Adapting a Soft Silicone Dressing to Enhance Infant Outcomes

Author(s): 
Zarah Kim Smith, RN, Clinical Nurse II



Of the various forms of CPAP and machine models, the author prefers the Aladdin/Infant Flow nasal CPAP system (Hamilton Medical, Reno, Nev) for its flexibility. Infants can be cared for on their sides or prone, making it somewhat easier to maintain good position. However, depending on the activity of the babies, clinicians have found them literally “hanging” from their noses (see Figure 2) whether using prongs or the mask; this results in significant pressure applied to the tip of the nose, the nasal septum, and surrounding tissue (see Figure 3). To try to minimize stripping, relieve pressure, stabilize the equipment, and reduce friction and shear, hydrocolloids and tape and gauze have been used as barriers and/or stabilizers. As a result of such practices, additional stripping and pain were evident. As noted in the literature,6 dressings and tapes with traditional adhesives remove the protective stratum corneum of many of the preterm infants in the author’s care. The complications of pressure ulceration and stripping have resulted, in extreme situations, in tissue loss that required postdischarge attention from the plastic surgery team.

The Solution

Over the last year, clinicians at Duke have enhanced their practice and outcomes through identifying products that protect the epidermis of the infants they treat. Soft silicone dressings have been a part of that endeavor — they are easily removed and repositioned on the skin and provide an extra barrier for protection from the equipment. Additionally, clinicians may alternate between using the mask or prongs for delivery of therapy. Education regarding the techniques and practice is included in departmental competence labs for respiratory therapists, nurses, nurse practitioners and physicians.

Under current protocol, when nasal CPAP therapy is initiated, silicone dressings are placed under the prongs or the mask to protect the fragile skin as a prophylactic measure (see Figure 4). Customized patterns are cut from Mepilex® Lite, (Mölnlycke Health Care, Norcross, Ga) to fit around the infants nose (see Figure 5) or across the upper lip (see Figures 6, 7) to address both types of CPAP delivery systems. The thinness and flexibility of the dressing provides conformability and security and does not interfere with the air delivery. Another significant benefit is that the edge of the soft silicone dressing can be lifted, allowing clinicians a quick observation of the area concerned with minimal disruption to the resting infant.

With the new CPAP protocol instituted in the Duke IC Nursery, a significant reduction in tissue damage among the infant population has been noted. Education is ongoing, as proper applications and compliance to the regimen enhance outcomes. Infant comfort levels are recognized as pain scores utilizing the CRIES8 pain scale have decreased and overall irritability of the baby has lessened.

Parent satisfaction with this new practice is evident — they see their baby’s comfort is addressed and that the nose and face are protected from injury. If a clinician has failed to place the dressing under the appliance, parents often will ask why. Since the skills labs were implemented and the new method of care accepted, staff members recognize the benefits and incorporate skin protection into their routine care. Application of the soft silicone protective barrier now is included in CPAP orders written by the physician and nurse practitioner team.

References: 

1. Tucker J, McGuire W. ABC of preterm birth: Epidemiology of preterm birth. Available at: http://www.studentbmj.com/issues/05/04/education/146.php. Accessed March 8, 2006.
2. Robertson NJ, McCarthy LS, Hamilton PA, Moss ALH. Nasal deformities resulting from flow driver continuous positive air pressure. Arch Dis Childhood, Fetal and Neonatal Edition. 1996;75(3):209F–212F.
3. Bronchopulmonary dysplasia. Available at: http://www.merck.com/mmhe/au/sec23/ch264/ch264l.html. Accessed March 8, 2006.
4. Quinn D, Newton N, Pieuch R. Effect of less frequent bathing on premature infant skin. JOGNN. 2005;34(6):741–746.
5. National Association of Neonatal Nurses. Position Statement #3019, Pain Management in Infants. 1999. Available at: http://www.nann.org/files/public/3019.doc. Accessed March 8, 2006.
6. Dykes PJ, Heggie R, Hill SA. Effects of adhesive dressings on the stratum corneum of the skin. J Wound Care. 2001;10(2):7–10.
7. Moffatt C. Pain at wound dressing changes: a guide to management. European Wound Management Association Position Document. London, UK: Medical Education Partnership LTD;2002.



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