SKIN INTEGRITY - NICU
Department NICU
PURPOSE
the neonate.
To outline the nursing management and maintenance of skin integrity in
POLICY
The skin serves as a protective barrier against chemical, mechanical, and
biological insults. Intact skin protects internal organs, provides a barrier to foreign
substances and organisms, regulates body temperature, stores fat and discharges
electrolytes and water. Altered skin integrity predisposes the neonate to infection,
increased insensible water loss and altered thermal regulation. The goal of neonatal skin
care is to minimize skin irritation and maintain the integrity of the epidermal barrier.
The purposes of bathing newborns include providing overall hygiene and aesthetics.
However, bathing is not an innocuous procedure and during the immediate postbirth
period can result in hypothermia, increased oxygen consumption, and respiratory distress.
The first bath should be delayed until the infant’s temperature has been stabilized in the
normal range for 2 to 4 hours. Bathing has also been shown to destabilize vital signs and
temperature in premature infants. Therefore, bathing should only be completed once the
infant is physiologically stable enough to tolerate the stress of the bath.
PROCEDURE
ASSESSMENT
1. Perform initial assessment on admission and each 12 hours to include skin color,
turgor and temperature; include mucous membranes.
2. Observe variations from normal; bruising, abrasions, areas of breakdown, pressure
areas, rashes, and edema every 12 hours.
3. Inspect surgical and chest tube sites for adequacy of healing every 12 hours.
4. Inspect skin/insertion sites around indwelling lines/catheters for signs of infection
every 12 hours.
5. Inspect oral mucosa every 4 – 6 hours and cleanse with VAPguard Oral Care products
for those infants not taking oral feedings.
6. Evaluate effectiveness of skin barriers.
7. Assess infants who have been on long term antibiotic therapy for development of
yeast infections.
INTERVENTION
INITIAL CARE
1. Handle all infants prior to first bath with gloves.
2. First bath should be provided to infants with a low alkaline soap as soon as
temperature and vital signs are stable (typically within 2-4 hours of birth).
Consult with physician regarding the need for bath if baby unstable.
3. Bathe infants every 3rd day utilizing a low alkaline soap. For infants greater than 20
days, daily soap baths may be given utilizing a low-alkaline soap.
4. Obtain order for Eucerin Cream if skin appears to be cracked. (Dry/flaky skin is
normal).
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5. Obtain order for Aquaphor Cream BID (as indicated) if infants are less than 1000
grams and/or less than 28 weeks.
 Cream should be used during the first 14 days of life on trunk and extremities
only.
 Cream is permitted on babies receiving phototherapy.
6. Obtain order for diaper cream when buttocks excoriated. Discuss the possibility of
ILEX stomahesive paste for infants with moderate to severe excoriation.
INSENSIBLE WATER LOSS PREVENTION:
1. Use radiant warmer's servo control to maintain abdominal skin temperature at 36.5
degrees Centigrade (97.7degrees Fahrenheit). (See Thermoregulation Protocol).
2. Use a saran blanket or plastic tent for infants less than 1000 grams. Change saran
blanket every 24 hours. Do not wrap baby in saran wrap. Avoid saran wrap contact
with skin
SKIN BREAKDOWN
Hydrogel may be used over areas of skin breakdown to protect the skin. When it is
feasible to use hydrogel and skin is sloughing off, bactericidal or antifungal cream or
ointment may be applied to the affected area with a physician’s order. The area should
then be wrapped with gauze; this should be done twice a day. When applying bacitracin,
cover only the open areas without overlapping onto healed areas, as this may cause
maceration.
HYDROGEL USE
Hydrogel dressing is composed of 96% water and 4% polyethylene oxide. The dressing
is permeable to oxygen, is occlusive, and can absorb its own weight in wound exudates.
It can be used in conjunction with topical medications or skin preparations, if desired, and
is used to prevent and treat skin breakdown.
EQUIPMENT
 Hydrogel wound dressing
 One pair of sterile gloves
 2” x 2” gauze
 Sterile saline wipes
 Suture set
PROCEDURE
1. Wash hands.
2. Position the patient to expose the area involved.
3. Apply gloves.
4. Remove drainage (which may appear on the wound) with a saline wipe.
5. Pat dry with a 2x2.
6. Using a suture set, cut the hydrogel dressing to the size of the wound.
7. Remove the film on the side of the dressing that will be placed on the wound.
Apply the dressing, gel side down.
8. Remove the film on top. Keep the area open to air and allow it to dry.
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9. Allow the hydrogel dressing to remain intact. It will peel off as the skin
underneath heals.
10. If drainage continues, assess the wound area for signs of infection (i.e. odorous
drainage, fever, increased redness, warmth). Any signs of infection should be
reported to the physician and documented in the nursing notes. A culture may be
indicated.
11. Document the use of hydrogel in the progress notes.
DIAPER AREA SKIN CARE
1. For infants having frequent, loose stools, it is important to protect the skin of the
diaper area from the irritating effects of the stool. Therefore, the nurse should discuss
and request an order for 3M No Sting Barrier Film in order to prevent skin
breakdown.
 Apply directly on red areas, including any rash
 Begin at the anal opening, swiping out in a circle about one or two inches from
the anus (areas that stool may come in contact with skin).
 The product goes on wet and dries in about one minute.
 While it is drying, hold the buttocks apart and don’t allow skin-to-skin contact
until completely dry.
 Once the barrier film is dry, butt balm may be applied thickly (1/8 inch) to the
diaper area.
 After each stool, remove the stool from the paste but do NOT completely remove
the paste from the skin. Then reapply the butt balm.
 When bathing, paste may be gently removed with mineral oil being careful not to
rub the skin.
 Continue using the barrier and butt balm until the skin is healed and the frequency
of stool decreases.
2. If skin becomes excoriated/open discuss with physician and request order for Ilex
paste instead of skin barrier.
 Apply Ilex paste thickly to a clean diaper area where broken skin is present.
 Cover Ilex paste with thick amount of petrolatum jelly
 After each stool, remove the stool from the paste, but, do NOT completely
remove the paste from the skin.
 Reapply Ilex and petrolatum jelly.
 Continue until broken down skin areas are healed and the frequency of stool
decreases.
 When tub bathing, soak the paste off, give the bath, pat the skin dry and reapply
paste as above.
 Mineral oil and a cotton ball can be utilized to gently remove paste or stool from
skin.
SAFETY
1. Monitor substances that come in contact with the infant’s skin and review the
ingredients to avoid use of toxic substances.
2. Avoid use of the following products/procedures:
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Creams, emollients, and lotions (unless skin cracked).
Repeated stripping of the epidermis with adhesives (stripping reduces barrier
properties of the skin).
 Oil based emollients while on warming table.
3. Avoid use of bandaids or gauze/tape combination on skin following skin punctures.
Carefully apply pressure at sites with gauze or cotton. If a bandage is necessary, cover
puncture with folded 2x2 gauze and wrap with Welbril. Remove Welbril and gauze
as soon as bleeding is stopped.
4. Limit amount of adhesive material used to secure endotracheal tubes (ETT), monitor
probes, IVs, feeding tubes, etc. Confine adhesive material to smallest possible surface
area. Utilize double backed or cotton prepped tape to minimize adhesion to skin.
5. Remove tape with warm water-soaked cotton balls and patience. Minimize use of
alcohol for this purpose as alcohol is drying to skin.
6. Do not use adhesive removers.
7. Wash off all betadine with sterile water after it has been used in a procedure.
8. Avoid use of benzoin beneath tape (exception: ETT). Benzoin can provide a stronger
bond between tape and epidermis than the cohesion between the epidermis and the
dermis in preterm skin. Do not use benzoin for routine application of urine collection
bags or IV sites.
9. Use ultrathin skin barrier as a blanket barrier between skin and tape to secure the
following devices: endotracheal tubes, nasal oxygen cannula, nasogastric tubes and
urine bags. Do not use barriers over infected skin.
10. Use transparent dressings or 3M No Sting skin barrier as a second skin over bony
reddened areas or bony prominences such as knees.
11. Utilize wound dressings only over excoriated areas of skin. Leave dressing in place
until it peels off.
12. Allow skin barriers/transparent dressings utilized as blanket barriers to naturally come
off infant’s skin. Do not manually remove from skin as this may decrease skin
integrity.
13. Avoid heating devices or hot water filled gloves.
14. Cover chemical heating mattresses before placing under infant.
15. Reposition cardio-respiratory monitor electrodes every shift and PRN. Assess skin
for intactness/infection. Consider use of limb leads on very low birth weight (VLBW)
infants. Utilize heart rate from umbilical arterial catheters on infants less than 750
grams.
16. Use lowest effective temperature for continuous transcutaneous carbon dioxide
monitor (TCM) (recommended 42-43.5 degrees Centigrade) and change as deemed
appropriate for the age and integrity of the infant’s skin (every 2 – 3 hours). Apply no
more than 2 TCM barnacles to infant.
17. Change infant’s position every 2-4 hours as tolerated. If infant intubated and/or
unstable, have respiratory care practitioner (RCP) at bedside to assist with position
changes.
18. Prevent constrictive tape/devices that may interfere with circulation (i.e. pulse
oximeter probes, IV boards).
19. Utilize sheepskin for appropriate developmental positioning.
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DOCUMENTATION
1. Document on NICU Flowsheet:
 Assessment data
 Treatments and procedures
2. Document any medication utilized on the Medication Administration Record.
REPORTABLE CONDITIONS
1. Notify MD for the following:
 Signs and symptoms of skin infection.
 Excoriated skin areas.
TEACHING
1. Inform parents that normal/optimal skin appearance is dry, even flaky in newborns.
2. Inform/instruct parents regarding procedures utilized to maintain skin integrity.
REFERENCES/ REGULATORY STANDARDS
 Kenner, C., & Lott, J. W. (2003). Comprehensive neonatal nursing: A physiologic
perspective. St. Louis: Saunders
 Medcon Bilab Technologies Package Insert (2004).
 AWHONN/NBANN (2001). NANN Guidelines for Practice: Neonatal Skin Care.
Author.
Origination Date
Approval Date
Review Dates
9/28/06
9/99, 9/01, 5/03, 4/04, 7/05, 6/06
Committee Approvals:
Neonatal Joint Practice: 9/99, 9/01, 5/03, 4/04, 7/05, 6/06
Pediatric Nurse Practice Committee: 6/03
Pediatric Joint Practice Committee: 6/03, 5/04
Pediatric Committee: 6/03, 6/04
Infection Control/Pharmacy & Therapeutics: 7/03, 7/04
MEC: 9/03, 8/04, 7/06
Policy & Procedure Committee: 8/05, 8/06
Operations Committee: 8/05, 8/06
Community Board: 9/05, 9/06
Protocols/Procedures: 1/02
Central Standards: 1/02, 10/03, 8/04