research and studies

Evaluation of a Tape to Protect Neonatal Skin

Pectin-based Barrier Under

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 moni- toring devices on fragile skin pre- sents a challenge and a dilemma for those caring for neonates in the intensive care nursery. The chal- lenge is to attach devices such as endotracheal tubes, umbilical ar- tery 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, par- ticularly in infants weighing less than 1500 grams at birth, alterna- tive methods were explored.’

The full-term infant’s skin func- tions as a barrier to infection, con- trols temperature and insensible

Accepted: November 1984.

water loss, and transmits sensa- tion. 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 in- clude 1) a decreased number of fi- brils that attach the dermal layer to the ep idermi~,~ 2) a thin stratum corneum layer: and 3) the pres- ence of significant edema that can compromise skin blood flow.5 With 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 nurs- ing 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 er- ythema and skin craters as a com- plication of transcutaneous oxygen monit~ring.~.’~ Increased perme- ability of the premature’s kin^.''*'^ and the concomitant risk of per- cutaneous toxicity from drugs and chemicals are do~umented.’~-’~

Harpin and Rutter found that the skin beneath adhesive tape and adhesive rings used for transcuta- neous monitor electrodes was stripped of the epidermal layer when the electrode was removed.17 This resulted in increased perme- ability 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 appli-

JanuaryIFebruary 1986 JOCNN 39

Table 1. Sample Characteristics

Mean Range

Gestational age

Postnatal age

Birthweight

Study weight

(weeks) 31.3 25-40

(days) 7.0 1-48

(grams) 1571.6 700-4220

(warns) 1545.2 700-4180

N = 45.

cation and removal of adhesives on infants in the intensive care nurs- ery. Tincture of benzoin and plastic polymers have been used exten- sively 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 se- vere stripping with adhesive re- moval. Products that assist in ad- hesive removal (Whisk@, Derma- sol@, and Unisolve@) are solvents and not only dry the skin but are readily absorbed through the pre- mature 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. HolliHesiveQ was cho- sen because it did not crumble un- der the heat of the radiant warmers and incubators used in the inten- sive care nursery. Also, HolliHesive molded easily to the many con- tours of the neonate’s body.

HolliHesive, a barrier used for adult ostomy patients, is a porous “blanket” composed of polyiso- butylene, water-absorbing pow- ders, pectin, gelatin, and sodium carboxymethylcellulose. After us- ing this barrier for a six-month pe- riod in the intensive care nursery, a marked reduction was noted in the incidence of skin excoriations’ and documentation of the effec-

tiveness of using this adhesive barrier for the neonatal patient population was needed.

PIJRPOSE

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 equip- ment and other devices securely attached to the infant.

METHODS

Sample

The study population consisted of a convenience sample of 45 in- fants. 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 nurs- ery, including respiratory distress syndrome, necrotizing enterocoli- tis, 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 medi- cal diagnosis. Data were collected before application and after re- moval of the pectin-based barrier by the staff nurses in the intensive care nursery. The data included the type of device attached (endotra- cheal tube, umbilical artery cath- eter, 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 se- cure nine different appliances: en- dotracheal tubes (nasal and oral), umbilical artery catheters, tem- perature probes, peripheral IVs (stainless steel needles and teflon catheters), ostomy and urine col- lection bags, and nasogastric and chest tubes. Skin condition was categorized as intact, dry/flaky, reddened, or excoriated. Cloth ad- hesive tape and plastic tape were used over the skin barrier. Adhe- sive 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 appli- cation and removal procedures were observed and recorded (Ta- ble 2). An average of four proce- dures were recorded for each sub- ject. The barrier and adhesives re- mained in place and effectively held the appliances for an average of 5.5 days.

Removal of barrier and tape oc- curred for a variety of reasons, ranging from routine site changes to nonadherence of either the bar- rier 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-re- lated reasons. However, the type of appliance that the barrier was used for and the reason for removal were significantly correlated (P

40 JanuaryIFebruary 1986 JOG”

< 0.012) using the chi-square test (2 = 16.2, d f = 6). The appliances most frequently removed for prob- lems with adhesion were the en- dotracheal tubes (oral and nasal), urine bags, and temperature probes.

Observations of overall skin condition and skin condition at the site of barrier application and re- moval 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 place- ment of an ostomy bag and an um- bilical artery catheter, the barrier

Table 2. Appliances Secured with HoiliHesive" Under Tape

Reason for Removal'

Number of Number of Adhesive- Nonadhesive- Appliance Cases Days in Place related related

Mean Range (Yo) (W Endotracheal tube

(oral/nasal) 52 5.35 1-13 35.4 64.6 Umbilical artery catheter 44 7.33 1-21 5.0 95.0 Nasogastric tube 4 3.33 3-4 33.3 66.7 Temperature probe 79 4.37 1-13 35.8 64.2 Intravenous tube 3 3.50 3-4 0 100 Ostorny 9 2.88 2-3 14.3 85.7 Urine bag 8 1.50 1-2 42.9 57.1

N = 199. X 2 = 16.2, df 6; P < 0.01.

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 poses. which the area had been excori- ated 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

integrity had been noted and staff hesive that does not easily fall off could not justify depriving infants with routine caregiving. The type of this technique for research pur- of appliance for which the barrier

was used was significantly corre- Removal of the appliance in 72% lated with the reason for appliance

of the cases (143 of the 199 appli- removal. cation/removal observations) oc- The appliances most frequently curred for nonadhesive-related removed for problems with adhe- reasons such as elective tube re- sion were endotracheal tubes (na- moval or discontinued therapy. sal and oral), urine bags, and tem- This indicates the feasibility of us- perature probes. Differentiation ing this barrier as an effective ad- between nasal and oral endotra-

- -I_

them). Skin condition did not, in this study, correlate with gesta- tional age, postnatal age, birth Table 3. Cases with Skin Excoriation After HolliHesive" Removal

weight, or study weight.

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 neo- natal patients from tape removal. The technique of using such a bar- rier had been instituted one year before the start of the study and had become standard nursing practice in the intensive care nurs- ery. A controlled, experimental, study design could not be used be- cause great improvement in skin

Cases (infant Gestational Postnatal Birth Skin Condition

Number) Appliance Age Age Weight Before HolliHesive

Weeks Days Grams

5 1 Temperature 25.5 1 800 Intact

2 Temperature intact

3 Umbilical intact at site/some

probe

probe

artery areas of catheter breakdown

probe 15 Temperature 28.0 2 800 Intact

20 Ostomy 32.0 25 1400 Excoriated 26 Temperature 29.0 1 1000 Intact

29 Temperature 28.0 1 900 intact

34 Temperature 28.0 2 1000 Intact

53 Temperature 27.0 2 1000 Intact

probe

probe

probe

probe

January/February 1986 JOCNN 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 prob- lems 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 be- cause of the use of the barrier, and no instances of accidental extuba- tion 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.

were documented. For infants re- quiring 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 an intact surface for future applica- tions.

Urine bag adhesion also was compromised due to moisture. However, because of t h e small sample size (8 cases), the effec- tiveness of the barrier in securing this appliance was difficult to eval- uate. 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 bar- rier around the temperature probes is unclear and warrants further investigation.

Of 199 application/removal ob- servations, excoriated skin was documented in only nine cases. In two of these cases, excoriations were present before the applica- tion of the barrier, at an ostomy site. Since an ostomy site is a pri- mary target for skin breakdown due to the corrosive action of the ostomy drainage, more frequent changes of the skin barrier and ap- pliance are indicated when break- down occurs until the area is healed, The skin around the stoma must be kept covered with a skin barrier to protect it from further breakdown.

In the seven cases where previ- ously intact skin showed excoria- tions after removal of the barrier, all occurred underneath tempera- ture probes that were secured with a ring of the skin barrier and cov- ered 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 oc- curred in infants less than 28 weeks gestation and weighing less than

42 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 hospi- talization. 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 con- dition, postnatal age, birth weight, and gestational age. This was not shown statistically and is believed to be due to the special character- istics of the study population. The infants were transported to the in- tensive care nursery from units that were instructed in the use of a barrier between tape and skin, and the infants arrived with a pec- tin-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 fol- lowing 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 sig- nificantly 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 Har- pin 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 bar- riers.” Nurses should begin to communicate with companies who develop adhesives and other ap- pliances that attach to skin (i.e.,

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 af- fect neonatal skin integrity and provide input for development of new products that will preserve and protect this vital organ.

CONCLUSION

Life support and monitoring de- vices must be attached to the frag- ile skin of neonates in intensive care units. A pectin-based barrier between tape and the neonate’s skin was used to minimize epider- mal stripping. The use of a pectin- based 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

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Kuller J, Lund L, Tobin C. Improved skin care for premature infants. American Journal of Maternal Child Nursing 1983;8(3):200-3. Wilson DR, Maibach H. An in vitro comparison of skin barrier func- tion. In: Maibach HI, Boisits EK, eds. Neonatal skin: structure and function. New York Marcel Decker, Inc., 1982: 101 - 10. Adams R. Principles and practice of topical therapy. Pediatr Clin North Am 1971;18(3):685-712. Montagna W, Van Scott E, Stough- ton R. Advances in biology of skin. Vol. XII: pharmacology and the skin. New York: Appleton-Century- Crofts, 1972. Dietel K. Morphological and func- tional development of the skin. In: Stave U, ed. Perinat Physiol. New York: Plenum Medical Book Com- pany, 1978: Chapter 36. Holbrook KA. A histological corn- parison of infant and adult skin. In: Maibach HI, Boisits EK, eds. Neo- natal skin: structure and function. New York Marcel Decker, Inc.,

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pathophysiology and management of the newborn. 2nd ed. Philadel- phia: J.B. Lippincott Co., 1981:

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10. Golden SM. Skin craters-a com- plication of transcutaneous oxygen monitoring. Pediatrics 1981;67:

11. Nachman RL, Esterly NB. In- creased skin permeability in pre- term infants. J Pediatr 1971;79:628- 32.

12. Hey E, Katz C. Evaporative water loss in the newborn baby. J Physiol

13. West DP, Worbec, Solomon. Phar- mocology and toxicity of infant skin. J Invest Dermatol 1981;76

14. Jackson H, Sutherland R. Effect of povidone iodine on neonatal thy- roid function. Lancet 1981:2:992.

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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 prop- erties 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 per- meability of adult versus neonatal skin. In: Maibach HI, Boisits EK, eds. Neonatal skin: structure and function. New York Marcel Decker, Inc., 1982149-64.

1977;91(5):825-8.

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, Oak- land, 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, C a I i f o r n i a.

Linda Lefrak is a neonatal clinical specialist at Children’s Hospital Medical Center, Oakland, California.

Linda Sturla Franck is a neonatal clinical spe- cialist 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

Emergency Delivery

Thursday, April 10 Perinatal Loss and Grief (continued) Resuscitation and Stabilization of the 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)

Parenthood

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 Strategies for Emotional Transition to

Parenthood

Saturday, June 21 Resuscitation and Stabilization of the Newborn Short-stay Postpartum Programs Women in Transition: The Middle Years

44 JanuaryIFebruary 1986 JOCNN