal blood pH sampling.

Treatment consists of keeping the area clean and dry, and assessing for infection.

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Lesions from Trauma

Intravenous extravasations Vascular access sites in infants should be

assessed hourly, evaluate for patency and extravasations. If apparent or if patency is not certain remove IV catheter immediately.

If extravasation occurs, elevate extremity. Avoid heat or moist dressings. Topical antimicrobial ointments may aid.

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Pigmented Skin Lesions Hyperpigmented macules (mongolian

spots) Large macules or patches, gray or blue-

green, seen most commonly over the buttocks, flanks, or shoulders.

Most common lesion seen at birth, occurring in 90% of black, Asian, and Hispanic babies, in 1-5% of white babies.

Due to increased presence of melanocytes dispersed in the dermis.

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Pigmented Skin Lesion Cafe’-au-lait spots

Tan or light brown patches with well-defined borders.

Less that 3 cm in length and less that 6 in number, no pathological significance.

6 or more spots may be an indication of neurofibromatosis (Eichenfield & Gibbs, 2001). Tumors which form on cutaneous nerves & along the thoracic, brachial, and lumbar nerve trunks.

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Vascular Lesions

Nevus simplex “Stork bite” macular pink areas of

distended capillaries found on the nape of the neck, upper eyelids, nose, or the upper lip.

They have diffuse borders, blanch with pressure, and become pinker with crying.

Tend to fade, but may persist.

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Vascular Lesions Port-wine stain

Flat vascular nevus, present at birth. Usually pink, may be purple or red. May be small or may cover almost half the body. Flat, sharply delineated, and blanches minimally. Facial lesions are most common.

Stains consist of mature capillaries that are dilated and congested directly below the epidermis. Cause not known.

Nevus does not grow in area or size. I will not resolve and should be considered permanent. May become darker and thicker.

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Vascular Lesions Strawberry Hemangioma

Raised, lobulated, soft, bright red tumor located on the head, neck, trunk, or extremities. May occur in the throat, can lead to airway obstruction.

Caused by dilated capillaries occupying the dermal and subdermal layers with endothelial proliferation.

20-30% are present at birth, and 90% are evident by w month of age.

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Strawberry Hemangioma Usually will increase in size in the first 6

months, then become stable in size before gradual spontaneous regression, most leave no trace. Will take several years.

Often there is more than one lesion. Treatment is to allow spontaneous

regression. If lesion effects vision, is bleeding, or ulcerating, impinging on other vital functions further treatment should be considered.

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Infectious Lesions

Thrush Fungal infection of the mouth or throat,

caused by Candida albicans, very common in infants.

Shows as patches of adherent white material scattered over the tongue and mucous membranes.

Treated with oral antifungal preparations such as nystatin (Mycostatin).

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Infectious Lesions Candida diaper dermatitis

Fungal infection of skin in the diaper area, buttocks, groin, thighs, and abdomen. (check for thrush as well)

Caused by organism C. Albicans. Shows as moist, erythematous eruption,

often with white or yellow satellite pustules.

Treatment is antifungal cream or ointment preparation, nystatin.

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Infections Lesions

Systemic Candida infection Very low birth weight infants are at risk

of having systemic, invasive fungal infections with invasion of the fungus beyond the stratum corneum.

Tx: Improve barrier function of the skin by minimizing trauma and maintaining a sterile environment may help prevent onset of illness.

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Infections Lesions Herpes

Neonatal herpes simplex infection is one of the most serious viral infections in the neonate.

Rash appears as vesicular or pustular rash.

70% of infants with herpes will have subsequent rash, but not always before other signs and symptoms of illness develop.

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Herpes

Absence of rash or vesicles does not eliminate the possibility of disease.

Tx: with antiviral agent such as acyclovir should begin immediately. The earlier treatment is begun, the better the outcome (Weston et al.,2002).

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References Verklan, M. T., Walden, M., (Eds.). (2005). Neonatal

Dermatology. Core Curriculum for Neonatal Intensive Care Nursing. (3rd Ed). Elsevier Saunders.

Thureen, P.J., Decan, J., Hernandez, J.A., Hall, D.M. (2005) Assessment and Care of the Well Newborn. (2nd Ed). Elsevier Saunders.

Eichenfield, L.F. and Gibbs, N.F.: Hyperpigmentation Disorders. Textbook of neonatal dermatology. Philadelphia, 2001, Saunders, pp. 370-394.

Weston, W.L., Lane, A.T., and Morelli, J.T.: Color textbook of pediatric dermatology (3rd ed.). St Louis, 2002, Mosby.