Skin Care
Caryn E. Douma
I. INTRODUCTION.
The skin performs a vital role in the newborn period. It provides a protective barrier that assists in the prevention of infection, facilitates thermoregulation, and helps control insensible water loss and electrolyte balance. Other functions include tactile sensation and protection against toxins. The neonatal intensive care unit (NICU) environment presents numerous challenges to maintaining skin integrity. Routine care practices, including bathing, application of monitoring devices, intravenous (IV) catheter insertion and removal, tape application, and exposure to potentially toxic substances disrupt the normal barrier function and predispose both premature and term newborns to skin injury. This chapter will address basic physiologic differences that affect newborn skin integrity, describe skin care practices in the immediate newborn period and discuss common disorders.
II. ANATOMY.
The three main layers of the skin are the epidermis, the dermis, and the subcutaneous layer. The epidermis is the outermost layer providing the first line of protection against injury. It performs a critical barrier function, retaining heat and fluid and providing protection from infection and environmental toxins. Its structural development has generally occurred by 24 weeks’ gestation, but the epidermal barrier function is not complete until after birth. Maturation typically takes 2 to 4 weeks following exposure to the extrauterine environment. The epidermis is composed primarily of keratinocytes, which mature to form the stratum corneum. The dermis is composed of collagen and elastin fibers that provide elasticity and connect the dermis to the epidermis. Blood vessels, nerves, sweat glands, and hair follicles are another integral part of the dermis. The subcutaneous layer, composed of fatty connective tissue, provides insulation, protection, and calorie storage.
The premature infant has significantly fewer layers of stratum corneum than term infants and adults, which can be seen by the transparent, ruddy appearance of their skin. Infants born at <30 weeks may have <2 to 3 layers of stratum corneum compared with 10 to 20 layers in adults and term newborns. The maturation of the stratum corneum is accelerated following premature birth, and improved barrier function and skin integrity is generally present within 10 to 14 days. Other differences in the skin integrity of premature infants include decreased cohesion between the epidermis and the dermis, less collagen, and a marked increase in transepidermal water loss.
III. SKIN CARE PRACTICES.
Routine assessment, identification, and avoidance of harmful practices combined with early treatment can eliminate or minimize neonatal skin injury. The identification of potential risk factors for injury and the development of skin care policies and guidelines are an essential part of providing care to both premature and term newborns.
An evidence-based neonatal skin care guideline was created through the collaboration of the National Association of Neonatal Nurses (NANN) and the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) (2007) in an effort to provide clinical practice recommendations for practitioners caring for newborns from birth to 28 days of age. This guideline provides a comprehensive reference for developing unit-based skin care policies.
Assessment
Daily inspection and assessment of all skin surfaces is an essential part of neonatal skin care. The utilization of a validated skin care assessment tool provides a standardized method to perform the assessment and develop the appropriate treatment plans. A widely used tool is the Neonatal Skin Condition Score (NSCS), developed and validated as part of the AWHONN/NANN skin care guideline (see Table 63.1).
Identification of risk factors.
Prematurity.
Use of monitoring equipment.
Adhesives used to secure central and peripheral access lines, endotracheal tubes.
Edema.
Immobility secondary to extracorporeal membrane oxygenation (ECMO), muscle relaxant, and high-frequency ventilation, which can cause pressure necrosis.
Table 63.1 AWHONN Neonatal Skin Condition Score (NSCS)
Dryness
1 = Normal, no sign of dry skin
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 suface
Breakdown
1 = None evident
2 = Small, localized areas
3 = Extensive
Note: perfect score = 3, worst score = 9
Use of high-risk medications, including vasopressors, calcium, and sodium bicarbonate.
Devices with potential for thermal injury such as radiant warmers. Temperature of any product in contact with the skin should not be higher than 41°C/105°F.
Avoidance of practices with potential to cause injury
B. Bathing
Initial bath should be performed 2 to 4 hours after admission, when temperature has been stabilized to prevent the risk of hypothermia. Provide a controlled environment utilizing warming lights and warm blankets. Bathing is often deferred for the first 24 hours in infants <36 weeks’ gestation.
Use mild nonalkaline, preservative-free soap. Avoid the use of dyes or perfumes.
Daily bathing is not indicated. Warm sterile water is sufficient for premature infants during the first few weeks of life. No more than two or three times per week is preferred.
C. Adhesives
Minimize the use of adhesives and tape.
Use nonadhesive products in conjunction with transparent dressings and double-backed tape to secure IV catheters.
Avoid the use of adhesive bonding agents that can be absorbed easily through the skin.
Use warm sterile water to remove adhesives from the skin to prevent epidermal stripping. Adhesive removers contain hydrocarbon derivatives or petroleum distillates that can result in toxicity in the preterm population.
Pectin barriers should be applied to the skin before application of adhesives when securing umbilical lines, endotracheal tubes, feeding tubes, nasal cannulae, and urine bags. Remove carefully using soft gauze or cotton balls soaked in warm water.
D. Cord care
Clean the umbilical cord area with mild soap and water during the first bath. Keep it clean and dry. Wipe gently with water if the area becomes soiled with stool or urine.
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