- Email: [email protected]
Evaluation of a Pectin-based Barrier Under Tape to Protect Neonatal Skin
research and studies Evaluation of a Pectin-based Barrier Under Tape to Protect Neonatal Skin CAROLYN LUND, RNC, MS, JOANNE MCMANUS KULLER, RNC, MS, CATHERINE TOBIN, RNC, MS, LINDA LEFRAK, RNC, MS, LINDA STURLA FRANCK, RN, MS The use of a pectin-based barrier between tape and skin as a method of minimizing epidermal stripping while keeping monitoring equipment and other devices securely attached to infants was evaluated. From 45 subjects, 199 application/removal procedures were recorded. The pectin-based barrier under tape held appliances securely for an average of 5.5 days (range 1-23 days). In 72% of the observations, the barrier was removed for nonadhesive-related reasons. Skin condition remained grossly normal in 97% of the observations after the barrier removal. A pectin-based barrier under tape provides effective adhesion for certain appliances and protects neonatal skin from damage caused by tape removal.
Securing life support and monitoring devices on fragile skin presents a challenge and a dilemma for those caring for neonates in the intensive care nursery. The challenge is to attach devices such as endotracheal tubes, umbilical artery catheters, and assorted probes securely to the infant. The dilemma is how to accomplish this without causing severe skin damage from adhesives. After observing a high incidence of epidermal stripping following adhesive removal, particularly in infants weighing less than 1500 grams at birth, alternative methods were explored.’ The full-term infant’s skin functions as a barrier to infection, controls temperature and insensible Accepted: November 1984.
JanuaryIFebruary 1986 JOCNN
water loss, and transmits sensation. The function level of the term infant’s skin is similar to that of adult skin.’ The function of the premature infant’s skin as a barrier to the environment is limited due to lack of maturation. Factors that lead to the decreased integrity include 1) a decreased number of fibrils that attach the dermal layer to the e p i d e r m i ~2), ~a thin stratum corneum layer: and 3) the presence of significant edema that can compromise skin blood flow.5With increasing gestational age, or by 10 days postnatal age, the integrity of the skin improves and approaches that of the term infant or aduk6 Scant information exists in nursing literature regarding skin care of the premature infant. Numerous reports of iatrogenic skin problems include burns and caustic lesions
from isopropyl a l ~ o h o l ,and ~ * ~erythema and skin craters as a complication of transcutaneous oxygen monit~ring.~.’~ Increased permeability of the premature’s kin^.''*'^ and the concomitant risk of percutaneous toxicity from drugs and chemicals are do~umented.’~-’~ Harpin and Rutter found that t h e skin beneath adhesive tape and adhesive rings used for transcutaneous monitor electrodes was stripped of the epidermal layer when the electrode was removed.17 This resulted in increased permeability to drugs and increased transepidermal water loss, and was documentation that epidermal stripping poses a significant threat to major skin functions. Maintaining epidermal integrity and, therefore, the barrier function led to an examination of the appli39
Table 1.
Range
tiveness of using this adhesive barrier for the neonatal patient population was needed.
31.3
25-40
PIJRPOSE
7.0
1-48
Sample Characteristics
Mean Gestational age (weeks) Postnatal age (days) Birthweight (grams) Study weight (warns)
1571.6
700-4220
1545.2
700-4180
N = 45.
cation and removal of adhesives on infants in the intensive care nursery. Tincture of benzoin and plastic polymers have been used extensively under adhesives on adults to toughen the skin and to increase adhesion. The absorption of these products through the neonatal skin is unknown. They may form a stronger bond to the epidermis than that between the epidermis and the dermis, causing more severe stripping with adhesive removal. Products that assist in adhesive removal (Whisk@,Dermasol@,and Unisolve@)are solvents and not only dry the skin but are readily absorbed through the premature infant’s skin.’* For this study, a pectin-based barrier was sought that was easier to remove than tape but without the possible toxic effects due to absorption. HolliHesiveQwas chosen because it did not crumble under the heat of the radiant warmers and incubators used in the intensive care nursery. Also, HolliHesive molded easily to the many contours of the neonate’s body. HolliHesive, a barrier used for adult ostomy patients, is a porous “blanket” composed of polyisobutylene, water-absorbing powders, pectin, gelatin, and sodium carboxymethylcellulose. After using this barrier for a six-month period in the intensive care nursery, a marked reduction was noted in the incidence of skin excoriations’ and documentation of the effec-
40
This descriptive study evaluates the use of a pectin-based barrier between tape and skin as a method of minimizing epidermal stripping, while keeping monitoring equipment and other devices securely attached to the infant.
METHODS Sample The study population consisted of a convenience sample of 45 infants. Infants of varying gestational ages were included to evaluate the effectiveness of using this barrier on all degrees of maturity seen in neonatal skin (Table 1). However, 76% of the infants weighed less than 1500 grams, 86% were less than seven days of age, and 67% were less than 32 weeks gestation. Infants in these categories are most at risk for epidermal stripping with adhesive removal. The diagnoses of the sample represent the range of problems in the neonatal nursery, including respiratory distress syndrome, necrotizing enterocolitis, asphyxia, and neonatal surgical conditions.
Data Collection Forty-five infants were entered by one researcher who recorded name, date of birth, gestational age, birth weight, and admitting medical diagnosis. Data were collected before application and after removal of the pectin-based barrier by the staff nurses in the intensive care nursery. The data included the type of device attached (endotracheal tube, umbilical artery catheter, etc.), overall skin condition before the study, skin condition of the site before barrier application,
type of tape used over the skin barrier, skin condition of the site immediately after barrier and tape removal, length of time that the barrier and/or tape remained on, and reason for barrier and/or tape removal. The pectin-based barrier, was used between tape and skin to secure nine different appliances: endotracheal tubes (nasal and oral), umbilical artery catheters, temperature probes, peripheral IVs (stainless steel needles and teflon catheters), ostomy and urine collection bags, and nasogastric and chest tubes. Skin condition was categorized as intact, dry/flaky, reddened, or excoriated. Cloth adhesive tape and plastic tape were used over the skin barrier. Adhesive tape was used most often with endotracheal tubes; plastic tape was used to secure umbilical artery catheters, temperature probes, and nasogastric tubes. Ostomy and urine bags were secured over the skin barrier with the adhesive plates of these devices.
RESULTS From the 45 subjects, 199 application and removal procedures were observed and recorded (Table 2). An average of four procedures were recorded for each subject. The barrier and adhesives remained in place and effectively held the appliances for an average of 5.5 days. Removal of barrier and tape occurred for a variety of reasons, ranging from routine site changes to nonadherence of either the barrier to skin or of the tape to barrier. These reasons were grouped into two categories: adhesive-related and nonadhesive-related. In 72%of the cases, the pectin-based barrier was removed for nonadhesive-related reasons. However, t h e type of appliance that the barrier was used for and the reason for removal were significantly correlated (P
JanuaryIFebruary 1986 JOG”
< 0.012) using the chi-square test (2= 16.2, d f = 6). The appliances most frequently removed for problems with adhesion were the endotracheal tubes (oral and nasal), urine bags, and temperature probes. Observations of overall skin condition and skin condition at the site of barrier application and removal were recorded and tabulated as intact or excoriated (Table 3). Of the sample, 95.7% had intact skin overall and 98.8% had intact skin at the site before skin barrier placement. In two cases, the placement of an ostomy bag and an umbilical artery catheter, the barrier was placed over excoriated skin. Excoriations were found in nine out of 199 cases after removal of the barrier. These included the two cases previously described, in which the area had been excoriated before the application, and seven cases in which excoriations occurred in previously intact skin. These excoriations occurred with temperature probes, under the probe itself (not under the barrier or the adhesive used to secure them). Skin condition did not, in this study, correlate with gestational age, postnatal age, birth weight, or study weight.
Table 2.
Appliances Secured with HoiliHesive" Under Tape
Reason for Removal'
Appliance
Number of Cases
Endotracheal tube (oral/nasal) Umbilical artery catheter Nasogastric tube Temperature probe Intravenous tube Ostorny Urine bag
52 44 4 79 3 9 8
Number of Days in Place
Adhesiverelated
Nonadhesiverelated
Mean
Range
(Yo)
(W
5.35 7.33 3.33 4.37 3.50 2.88 1.50
1-13 1-21 3-4 1-13 3-4 2-3 1-2
35.4 5.0 33.3 35.8 0 14.3 42.9
64.6 95.0 66.7 64.2 100 85.7 57.1
N = 199. X 2 = 16.2,df 6;P < 0.01.
integrity had been noted and staff could not justify depriving infants of this technique for research purposes. Removal of the appliance in 72% of the cases (143 of the 199 application/removal observations) occurred for nonadhesive-related reasons such as elective tube removal or discontinued therapy. This indicates the feasibility of using this barrier as an effective ad-
hesive that does not easily fall off with routine caregiving. The type of appliance for which the barrier was used was significantly correlated with the reason for appliance removal. The appliances most frequently removed for problems with adhesion were endotracheal tubes (nasal and oral), urine bags, and temperature probes. Differentiation between nasal and oral endotra-
-
I _
Table 3.
Cases (infant Number)
Cases with Skin Excoriation After HolliHesive" Removal
Appliance
Gestational Age
Postnatal Age
Birth Weight
Weeks
Days
Grams
25.5
1
800
Skin Condition Before HolliHesive
DISCUSSION A descriptive design was chosen to document systematically that a pectin-based skin barrier does have sufficient adhesive properties to secure equipment to the infant and does reduce the amount of trauma observed in skin of neonatal patients from tape removal. The technique of using such a barrier had been instituted one year before the start of the study and had become standard nursing practice in the intensive care nursery. A controlled, experimental, study design could not be used because great improvement in skin
January/February 1986 JOCNN
5
15 20 26 29 34 53
1 Temperature probe 2 Temperature probe 3 Umbilical artery catheter Temperature probe Ostomy Temperature probe Temperature probe Temperature probe Temperature probe
Intact intact intact at site/some areas of breakdown Intact
28.0
2
800
32.0 29.0
25 1
1400 1000
28.0
1
900
intact
28.0
2
1000
Intact
27.0
2
1000
Intact
Excoriated Intact
41
Figure 1. Premature infant with oral endotracheal tube secured with adhesive tape over a pectin-based barrier. The metal brace (“Logan’s Bow”) also helps to stabilize the tube and prevents dislodgement.
cheal tubes was not made in the study and would be of interest in future studies. The obvious reason for more frequent adhesion problems with endotracheal tubes is that saliva undermines adhesion. This also occurs when using tape
alone to secure endotracheal tubes. In no circumstances was the location of the endotracheal tube believed to be compromised because of the use of the barrier, and no instances of accidental extubation secondary to adhesion failures
Figure 2. Umbilical artery catheter secured with “Goal Post” method using plastic tape and a pectin-based barrier between tape and skin.
42
were documented. For infants requiring frequent resecuring of the endotracheal tube due t o copious secretions or for instances when emergency removal of the tube is indicated, a skin barrier would probably significantly reduce trauma to facial skin and ensure a n intact surface for future applications. Urine bag adhesion also was compromised due to moisture. However, because of t h e small sample size (8 cases), the effectiveness of the barrier in securing this appliance was difficult to evaluate. The integrity of the skin was maintained, which was the main objective of using the pectin-based barrier. The reason for adhesion problems with the use of the barrier around the temperature probes is unclear and warrants further investigation. Of 199 application/removal observations, excoriated skin was documented in only nine cases. In two of these cases, excoriations were present before the application of the barrier, at an ostomy site. Since an ostomy site is a primary target for skin breakdown due to the corrosive action of the ostomy drainage, more frequent changes of the skin barrier and appliance are indicated when breakdown occurs until the area is healed, The skin around t h e stoma must be kept covered with a skin barrier to protect it from further breakdown. In the seven cases where previously intact skin showed excoriations after removal of the barrier, all occurred underneath temperature probes that were secured with a ring of the skin barrier a n d covered with tape. The excoriations appeared to have been caused by pressure from the stiff wire probe rather than from the adhesive used to secure it. These excoriations occurred in infants less than 28 weeks gestation and weighing less than
January/February 1986 JOG”
1000 grams; two of the excoriations occurred on the same infant; and all of the excoriations occurred during the first two days of hospitalization. The number of cases with skin excoriations was too small to correlate with age and weight. However, the fact that the affected group was of a specific age and weight category indicates that infants in this group are especially at risk for skin trauma. The researchers hoped to show a positive correlation between skin excoriations and overall skin condition, postnatal age, birth weight, and gestational age. This was not shown statistically and is believed to be due to the special characteristics of the study population. The infants were transported to the intensive care nursery from units that were instructed in the use of a barrier between tape and skin, and the infants arrived with a pectin-based barrier under all taped appliances. The intensive care nursery staff nurses were keenly aware of the need to protect the skin from adhesives and continued to maintain skin integrity by following the skin care guidelines developed by the intensive care nursery unit. Therefore, the amount of skin trauma seen, even in very small infants, had been significantly reduced before the study. Another study should be done in an intensive care nursery where skin practices have not been changed yet to determine if any correlation can be documented. Further nursing research of skin care practices for infants is needed. The instrumentation used by Harpin and Rutter to document skin trauma from adhesive rings could be used to compare the amount of skin damage caused by the removal of other adhesives and skin barriers.” Nurses should begin to communicate with companies who develop adhesives and other appliances that attach to skin (i.e.,
JanuaryIFebruary 1986 JOGNN
Figure 3. Servo-control temperature probe is placed in a pectin-based barrier cutout and secured with plastic tape.
temperature probes). Nurses can emphasize how these products affect neonatal skin integrity and provide input for development of new products that will preserve and protect this vital organ. CONCLUSION
Life support and monitoring devices must be attached to the fragile skin of neonates in intensive care units. A pectin-based barrier between tape and the neonate’s skin was used to minimize epidermal stripping. The use of a pectinbased barrier under tape was proven valuable in two ways. First, few skin excoriations were seen as a result of barrier-backed adhesive removal. Second, the barrier proved to be an effective adhesive, resulting in secure attachment of necessary medical devices. ACKNOWLEDGMENT
Partial financial support for this study was provided by Hollister, Inc., Libertyville, Illinois.
REFERENCES 1. Kuller J, Lund L, Tobin C. Improved skin care for premature infants. American Journal of Maternal Child Nursing 1983;8(3):200-3. 2. Wilson DR, Maibach H. An in vitro comparison of skin barrier function. In: Maibach HI, Boisits EK, eds. Neonatal skin: structure and function. New York Marcel Decker, Inc., 1982:101- 10. 3. Adams R. Principles and practice of topical therapy. Pediatr Clin North Am 1971;18(3):685-712. 4. Montagna W, Van Scott E, Stoughton R. Advances in biology of skin. Vol. XII: pharmacology and t h e skin. New York: Appleton-CenturyCrofts, 1972. 5. Dietel K. Morphological and functional development of the skin. In: Stave U, ed. Perinat Physiol. New York: Plenum Medical Book Company, 1978: Chapter 36. 6. Holbrook KA. A histological cornparison of infant and adult skin. In: Maibach HI, Boisits EK, eds. Neonatal skin: structure and function. New York Marcel Decker, Inc., 1982:3-31. 7. Schick JB, Milstein JM. Burn hazard of lsopropyl alcohol in the neonate. Pediatrics 1981;68:587-8. 8. Margileth A. Dermatologic conditions. In: Avery G, ed. Neonatology:
43
9. 10.
11.
12. 13.
14.
pathophysiology and management of the newborn. 2nd ed. Philadelphia: J.B. Lippincott Co., 1981: 1061- 103. Boyle RJ, Oh W. Erythema following transcutaneous p02 monitoring. Pediatrics 1980;65:333-4. Golden SM. Skin craters-a complication of transcutaneous oxygen monitoring. Pediatrics 1981;67: 514-6. Nachman RL, Esterly NB. Increased skin permeability in preterm infants. J Pediatr 1971;79:62832. Hey E, Katz C. Evaporative water loss in the newborn baby. J Physiol 1969;200:605-19. West DP, Worbec, Solomon. Pharmocology and toxicity of infant skin. J Invest Dermatol 1981;76 147-50. Jackson H, Sutherland R. Effect of povidone iodine on neonatal thyroid function. Lancet 1981:2:992.
15. Pyati S, Ramamurthy R, Kraus M, Pildes R. Absorption of iodine in the neonate following topical use of povidone-iodine. J Pediatr 1977;91(5):825-8. 16. Wester R, Maibach H. Comparative percutaneous toxicity. In: Maibach HI, Boisits EK, eds. Neonatal skin: structure and function. New York Marcel Decker, Inc., 1982. 17. Harpin VA, Rutter N. Barrier properties of the newborn infant’s skin. J Pediatr 1983;102:419-25. 18. McCormack J, Boisits E, Fisher LB. An in vitro comparison of the permeability of adult versus neonatal skin. In: Maibach HI, Boisits EK, eds. Neonatal skin: structure and function. New York Marcel Decker, Inc., 1982149-64.
Address for correspondence: Carolyn Lund, RNC, MS, Children’s Hospital
Medical Center of Northern California, 747 52nd Street, Oakland, CA 94609.
Carolyn Lund is a neonatal clinical specialist at Children‘s Hospital Medical Center, Oakland, California. Joanne McManus Kuller is a neonatal clinical specialist and Nursery Coordiqator at Aka Bates Hospital, Berkeley, California. Catherine Tobin is a neonatal clinical specialist and Associate Coordinator, Transport, at Children’s Hospital Medical Center, Oakland, CaIifornia. Linda Lefrak is a neonatal clinical specialist at Children’s Hospital Medical Center, Oakland, California. Linda Sturla Franck is a neonatal clinical specialist and Associate Coordinator. ICN, at Children’s Hospital Medical Center, Oakland, California.
MASTER CALENDAR FOR THE NAACOG 1986 REGIONAL CONFERENCES
For registration information, contact Denise Savage, NAACOG Dept. of Education and Research, 600 Maryland Ave., SW, Suite 200E, Washington, DC 20024 (I-800-533-8822). April 9-1 0,1986 Vancouver, Washington COG Washington-Oregon joint
section meeting REGISTRATION CUT-OFF DATE: March 17
Wednesday, April 9 Perinatal Loss and Grief (2-day course) Teaching Strategies for Emotional Transition to Parenthood
Emergency Delivery Thursday, April 10 Perinatal Loss and Grief (continued) Resuscitation and Stabilization of t h e Newborn Women in Transition: The Middle Years Short-stay Postpartum Programs May 15-17,1986
St. Louis, Missouri REGISTRATION CUT-OFF DATE: April 23
Thursday, May 15 The Pregnant Adolescent (2-day course) Perinatal Loss and Grief (2-day course) Insights Into Infertility Friday, May 16 The Pregnant Adolescent (continued) Perinatal Loss and Grief (continued)
44
Teaching Strategies for Emotionat Transition to Parenthood
Saturday, May I? Resuscitation and Stabititation of the hidwborn Short-stay Postpartum Programs Women in Transition: The Middle Years June 19-21,1980 Pittsburgh, Pennsylvania REGISTRATION CUT-OFF DATE: May 28 Thursday, June 19 The Pregnant Adolescent (2-day course) Perinatal Loss and Grief (2-day course) Insights Into Infertility Friday, June 20 The Pregnant Adolescent (continued) Perinatal Loss and Grief (continued)
Emergency Delivery Teaching Strategiesfor Emotional Transition to
Parenthood Saturday, June 21 Resuscitation and Stabilization of the Newborn Short-stay Postpartum Programs Women in Transition: The Middle Years
JanuaryIFebruary 1986 JOCNN
Securing life support and monitoring devices on fragile skin presents a challenge and a dilemma for those caring for neonates in the intensive care nursery. The challenge is to attach devices such as endotracheal tubes, umbilical artery catheters, and assorted probes securely to the infant. The dilemma is how to accomplish this without causing severe skin damage from adhesives. After observing a high incidence of epidermal stripping following adhesive removal, particularly in infants weighing less than 1500 grams at birth, alternative methods were explored.’ The full-term infant’s skin functions as a barrier to infection, controls temperature and insensible Accepted: November 1984.
JanuaryIFebruary 1986 JOCNN
water loss, and transmits sensation. The function level of the term infant’s skin is similar to that of adult skin.’ The function of the premature infant’s skin as a barrier to the environment is limited due to lack of maturation. Factors that lead to the decreased integrity include 1) a decreased number of fibrils that attach the dermal layer to the e p i d e r m i ~2), ~a thin stratum corneum layer: and 3) the presence of significant edema that can compromise skin blood flow.5With increasing gestational age, or by 10 days postnatal age, the integrity of the skin improves and approaches that of the term infant or aduk6 Scant information exists in nursing literature regarding skin care of the premature infant. Numerous reports of iatrogenic skin problems include burns and caustic lesions
from isopropyl a l ~ o h o l ,and ~ * ~erythema and skin craters as a complication of transcutaneous oxygen monit~ring.~.’~ Increased permeability of the premature’s kin^.''*'^ and the concomitant risk of percutaneous toxicity from drugs and chemicals are do~umented.’~-’~ Harpin and Rutter found that t h e skin beneath adhesive tape and adhesive rings used for transcutaneous monitor electrodes was stripped of the epidermal layer when the electrode was removed.17 This resulted in increased permeability to drugs and increased transepidermal water loss, and was documentation that epidermal stripping poses a significant threat to major skin functions. Maintaining epidermal integrity and, therefore, the barrier function led to an examination of the appli39
Table 1.
Range
tiveness of using this adhesive barrier for the neonatal patient population was needed.
31.3
25-40
PIJRPOSE
7.0
1-48
Sample Characteristics
Mean Gestational age (weeks) Postnatal age (days) Birthweight (grams) Study weight (warns)
1571.6
700-4220
1545.2
700-4180
N = 45.
cation and removal of adhesives on infants in the intensive care nursery. Tincture of benzoin and plastic polymers have been used extensively under adhesives on adults to toughen the skin and to increase adhesion. The absorption of these products through the neonatal skin is unknown. They may form a stronger bond to the epidermis than that between the epidermis and the dermis, causing more severe stripping with adhesive removal. Products that assist in adhesive removal (Whisk@,Dermasol@,and Unisolve@)are solvents and not only dry the skin but are readily absorbed through the premature infant’s skin.’* For this study, a pectin-based barrier was sought that was easier to remove than tape but without the possible toxic effects due to absorption. HolliHesiveQwas chosen because it did not crumble under the heat of the radiant warmers and incubators used in the intensive care nursery. Also, HolliHesive molded easily to the many contours of the neonate’s body. HolliHesive, a barrier used for adult ostomy patients, is a porous “blanket” composed of polyisobutylene, water-absorbing powders, pectin, gelatin, and sodium carboxymethylcellulose. After using this barrier for a six-month period in the intensive care nursery, a marked reduction was noted in the incidence of skin excoriations’ and documentation of the effec-
40
This descriptive study evaluates the use of a pectin-based barrier between tape and skin as a method of minimizing epidermal stripping, while keeping monitoring equipment and other devices securely attached to the infant.
METHODS Sample The study population consisted of a convenience sample of 45 infants. Infants of varying gestational ages were included to evaluate the effectiveness of using this barrier on all degrees of maturity seen in neonatal skin (Table 1). However, 76% of the infants weighed less than 1500 grams, 86% were less than seven days of age, and 67% were less than 32 weeks gestation. Infants in these categories are most at risk for epidermal stripping with adhesive removal. The diagnoses of the sample represent the range of problems in the neonatal nursery, including respiratory distress syndrome, necrotizing enterocolitis, asphyxia, and neonatal surgical conditions.
Data Collection Forty-five infants were entered by one researcher who recorded name, date of birth, gestational age, birth weight, and admitting medical diagnosis. Data were collected before application and after removal of the pectin-based barrier by the staff nurses in the intensive care nursery. The data included the type of device attached (endotracheal tube, umbilical artery catheter, etc.), overall skin condition before the study, skin condition of the site before barrier application,
type of tape used over the skin barrier, skin condition of the site immediately after barrier and tape removal, length of time that the barrier and/or tape remained on, and reason for barrier and/or tape removal. The pectin-based barrier, was used between tape and skin to secure nine different appliances: endotracheal tubes (nasal and oral), umbilical artery catheters, temperature probes, peripheral IVs (stainless steel needles and teflon catheters), ostomy and urine collection bags, and nasogastric and chest tubes. Skin condition was categorized as intact, dry/flaky, reddened, or excoriated. Cloth adhesive tape and plastic tape were used over the skin barrier. Adhesive tape was used most often with endotracheal tubes; plastic tape was used to secure umbilical artery catheters, temperature probes, and nasogastric tubes. Ostomy and urine bags were secured over the skin barrier with the adhesive plates of these devices.
RESULTS From the 45 subjects, 199 application and removal procedures were observed and recorded (Table 2). An average of four procedures were recorded for each subject. The barrier and adhesives remained in place and effectively held the appliances for an average of 5.5 days. Removal of barrier and tape occurred for a variety of reasons, ranging from routine site changes to nonadherence of either the barrier to skin or of the tape to barrier. These reasons were grouped into two categories: adhesive-related and nonadhesive-related. In 72%of the cases, the pectin-based barrier was removed for nonadhesive-related reasons. However, t h e type of appliance that the barrier was used for and the reason for removal were significantly correlated (P
JanuaryIFebruary 1986 JOG”
< 0.012) using the chi-square test (2= 16.2, d f = 6). The appliances most frequently removed for problems with adhesion were the endotracheal tubes (oral and nasal), urine bags, and temperature probes. Observations of overall skin condition and skin condition at the site of barrier application and removal were recorded and tabulated as intact or excoriated (Table 3). Of the sample, 95.7% had intact skin overall and 98.8% had intact skin at the site before skin barrier placement. In two cases, the placement of an ostomy bag and an umbilical artery catheter, the barrier was placed over excoriated skin. Excoriations were found in nine out of 199 cases after removal of the barrier. These included the two cases previously described, in which the area had been excoriated before the application, and seven cases in which excoriations occurred in previously intact skin. These excoriations occurred with temperature probes, under the probe itself (not under the barrier or the adhesive used to secure them). Skin condition did not, in this study, correlate with gestational age, postnatal age, birth weight, or study weight.
Table 2.
Appliances Secured with HoiliHesive" Under Tape
Reason for Removal'
Appliance
Number of Cases
Endotracheal tube (oral/nasal) Umbilical artery catheter Nasogastric tube Temperature probe Intravenous tube Ostorny Urine bag
52 44 4 79 3 9 8
Number of Days in Place
Adhesiverelated
Nonadhesiverelated
Mean
Range
(Yo)
(W
5.35 7.33 3.33 4.37 3.50 2.88 1.50
1-13 1-21 3-4 1-13 3-4 2-3 1-2
35.4 5.0 33.3 35.8 0 14.3 42.9
64.6 95.0 66.7 64.2 100 85.7 57.1
N = 199. X 2 = 16.2,df 6;P < 0.01.
integrity had been noted and staff could not justify depriving infants of this technique for research purposes. Removal of the appliance in 72% of the cases (143 of the 199 application/removal observations) occurred for nonadhesive-related reasons such as elective tube removal or discontinued therapy. This indicates the feasibility of using this barrier as an effective ad-
hesive that does not easily fall off with routine caregiving. The type of appliance for which the barrier was used was significantly correlated with the reason for appliance removal. The appliances most frequently removed for problems with adhesion were endotracheal tubes (nasal and oral), urine bags, and temperature probes. Differentiation between nasal and oral endotra-
-
I _
Table 3.
Cases (infant Number)
Cases with Skin Excoriation After HolliHesive" Removal
Appliance
Gestational Age
Postnatal Age
Birth Weight
Weeks
Days
Grams
25.5
1
800
Skin Condition Before HolliHesive
DISCUSSION A descriptive design was chosen to document systematically that a pectin-based skin barrier does have sufficient adhesive properties to secure equipment to the infant and does reduce the amount of trauma observed in skin of neonatal patients from tape removal. The technique of using such a barrier had been instituted one year before the start of the study and had become standard nursing practice in the intensive care nursery. A controlled, experimental, study design could not be used because great improvement in skin
January/February 1986 JOCNN
5
15 20 26 29 34 53
1 Temperature probe 2 Temperature probe 3 Umbilical artery catheter Temperature probe Ostomy Temperature probe Temperature probe Temperature probe Temperature probe
Intact intact intact at site/some areas of breakdown Intact
28.0
2
800
32.0 29.0
25 1
1400 1000
28.0
1
900
intact
28.0
2
1000
Intact
27.0
2
1000
Intact
Excoriated Intact
41
Figure 1. Premature infant with oral endotracheal tube secured with adhesive tape over a pectin-based barrier. The metal brace (“Logan’s Bow”) also helps to stabilize the tube and prevents dislodgement.
cheal tubes was not made in the study and would be of interest in future studies. The obvious reason for more frequent adhesion problems with endotracheal tubes is that saliva undermines adhesion. This also occurs when using tape
alone to secure endotracheal tubes. In no circumstances was the location of the endotracheal tube believed to be compromised because of the use of the barrier, and no instances of accidental extubation secondary to adhesion failures
Figure 2. Umbilical artery catheter secured with “Goal Post” method using plastic tape and a pectin-based barrier between tape and skin.
42
were documented. For infants requiring frequent resecuring of the endotracheal tube due t o copious secretions or for instances when emergency removal of the tube is indicated, a skin barrier would probably significantly reduce trauma to facial skin and ensure a n intact surface for future applications. Urine bag adhesion also was compromised due to moisture. However, because of t h e small sample size (8 cases), the effectiveness of the barrier in securing this appliance was difficult to evaluate. The integrity of the skin was maintained, which was the main objective of using the pectin-based barrier. The reason for adhesion problems with the use of the barrier around the temperature probes is unclear and warrants further investigation. Of 199 application/removal observations, excoriated skin was documented in only nine cases. In two of these cases, excoriations were present before the application of the barrier, at an ostomy site. Since an ostomy site is a primary target for skin breakdown due to the corrosive action of the ostomy drainage, more frequent changes of the skin barrier and appliance are indicated when breakdown occurs until the area is healed, The skin around t h e stoma must be kept covered with a skin barrier to protect it from further breakdown. In the seven cases where previously intact skin showed excoriations after removal of the barrier, all occurred underneath temperature probes that were secured with a ring of the skin barrier a n d covered with tape. The excoriations appeared to have been caused by pressure from the stiff wire probe rather than from the adhesive used to secure it. These excoriations occurred in infants less than 28 weeks gestation and weighing less than
January/February 1986 JOG”
1000 grams; two of the excoriations occurred on the same infant; and all of the excoriations occurred during the first two days of hospitalization. The number of cases with skin excoriations was too small to correlate with age and weight. However, the fact that the affected group was of a specific age and weight category indicates that infants in this group are especially at risk for skin trauma. The researchers hoped to show a positive correlation between skin excoriations and overall skin condition, postnatal age, birth weight, and gestational age. This was not shown statistically and is believed to be due to the special characteristics of the study population. The infants were transported to the intensive care nursery from units that were instructed in the use of a barrier between tape and skin, and the infants arrived with a pectin-based barrier under all taped appliances. The intensive care nursery staff nurses were keenly aware of the need to protect the skin from adhesives and continued to maintain skin integrity by following the skin care guidelines developed by the intensive care nursery unit. Therefore, the amount of skin trauma seen, even in very small infants, had been significantly reduced before the study. Another study should be done in an intensive care nursery where skin practices have not been changed yet to determine if any correlation can be documented. Further nursing research of skin care practices for infants is needed. The instrumentation used by Harpin and Rutter to document skin trauma from adhesive rings could be used to compare the amount of skin damage caused by the removal of other adhesives and skin barriers.” Nurses should begin to communicate with companies who develop adhesives and other appliances that attach to skin (i.e.,
JanuaryIFebruary 1986 JOGNN
Figure 3. Servo-control temperature probe is placed in a pectin-based barrier cutout and secured with plastic tape.
temperature probes). Nurses can emphasize how these products affect neonatal skin integrity and provide input for development of new products that will preserve and protect this vital organ. CONCLUSION
Life support and monitoring devices must be attached to the fragile skin of neonates in intensive care units. A pectin-based barrier between tape and the neonate’s skin was used to minimize epidermal stripping. The use of a pectinbased barrier under tape was proven valuable in two ways. First, few skin excoriations were seen as a result of barrier-backed adhesive removal. Second, the barrier proved to be an effective adhesive, resulting in secure attachment of necessary medical devices. ACKNOWLEDGMENT
Partial financial support for this study was provided by Hollister, Inc., Libertyville, Illinois.
REFERENCES 1. Kuller J, Lund L, Tobin C. Improved skin care for premature infants. American Journal of Maternal Child Nursing 1983;8(3):200-3. 2. Wilson DR, Maibach H. An in vitro comparison of skin barrier function. In: Maibach HI, Boisits EK, eds. Neonatal skin: structure and function. New York Marcel Decker, Inc., 1982:101- 10. 3. Adams R. Principles and practice of topical therapy. Pediatr Clin North Am 1971;18(3):685-712. 4. Montagna W, Van Scott E, Stoughton R. Advances in biology of skin. Vol. XII: pharmacology and t h e skin. New York: Appleton-CenturyCrofts, 1972. 5. Dietel K. Morphological and functional development of the skin. In: Stave U, ed. Perinat Physiol. New York: Plenum Medical Book Company, 1978: Chapter 36. 6. Holbrook KA. A histological cornparison of infant and adult skin. In: Maibach HI, Boisits EK, eds. Neonatal skin: structure and function. New York Marcel Decker, Inc., 1982:3-31. 7. Schick JB, Milstein JM. Burn hazard of lsopropyl alcohol in the neonate. Pediatrics 1981;68:587-8. 8. Margileth A. Dermatologic conditions. In: Avery G, ed. Neonatology:
43
9. 10.
11.
12. 13.
14.
pathophysiology and management of the newborn. 2nd ed. Philadelphia: J.B. Lippincott Co., 1981: 1061- 103. Boyle RJ, Oh W. Erythema following transcutaneous p02 monitoring. Pediatrics 1980;65:333-4. Golden SM. Skin craters-a complication of transcutaneous oxygen monitoring. Pediatrics 1981;67: 514-6. Nachman RL, Esterly NB. Increased skin permeability in preterm infants. J Pediatr 1971;79:62832. Hey E, Katz C. Evaporative water loss in the newborn baby. J Physiol 1969;200:605-19. West DP, Worbec, Solomon. Pharmocology and toxicity of infant skin. J Invest Dermatol 1981;76 147-50. Jackson H, Sutherland R. Effect of povidone iodine on neonatal thyroid function. Lancet 1981:2:992.
15. Pyati S, Ramamurthy R, Kraus M, Pildes R. Absorption of iodine in the neonate following topical use of povidone-iodine. J Pediatr 1977;91(5):825-8. 16. Wester R, Maibach H. Comparative percutaneous toxicity. In: Maibach HI, Boisits EK, eds. Neonatal skin: structure and function. New York Marcel Decker, Inc., 1982. 17. Harpin VA, Rutter N. Barrier properties of the newborn infant’s skin. J Pediatr 1983;102:419-25. 18. McCormack J, Boisits E, Fisher LB. An in vitro comparison of the permeability of adult versus neonatal skin. In: Maibach HI, Boisits EK, eds. Neonatal skin: structure and function. New York Marcel Decker, Inc., 1982149-64.
Address for correspondence: Carolyn Lund, RNC, MS, Children’s Hospital
Medical Center of Northern California, 747 52nd Street, Oakland, CA 94609.
Carolyn Lund is a neonatal clinical specialist at Children‘s Hospital Medical Center, Oakland, California. Joanne McManus Kuller is a neonatal clinical specialist and Nursery Coordiqator at Aka Bates Hospital, Berkeley, California. Catherine Tobin is a neonatal clinical specialist and Associate Coordinator, Transport, at Children’s Hospital Medical Center, Oakland, CaIifornia. Linda Lefrak is a neonatal clinical specialist at Children’s Hospital Medical Center, Oakland, California. Linda Sturla Franck is a neonatal clinical specialist and Associate Coordinator. ICN, at Children’s Hospital Medical Center, Oakland, California.
MASTER CALENDAR FOR THE NAACOG 1986 REGIONAL CONFERENCES
For registration information, contact Denise Savage, NAACOG Dept. of Education and Research, 600 Maryland Ave., SW, Suite 200E, Washington, DC 20024 (I-800-533-8822). April 9-1 0,1986 Vancouver, Washington COG Washington-Oregon joint
section meeting REGISTRATION CUT-OFF DATE: March 17
Wednesday, April 9 Perinatal Loss and Grief (2-day course) Teaching Strategies for Emotional Transition to Parenthood
Emergency Delivery Thursday, April 10 Perinatal Loss and Grief (continued) Resuscitation and Stabilization of t h e Newborn Women in Transition: The Middle Years Short-stay Postpartum Programs May 15-17,1986
St. Louis, Missouri REGISTRATION CUT-OFF DATE: April 23
Thursday, May 15 The Pregnant Adolescent (2-day course) Perinatal Loss and Grief (2-day course) Insights Into Infertility Friday, May 16 The Pregnant Adolescent (continued) Perinatal Loss and Grief (continued)
44
Teaching Strategies for Emotionat Transition to Parenthood
Saturday, May I? Resuscitation and Stabititation of the hidwborn Short-stay Postpartum Programs Women in Transition: The Middle Years June 19-21,1980 Pittsburgh, Pennsylvania REGISTRATION CUT-OFF DATE: May 28 Thursday, June 19 The Pregnant Adolescent (2-day course) Perinatal Loss and Grief (2-day course) Insights Into Infertility Friday, June 20 The Pregnant Adolescent (continued) Perinatal Loss and Grief (continued)
Emergency Delivery Teaching Strategiesfor Emotional Transition to
Parenthood Saturday, June 21 Resuscitation and Stabilization of the Newborn Short-stay Postpartum Programs Women in Transition: The Middle Years
JanuaryIFebruary 1986 JOCNN