ASHFORD & ST PETER S HOSPITALS NHS TRUST Neonatal Unit. Neonatal Skin and Wound Care Guideline

Transcription

1 ASHFORD & ST PETER S HOSPITALS NHS TRUST Neonatal Unit Neonatal Skin and Wound Care Guideline Contents Preventative measures 2 Initiating wound care 3 Wound classification and management 4 Recommended dressings 5 Nappy rash 5-6 Wound assessment form, initial assessment 7 Wound assessment form, ongoing assessment 8 Glossary of terms 9 References 10 Extravasation injuries 10 Hyaluronidase 11 Glycerine trinitrate 11 References 12 Wound classification and management aim 13 Wound care flow chart 14 The lower edge of viability of the epidermis is only 2-3 cells thick and has a poor barrier function. The ski is not functionally mature until 33 weeks gestation. Several consequences of this immaturity for the infan include a high risk of epidermal stripping, pressure necrosis and extravasation injury. 1 Any breakdown of the skin places the infant at increased risk of infection and can ultimately lead to loss of life. Another consequence of skin injury is scarring, which may be detrimental to the quality of life in later years. 2 1

2 Preventative measures Action All staff must keep their fingernails short and ensure that all stoned rings are removed as in some cases handling alone may cause epidermal stripping 3 See hand washing guideline Minimal use of adhesive tape 4 Do not use tape on the skin when securing umbilical lines A thin layer of hydrocolloid (Duoderm) should be used under tape as appropriate e.g. for nasogastric tube fixation and under temperature probes 5 To reduce the risk of epidermal stripping Careful removal of tapes and adhesive dressings following manufacturer s instructions e.g. Remove film dressing by stretching the dressing parallel to the patient s skin while stabilising the patient s skin and IV catheter with the other hand. Use of adhesive removers if risk of epidermal stripping is high Action Timing of re-siting of probes will depend on the assessment of the individual infant s skin condition and will be documented on the infant s chart. 3 Care must be taken when securing ET tubes that ear lobes are not compressed under the ties of the hat 3 Consider the use of thin hydrocolloid under CPAP nasal prongs if redness is occurring on or under nasal septum. Give short breaks from CPAP to relieve pressure if tolerated by infant or consider use of the mask. Action To reduce the risk of pressure necrosis Infants are at increased risk if they are poorly perfused or become oedematous 6 Intravenous cannulae and central lines should be secured with a sterile clear film dressing 7 to ensure cannulation site is clearly visible. A central line should be sited for the administration of total parental nutrition and infusions that contain glucose in concentrations greater than 12.5% 6 and certain drugs e.g. morphine Positioning of limb to aid visibility of site of infusion. This may involve nursing infant in an incubator if temperature cannot be maintained with the limb exposed in a cot. Frequent observation of site of infusion with hourly documentation of condition of site. Check the pressure limit alarm on the pump is set correctly when taking over infant s care. (see safety check list) To reduce the risk of extravasations Use of splints to restrict movement of joint adjacent to cannula site. To reduce the risk of extravasation injury Initiating Wound Care 2

3 Action If an extravasation injury is suspected inform doctor immediately. Assist with Hyaluronidase treatment or GTN treatment without delay. 9 See extravasation guideline Consider the need for paracetamol. Complete an Incident Form Complete a Wound Assessment Form (with reference to the glossary and wound-care folder as necessary). Document in Medical Notes/nursing notes how injury occurred, action taken and record information given to parents *Photograph the wound-site using ward camera or refer to medical photography if camera unavailable To reduce incidence and severity of scarring. To minimise pain and discomfort To ensure comprehensive assessment and documentation. To provide a record for infants notes, and reduce frequency of dressing removal for wound inspection. Up-date parents at first available opportunity. Provide explanation as required. Place limb in a comfortable Apply Mepitel and gauze dressing if necessary; fix using minimal amount of cotton bandage. Affected limb not to be used for further cannulation. Inform attending consultant Note baby s name in Wound Care Folder To ensure parents are fully informed To reassure parents treatment/wound-care has been initiated To reduce swelling To provide protection and allow fluid to escape from tissues. To prevent further damage to vulnerable tissue Consider using antibiotics To minimise the risk of infection *parental consent must be obtained either before the photograph is taken or before it is printed and put in the patient s notes Recommended Dressings (See formulary for further information) 3

4 Hydrogel (Intrasite) Action Examples If wound bed appears necrotic or covered with slough, and the wound site is on the hand or foot, Intra-site gel may be applied To facilitate autolytic debridement, leading to faster wound healing and reduced scarring. Barrier film (Cavilon stick) may be applied to the surrounding area, prior to applying the gel. (Take care to separate toes/fingers for a few seconds while film is drying) Apply 0.5cm of gel to the to wound bed Cover hand/foot with a sterile plastic bag (Thumb of large transparent glove for infant<1kg or whole small glove for larger infants) Secure bag-using tape. Tape semi-loosely around limb, over the bag (avoiding infants skin) See Wound Care Folder for picture. Extra hydrogel may be added as necessary to maintain a depth of 0.5cm Bag may be renewed every 2-3 days, surrounding skin to be cleaned with saline, dried and Barrier Film reapplied Wound bed to be cleansed with warmed saline and gauze swab only if loose debris present otherwise irrigate with a syringe If the gel / wound bed is discoloured, remove dressing and reassess To prevent maceration of the healthy skin enclosed with the gel. To prevent toes/fingers sticking together As per manufacturer s instructions To prevent gel from rubbing off or drying out. To maintain a moist wound healing environment To prevent further damage. To keep the wound bed moist. To facilitate inspection of condition of, and protection of surrounding skin To avoid damaging epithelial growth with unnecessary cleansing. To remove barriers to healing To minimise the risk of infection Extravasation injury prior to treatment Extravasation injury dressed with a boot made from a urine drainage bag filled with hydrogel During healing, a pale-yellow semi-solid fibrinous layer may develop on the wound surface. This layer does not appear to affect the healing process and need not be removed. A new tube of gel needs to be used with each application Recommended dressings (cont.) 4

5 Hydrocolloid (Comfel transparent) Action If wound bed appears to be granulation or To provide a moist wound healing epithelial tissue, and there is at least 1cm environment. of healthy skin surrounding the area, hydrocolloid may be applied 10 Use sterile scissors to cut hydrocolloid to size allowing 1cm overlap with the wound edge. Duoderm may be left in situ for as long as intact but not for longer than 7 days (unless dressing bubbles up indicating a collection of exudate underneath). To ensure adhesion of dressing (manufacturer s instructions) To facilitate the healing process and provide a bacterial barrier. Nappy Rash Preventative Measures Action Check infant s nappy 3-4hrly and wash and dry area Identify infants at increased risk of developing nappy rash eg. Infants with loose, frequent stools 8 or Neonatal Abstinence Syndrome, and apply barrier ointment with nappy changes e.g. zinc ointment To facilitate prompt removal of stool/urine from contact with infant s skin To protect the skin and reduce risk of rash Update parents on care required To enable them to contribute towards their baby s care 5

6 Treatment of nappy rash Action Having excluded yeast/fungal infection by visual inspection, apply barrier cream with nappy changes To add moisture to promote healing and provide protection from stool and urine Daily bathing as appropriate using Aqueous cream. Do not use any baby bathing products 11 Provide explanation for parents To add moisture and promote healing To prevent further skin damage To enable them to contribute towards their baby s care Consider the need for analgesia Orobase can be used in severe cases To minimise pain and discomfort Discharge preparations for babies discharged with ongoing management Action Refer to neonatal community sister as soon as discharge is planned Send copy of wound assessment and treatment forms to the community sister To enable community sisters to familiarise themselves with the infants wound care needs To facilitate good communication and continuity of care 6

7 Neonatal Intensive Care Unit Wound assessment form Initial assessment PLACE PATIENT ID LABEL HERE OR WRITE Name: Hospital number Date of birth DATE Tick as appropriate Pressure sore Surgical wound Chemical burn Heat burn Stripping Excoriation Infection Extravasation Other Injury Causative agent SIZE (mm) Total affected area Wound area Maximum length(mm) Maximum width (mm) Maximum depth (mm) EXUDATE (delete as appropriate) Serous/viscous Moderate Colour: WOUND BED (see wound classification chart) Wound type Epithelium Granulation Slough Infected Necrosis Wound code Pink Bright red Yellow Green/yellow Black/brown DESIRED TREATMENT OBJECTIVE tick as appropriate Protection Hydration Absorption Autolytic debridement Other (state) INITIAL DRESSING APPLIED (if any) Date Type of dressing Additional information Comments e.g. referral to plastic surgeons, physiotherapist, swabs taken etc date SIGNATURE NAME DATE 7

8 Neonatal Intensive Care Unit Wound assessment form Ongoing assessment PLACE PATIENT ID LABEL HERE OR WRITE Name: Hospital number Date of birth Dressing Date Type of dressing Date due for change/review Date of assessment Wound size (mm) Maximum length Maximum width Maximum depth Wound bed (see glossary for terms) % Epithelial Granulation Slough Infection Necrosis Exudates Quantity (+,++, +++) Serous/viscous (S or V) Colour Signs of pain Swab taken Initial of assessor 8

9 GLOSSARY OF TERMS Autolytic debridement: Removal of dead tissue by facilitating the natural breakdown of the cells Chemical burn: Lesion caused be skin contact with harmful substance Epidermal stripping: Caused when the strength of the adhesive is stronger than the epidermal/ dermal bond resulting in the removal of areas of epidermis with the product Excoriation: wearing away of skin caused by prolonged contact with harmful substances (most commonly seen in the groin and buttocks caused by enzymes in stools Exudate: Any fluid draining from a wound Epithelium: Outer layer of skin. The wound bed may have complete patches of epithelium while other areas are still granulating Granulation: New tissue growth appearing in base of a wound (wound base) consisting mainly of capillary loops and collagen producing cells. Pink/ red and granular in appearance. Necrosis: Death of tissue. Black or brown, often leathery in texture. If wet it presents as slough Pressure Injury: Any lesion caused by unrelieved pressure, friction or shear forces resulting in damage to the skin or underlying tissues Serous: watery Slough: Dead tissue on wound bed. Usually yellow or white. Possible focus for infection. Must be removed Viscous: glutinous, sticky REFERENCES 1. Rutter The immature skin. European Journal of Paediatrics. Vol 155, supp2, p.s.18-s20 2. Rutter R 1988 The immature skin British Medical Bulletin; 4: Irving et al 2006 Neonatal wound care, minimising trauma & pain. Wounds UK: vol 2, issue 1, p Malloy MB and Perez-Woods RC 1991 Neonatal Skincare: prevention of skin breakdown Dermatology Nursing; 3:5, Lund C 1999 Prevention & management of infant skin breakdown. Nursing Clinics of North America vol 34, no 3, p Bethell et al -. June Issues in Neonatal wound care; minimising trauma & pain. A report from an independent advisory group 7. Peyit J and Hughes K 1993 Intravenous Extravasation: Mechanisms, Management and Prevention Journal of Perinatal and Neonatal Nursing vol.6; no.4; pg Benjamin L Clinical correlates with diaper dermatitis. Paediatrician: 14, suppl 1, Davies J et al Preventing the scars of neonatal intensive care. Archives of Disease in Childhood: 70; Young T, Atkinson J, Irving V 1996 The use of a Hydrocolloid Dressing in the treatment of Iatrogenic Neonatal Skin Trauma. Proceeding of the 6 th European Conference on Advances in Wound Management Macmillan: London 11. Atherton D July Maintaining healthy skin in infancy using prevention of irritant napkin dermatitis as a model. Community Practitioner: 78, 7, page 255 Further reading Putet G et al 2001 Effect of Bepanthan Ointment on the prevention and treatment of diaper rash on premature and full-term babies Realites Pediatriques63:33-8 Thomas S et al 1987 A New Approach to the Management of Extravasation Injury in Neonates The Pharmaceutical Journal vol.239 p

10 Extravasation injuries Extravasation is defined as the inadvertent leakage of infused fluid into the surrounding tissue. 1 the resultant damage to tissue can be very serious ranging from skin loss and tendon damage to loss of digits or limb. About 4% of infants leave neonatal intensive care units with cosmetically of functionally significant scars, thought to be caused by extravasation injuries. 2 A survey of regional neonatal units in the United Kingdom determined a prevalence of 38 per 1000 neonates who sustained an extravasation injury that caused skin necrosis with 70% of these injuries occurring in infants of 26 weeks or less gestation. 1 Most extravasations occur from extravasation of peripheral venous cannulae (93%) with the veins in the dorsum of the foot and the back of the hand being most vulnerable Various agents have been implicated in causing tissue necrosis after intravenous infusions have extravasated. These include solutions of calcium, potassium, bicarbonate, hypertonic dextrose, TPN, vasoactive drugs eg, dopamine/ dobutamine/ adrenaline and antibiotics. Views on management of these injuries differ, and range from a non-operative conservative approach to early debridement and grafting. The management of extravasation is partially dependent on the characteristics of the extravasated agent and include limb elevation, exposure of affected site, occlusive dressing, use of hyaluronidase 3,4 and use of topical nitroglycerin 5,6. Once extravasation has occurred it may be difficult to predict whether a soft tissue complication will occur or whether the leak will dissipate without problems NOTE : Once a significant extravasation has occurred, 1. Notify the neonatal doctor immediately 2. Fill in a wound assessment form 3. Complete an incident form 4. Take a photograph of the site. Parental consent MUST be obtained before the pictures are printed and attached to the patients records, but treatment should be initiated without delay. If consent is refused, then pictures must be deleted 5 Use Hyaluronidase as soon as possible HYALURONIDASE for extravasation injuries Materials 0.5% Lignocaine/Xylocaine (no adrenaline) 1 vial Hyaluronidase (1500units). Dilute with 1.5ml of normal saline as per neonatal formulary 250ml Normal saline 20 or 50cc syringe 2x 10ml/ 50ml syringes 2 x 21G green needles 2 x 25G orange needles 23/25 gauge cannula 1 kidney dish 10

11 Method (Aseptic conditions) Remove the cannula Give sucrose 1. Infiltrate local anaesthetic agent in and around the extravasation site (0.3ml/kg maximum) Wait 3-5 minutes after infiltrating the anaesthetic agent 2. Using a 25G needle, infiltrate hyaluronidase in ml aliquots into the subcutaneous tissue (1 vial is diluted with 1.5ml of normal saline) in 3-4 separate sites around the extravasation aiming at the centre of the site. Wait 3 5 minutes after administrating the hyaluronidase 3. Make multiple small exit wounds with a green needle around the periphery of the area and within the affected area 4. * Flush 20-50ml of normal saline through the subcutaneous space in 3-5ml aliquots. The saline is irrigated through 4-5 of the exit wound sites, exiting as a shower through the remainder. (*The amount of fluid used depends on the size of the baby and extent of the wound) 5. Gentle massage of the limb can be done to express fluid through the injection site 6. Apply a sterile non-stick dressing and place the limb in a comfortable neutral position. 7. The site must be reviewed on a regular basis 8. Post procedural photographs are recommended 9. If necessary, the patient will be followed up by the plastic surgery service in conjunction with the neonatal service (community and outpatient follow up) GLYCERINE TRINITRATE (GTN) for extravasation injuries and ischaemic injuries Nitroglycerin increases collateral circulation to the local area of peripheral venous ischemia and has been found to be useful to use after extravasation with certain agents. 3 These have included dopamine, adrenaline and TPN. It has also been found to reduce peripheral vasospasm caused by indwelling umbilical arterial catheters and peripheral arterial lines 5. A patch or ointment can be used. The latter is preferred when used on irregular joints. The main side effect is systemic vasodilatation and a rise in methaemoglobin level. The blood pressure needs to be monitored on regular basis. If used for prolonged periods, measure methb levels Current indications for use Ischaemia secondary to arterial cannulation Treatment If there is persistent blanching or duskiness of the peripheries of the affected limb, remove the catheter/cannula Keep under close observation If the vasospasm does not improve in a few minutes, apply a GTN patch Dosage and duration 3 Transdermal patch Apply a 18.5mg patch (delivers 5mg/day) to the affected area for 24 hours or less Review and reassess on a regular basis If required reapply a patch and review at regular intervals Document all findings and actions, with timings, very carefully in the notes. Make drawings and take photos (parental consent needed) where possible. 11

12 REFERENCES CE Wilkins and AJB Emmerson. Extravasation injuries on regional neonatal units. Arch Dis. Child. Fetal Neontal Ed 2004: 89: Cartlidge PH, Fox PE, Rutter N. The scars of newborn intensive care. Early Hum Dev 1990; 21: 1-10 Jayashree Ramasethu. Prevention and management of Extravasation Injuries in Neonates. NeoReviews Vol 5 No e491 J. Kumar, Stuart P. Pegg, Roy M. Kimble (2001) Management of extravasation injuries. ANZ Journal of Surgery 71 (5), Joyce Generali, Dennis J Cada Nitroglycerin (Topical): Extravasation treatment, Hospital Pharmacy, Volume 36 No 10 pp Baserga m, Puri A and Sola A. The use of topical nitroglycerin ointment to treat peripheral tissue Ischaemia Secondary to arterial Line Complications in Neonates. Journal of Perinatology (2002)22, dio10 Additional reading Lehr.V. et al Management of infiltration injury in Neonates using duoderm Hydroactive gel. Am. J. Perinatol. 21(7): , October 2004 Lamb H et al. Newborn services Clinical Guideline, May 2006 SLY Siu, KL Kwong, SST Poon, KT So, The use of hyaluronidase for the treatment of extravasations in a premature infant. HK J Paediatr(new series) 2007:12:

13 Wound Classification and management aim Wound type Epithelialising Granulating Sloughy Infected Necrotic Colour Description Note Management aim Pink Bright red Yellow Green/yellow Black/brown discolouration (Eschar) Epithelial cells Shiny granulation Soft necrotic tissue Inflammation and Dead devitalised tissue multiplying and tissue with connective and dead phagocytes pyrexia. Localised migrating toward area tissue and capillary pain of cell deficit where loops granulation is evident Epithelial cells only migrate on healthy granulation tissue Maintain a warm moist environment Granulation wounds generally produce small amounts of exudate Maintain a warm moist environment and protect granulation tissue Wound will not heal until slough is removed Remove slough and absorb exudate Localised heat and swelling. Offensive odour Identify and eliminate infection Wound will not heal until necrotic tissue is removed Rehydrate and remove Eschar by autolysis 13

14 ASSESSMENT OF WOUND EXTRAVASATION INJURY ALL OTHER SIGNIFICANT INJURIES Inform Neonatal Doctor immediately and photograph the wound (Refer to trust guidelines Inform neonatal doctor and photograph wound Give analgesia as required. Consider sucrose when performing painful procedures (ref to sucrose guidelines) Hyaluronidase should be administered as soon as possible if indicated (refer to intranet Extravasation Injury guideline) Decide on treatment objective and dress wound according to condition of wound bed Apply non adhesive dressing and gauze if protection required. Secure with minimal tape or gauze Complete wound assessment form, incident form if applicable and document in baby s notes type of injury action taken and discussion with parents Elevate limb on rolled up blanket and do not use for further cannulation Inform attending consultant and Inform parents as soon as possible at a reasonable time Assess wound after 24 hours and on a regular basis and apply appropriate dressing. Update wound assessment form Photograph wound regularly to record progress 14

15 Guideline Prepared by Sr. Catherine Gilbertson and Dr. Olayinka Ejiwumi Reviewed and approved by Neonatal Clinical Management Group Date May 2007 Reviewed by Dr. Haddad, Chair Children s Clinical Governance Group Date Aug 2007 Review date Aug 2010 Reviewed Jan 2011 by Dr. Peter Reynolds Re-review Jan