RGatlin 2016 NANT Conference updated€¦ · ò Z v v µ o E Ed } v ( v r ] o î ì í ò. ò Z v v...

6th Annual NANT Conference - April 2016

4/26/2016 1

Neonatal Wound Care and Skin IntegrityRoberta “Bertie” Gatlin, PT, ScD, PCS

[email protected]@att.net

Disclosure

Roberta Gatlin has no financial relationship with any of the mentioned productsNon-financial: Roberta Gatlin is a member of Board of the APTA

2

Skin• Largest organ of the human body• Serves as a protectant from trauma, pathogens, ultraviolet rays, and a barrier to fluid loss• Injury

– Intentional • Surgical

– Unintentional• Skin breakdown

Fox, MD. Wound Care in the Neonatal Intensive Care Unit. Neonatal Network. 2011;30(5):291-303


4/26/2016 2

Skin Protection And Breakdown In The ELBW Infant. A National Survey.1999; 8: 222 Clin Nurs Res Maguire DP

• A 1998 survey of 215 neonatal intensive care units reported that an average of 21% of extremely low birth weight neonates developed skin breakdown in the first week of life.

Risk of Neonatal Skin Wounds/Breakdown • Higher risk of developing skin and pressure injuries due to prematurity, immobility and medical intervention.• Skin injuries may occur:

– Antenatally, resultant of birthing process– Direct care secondary to immaturity of skin– Consequence of intensive therapy required to sustain the neonates life

Irving, V. Wound care for preterm neonates. Infant. 2006:2(3; 102-106

Neonatal Skin Characteristics – Development is beginning at 4 wks gestation– 14-16 wks skin is transparent no Stratum Corneum– Lanugo presents 5th month gestation and is shed by 9th month – Last trimester Vernix presents as a protective coating


4/26/2016 3

Skin Strata • Base layer of epidermis -> Stratum Basale• 24 wks GA = Stratum Corneum may or may not be present • 40 wks GA = 10-20 layers are present• Weight gain during last trimester increases the Sub Q (fatty deposits) which aides in newborn skin integrity

Fox, MD. Wound Care in the Neonatal Intensive Care Unit. Neonatal Network. 2011;30(5):291-303

Stratum Corneum• SC is dependent on hydration

– Drying out of the SC leads to desquamation and decrease ability of protecting the dermis– Because of the deficiency in layers of stratum corneum, large fluid and evaporative heat loss occurs in the first weeks of life, leading to significant alterations in electrolyte levels, hypernatremia and dehydration.

Fox, M. Wound care in the neonatal intensive care unit. Neonatal Network. 2011;30(5):291-303Blume-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;28(3):241-54.

Risk of Neonatal Skin• Epidermal layer loosely bound to dermis• Poorly defined layering of SC• Dry, scaly and leathery texture of SC (dehydrated)->Ineffective barrier to infection• Poorly defined layers

– decrease strength of skin– increase fragility and shearing

• ↑ suscep bility to epidermal tears, blisters, abrasions


4/26/2016 4

2014 Clinical Practice GuidelinesNeonatal Skin Care• Association of Women's Health, Obstetric, and Neonatal Nurses and the National Association of Neonatal Nurses published EBR for clinical practice guidelines for general neonatal skin care.

• Must Include Neurodevelopmental And Behavioral ConsiderationsKing A, Stellar JJ, Blevins A, Shah KN. Dressings and Products in Pediatric Wound Care 2014 April 1;3(4):324-334

Two Team SupportCluster Care

12

Positional Aides for Behavioral Support During Wound Care


4/26/2016 5

Adult WC -> Pediatric WC-> Neonatal WCBased on Research StudiesClinical ExperienceProduct development in adult wound care

Adaptation of products • Works well in adults DOES NOT mean it is appropriate for pediatric WC and if it works well in pediatric WC DOES NOT mean it is appropriate for our neonatal patientsWHY?• Unknown absorption or clearance of products in neonatesHowever…• Principles of adult WC are applicable and practical for neonatal WC

King A., Stellar JJ., Blevins A., Shah KN. Dressings and Products in Pediatric Wound Care.Advance in Wound Care. 2014:3(4):324-334

Neonatal Infant Wounds • Occur during NICU stay• Often from external forces

– Leads– Intravenous punctures– Chemical burns

• Not typically from birthing process but…– Forceps– Suction – Shearing forces

Common Wounds Seenwith the Neonate• IV infiltrates• Skin tears/burns• Diaper dermatitis• Pressure ulcers• Profusion complications • Genetic/congenital conditions• Infections


4/26/2016 6

IV Infiltrates• Most common• PIV fluid/medication leaks out of venous system into surrounding tissue• S/S: redness

– Edema– Erythema– Blisters– Skin breakdown– Skin necrosis

Skin Tears/Burns• Adhesives from leads or tape• Burns from chemicals such as antiseptics

Diaper Dermatitis• Diaper Rash• Maceration of the skin along the buttocks, groin and genital area

• Genital and Sacral areas–Soreness–Red bumps –Peeling–Scaly skin– Irritability

• Easily contaminated


4/26/2016 7

Contact dermatitis and Candidiasis (yeast) • Antibiotic• Antifungal• S/S• Red bumps• Blisters or open sores• Pus-filled sores• Fluid or seeping fluid for blisters or sores

Pressure Ulcers

• Positioning restrictions• Decrease in activity• Poor profusion, medical fragility• Poor nutrition • Blistering from contact of equipment

Genetic/Congenital Conditions• Epidermolysis Bullosa

– Blistering of the skin– Mild to severe and life threatening– Internal organs, throat, eyes, all involved

• Harlequin Ichthyosis– Tough, thickening of skin– Dysfunction in moisture regulation, temperature


4/26/2016 8

Congenital AbnormalitiesEpidermolysis bullosa Ichthyosis

Infections• Increased risk of bacterial and fungal infections• Decrease in immunity

Assessment• Anatomical location• Age of wound• Type of wound: acute or chronic

– Causative factors documented• Size of wound

– Circumference– Depth

• Exudate quality and quantity • Tissue involvement

– Color of wound black, yellow red or pink• Wound bed margins• Inflammatory signs • Infection signs• Pain (NIPS)


4/26/2016 9

Infiltration vs. Extravasation• Infiltration is fluid administered intravenously & leaking from the vein into the surrounding tissue • Extravasation is toxic fluid leaking into tissue

– Chemotherapy– Antibiotics– K+ and Na++ solutions– Ca+ or > 5% dextrose solution– NaHCO3– Hyper alimentation– Vasopressors

Extravasation Stages Montgomery and et al. 1999

• Stage 1: no redness or swelling, IV flushes with difficulty, pain at site• Stage 2: slight swelling at site, redness and pain, good pulse and 1-2 cap refill time below site• Stage 3: moderate swelling, blanching and pain at site, good pulse, 1-2 cap refill, but skin cool to touch• Stage 4: severe swelling, blanching, pain, deceased or absent pulse, skin cool to touch with evidence of breakdown or necrosis and decreased or absent pulse below site

Montgomery, et al. Guideline for I. V. infiltrations in pediatric patients. Pediatric Nursing. 1999. 25(2):167-69,173-80.

Staging of Wounds • Stage 1: epidermis layer; erythema lasting 30 min or > after pressure is removed• Stage 2: partial thickness; epidermis and dermis with very shallow opening may have blister, pink/red in color• Stage 3: full thickness; epidermis, dermis and subcutaneous layer involvement, sloughing of skin layers, undermining or tunneling may be present• Stage 4: muscle tendon or bone exposed within the wound bed


4/26/2016 10

Stage 1 WoundStage 1: epidermis layer; erythema lasting 30 min or > after pressure is removedStage 2 ExtravasationStage 2: slight swelling at site, redness and pain, good pulse and 1-2 cap refill time below site

Skin Tear Stage 2Stage 2: partial thickness; epidermis and dermis with very shallow opening may have blister, pink/red in color

Stage 3 ExtravasationStage 3: moderate swelling, blanching and pain at site, good pulse, 1-2 cap refill, but skin cool to touchStage 3 WoundStage 3: full thickness; epidermis, dermis and subcutaneous layer involvement, sloughing of skin layers, undermining or tunneling may be present


4/26/2016 11

Stage 4 ExtravasationStage 4: severe swelling, blanching, pain, deceased or absent pulse, skin cool to touch with evidence of breakdown or necrosis and decreased or absent pulse below siteStage 4 WoundStage 4: muscle tendon or bone exposed within the wound bed

Neonatal Skin Condition ScaleNSCS• 2007 guideline:

– Objective scale quantifies skin condition– Skin pressure ulcers primarily– Still must complete a head to toe assessment– Skin team– Infants high risk for pressure

ulcers – HFV, hypotension/hypo-perfusion, ECMO, NCPAP

Neonatal Skin Condition Scale• Dryness:

– 1= Normal, no signs dryness– 2= Dry skin, visible scaling– 3= very dry skin, cracking/fissures

• Erythema:• 1 = No evidence erythema• 2 = visible erythema, < 50% body surface• 3 = visible erythema, > 50% body surface

• Breakdown:– 1= None evident– 2 = small, localized areas– 3 = extensive– Perfect Score = 3– Worst Score = 9

D= 2E= 2B= 2Total= 6


4/26/2016 12

Wound Healing Process• Inflammation phase• Proliferative

Phagocytic phaseGranulation phase

• Maturation:Remodeling with wound contraction

Inflammation• Hemostasis and clot formation

(to protest the denuded wound tissue)• Clot is made up of platelets embedded in fibrin fibers which store cytokines and growth factors • Cytokines influence leucocyte activity and production of growth factors which influence neutrophils and monocytes• Histamine increases the permeability of capillary bed allowing neutrophils and macrophages into wound bed

Denuded congenital lesions: Recessive dystrophic epidermolysis bullosaKristy F Fleming MD1, Jashin J Wu MD2, Senait W Dyson MD3, Soheil S Dadras MD PhD4, Brandie J Metz MD3Dermatology Online Journal 15 (4): 4

EB

Phagocytic Phase• Neutrophils and macrophages play a role in phagocytosis of the devitalized tissue• Destruction of bacteria in wound bed• Macrophages trigger the formation of fibroblasts which produce collagen


4/26/2016 13

Proliferation/Granulation • Fibroblasts lay down a matrix of fibers to strengthen the bed• Angiogensis occurs: production of new blood vessels• Wound is red in appearance due to the capillary tips visually present• They are easily damaged -> ease of bleeding

Maturation • Final phase• Epithelization of wound from outer edges to middle of wound bed• Contraction of the wound circumferentially inward• Collagen fibers remodel resulting in the appearance of the wound from red to pink• May take a year to complete• Skin tensile strength is 70% as strong as normal skin

Irving, V. Wound care for preterm neonates. Infant. 2006; 2(3);102-06.

Wound Progression• Inflammation• Phagocytic• Granulation• Maturation


4/26/2016 14

Pain Scale• NIPS• NPASS• PIPS• FLACC• Must • Document Pain Level• Utilize two person care team during wound assessment and dressing changes

Dressings and Products in Pediatric Wound Care2014 April 1;3(4):324-334

King A, Stellar JJ, Blevins A, Shah KN• Choice of dressing often made by provider experience and preference• Small number EBP• WC products: New, Traditional, Medical Grade, Honey, Nanocrystalline Silver And Silicone Adhesive

Preventative Tools


4/26/2016 15

Wound Care/Treatment • Dressings vs No Dressing• No Dressing: Dry Wound Bed

– Wound is dry, No odor, No drainage– Typically stage 1-3 with dry or necrotic eschar over wound bed– Leave to air dry: if environment is clean

• Infant has no other infectious dx that may contaminate the wound bed

Dry Diaper Rash• Dry area• Wash diaper area with warm water

– No soapsDiaper Ointment with zinc oxide ↓If pimples, blisters or sores, diarrhea, orfever appear↓Possible Infection -> Notify MD, NNP -> Culture & Abx

Diaper Dermatitis• Barrier preparations • Protect the skin • Coat the surface of the skin • supply lipids that can penetrate the intercellular spaces of the stratum corneum


4/26/2016 16

Moisture in Wound Bed• Balance of moisture• Research in human and animal subjects

→ 2-3x the rate of wound healing in moistwounds

• ↑ in desicca on secondary to dryness – Moisturizing Dressing

• ↑ in macera on secondary to ↑ exudate– Absorptive Dressing

Primary Dressing Categories • Films• Hydrocolloids• Hydrogels• Foams• Alginates

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3985526/pdf/wound.2013.0477.pdf

Wound care products commonly used in neonates• Skin Tears or Superficial wounds

– Transparent Polyurethane epidermal stripping• Contact layer (Mepitel)

– Maintains moist wound, exudate absorbed by product• Partial to full thickness wounds

– Hydrocolloid: min to mod exudative wounds– Polyurethane foam: mod to heavy exudative wounds– Hydrogel: min exudate or DRY wound– Hydrofiber: mod to heavy exudate – Alginate: mod to heavy exudate & infected wounds

Common Wound Care Products Categorization


4/26/2016 17

Diaper DermatitisBarrier • Protects against moisture-associated skin concerns• Protects against epidermal stripping• Ingredients

– Zinc oxide– Petroleum– Pectin– Dimethicone (silicone)– Plastic polymers– Lanolin– Glycerin– Cholestyramine (Aquadphor)

Wet Wound DressingsSilicone Adhesives• Soft • Conformable foam drsg• Absorbs exudate• Atraumatic to wound bed• Decrease risk of maceration

• Mepitel• Optifoam Adhesive• Allevyn Gentle Border

• Cause less skin tearing• Skin sealants• Hydrogel products• Occlusive drsgs discouraged• WtD drsg -> damage granulation tissue by adhering and drying

NOT USED IN NICU

Care of Wounds

51

Hydrogel Mepitel Acquaphor Gauze


4/26/2016 18

Dressing Changes and Behavior• Dressing changes are painful• 2 Healthcare professionals

– Complete wound care– Complete calming and soothing input– Reinforce individualized developmental care

Cleansing• Two cleansers for neonatal wounds

– Normal saline– Sterile H20

• Skin cleansers and antiseptics are cytotoxic to white cells and fibroblasts in vitro and in vivo studies. DO NOT USE ON NEONATES – Dakin sol– Alcohol– Hydrogen peroxide

DebridementHelps to ↓ bacteria and promotes leukocytes and macrophages → inflammatory process → fibroblast recruitment and collagen deposition

• Enzymatic: – Chemical enzymes are fast acting products that produce slough of necrotic tissue

• Autolytic debridement vs sharp debridement– Autolysis uses the body's own enzymes and moisture to re-hydrate, soften and finally liquefy hard eschar and slough.– Hydrocolloid dressing– Wound gel


4/26/2016 19

Extravasation• Administration of antidote to the substance infiltrated• Minimization of tissue damage• Administered with several injections through the skin or IV catheter if still in place• Phentolamine OR Hyaluronidase• Hyaluronidase: not antidote but protein enzyme inhibits the substance hyaluronin in the inflammatory response• Injection reduces the inflammation and enhances the absorption of infiltrated solutions

Wydase • Wydase (Hyaluronidase) is an enzyme that allows rapid dispersion of fluid through tissues • By giving Wydase, the fluid is dispersed or spread out, so it has a less damaging effect on the surrounding tissues

56

Dressing Coverage


4/26/2016 20

Dr. Rene AmayaPediatric WC Center of Houston

Bottom Line• Evidence-based wound care practices and documentation of the safety, efficacy, and appropriate utilization of available wound care dressings and products in the neonatal population need to be established to address specific concerns regarding wound management in these populations

References• 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;28(3):241-54.• Fox, MD. Wound Care in the Neonatal Intensive Care Unit. Neonatal Network. 2011;30(5):291-303• Irving, V. Wound care for preterm neonates. Infant. 2006:2(3; 102-106• Maguire DP.: Skin protection and breakdown in the ELBW infant. A national survey. Clin Nurs Res 1999; 8: 222 [PubMed]• McCord SS, Leby ML. Practical Guide to Pediatric Wound Care. Semin Plast Surg. August 2006; 20(3):192-199• Munson KA., Bare DE., Hoath SB., and Visscher MO.: A survey of skin care practices for premature low birth weight infants. Neonatal Netw 1999; 18: 25. [PubMed]• Baker SF., Smith BJ., Donohue PK., and Gleason CA.: Skin care management practices for premature infants. J Perinatol 1999; 19: 426. [PubMed]• Lund CH., Osborne JW., Kuller J., Lane AT., Lott JW., and 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 [PubMed]

RGatlin 2016 NANT Conference updated€¦ · ò Z v v µ o E Ed } v ( v r ] o î ì í ò. ò Z v v...

Documents

Transcript of RGatlin 2016 NANT Conference updated€¦ · ò Z v v µ o E Ed } v ( v r ] o î ì í ò. ò Z v v...