Factors which can contribute to skin break down, in general
Nasal prongs too small will move excessively can cause irritation inside the nose and can pinch the septum of the nose impeding blood flow.
Not using a water base lubricate with the nasal prongs
Nasal prongs too big can cause blanching at the nares which will impede blood flow and can impede blood flow in the inside of the nose
Nasal masks too small will blanch the outer portion of the nares, and can push on the tip of the nose
Nasal masks too big will cause excessive tightening of the CPAP bonnet strap at the cheek area and on the fore head leading to redness, bruising and breakdown
Improper fit of both mask and prongs will necessitate the use of a chin strap. Can cause excessive air in the abdomen which can interfere with digestion. Also placing another device on fragile skin to maintain CPAP
Ways of Preventative Skin Care for Nasal Cannula:
Select appropriate nasal cannula size
Utilize a securing product (i.e. Tender Grips, wiggle pads) to cheeks to secure the nasal cannula
Prepare the skin for the securing product (i.e. Tender Grips, wiggle pads) by applying approved protectant (No Sting Barrier Film). Do not use Mastisol
Change securing device PRN
Assess for correct device placement at least every 4 hours and PRN. Leave 2 mm between nasal septum and prongs
Assess the areas where the nasal cannula meets the skin for redness, non-blanchable erythema, and skin breakdown at least twice a shift with hands on assessment. Observe for bloody and/or serous secretions inside the nares when suctioning and PRN
Use approved solvent (i.e. Medisol), when removing Tender Grips. Then, clean skin with sterile water. Pat the area dry with gauze
Do not cut or alter prongs
Ways of Preventative Skin Care for Nasal CPAP (NCPAP):
Apply appropriate CPAP adjunct per policy
Alternate between nasal prongs and nasal mask every 4-6 hours (as tolerated or per physician order
Patients under 30 weeks gestation will only be placed on prongs for the first 3 days of life, then every 4-6-hour exchange between mask and prongs
Adjust nasal prongs / mask and bonnet/headgear as needed to relieve / redistribute pressure. Leave a 2 mm space between nasal septum and prongs
Ensure the CPAP bonnet/headgear is correctly positioned
Change F&P bonnet/headgear every 7 days and PRN
Unload prongs/mask (loosen and release pressure) every 4-6 hours
Prongs / mask and tubing should be properly positioned without corrugated tubing or foam adaptor touching the infants skin
Secure circuit tubing and ensure that the tubing is not “torqued”/causing tension from twisting. Keep the weight of the circuit from pulling on the nares
All care providers will observe for bloody and/or serous secretions inside nares and when suctioning and PRN
Do not cut or alter prongs. Do not overtighten mask. May need to wipe mask with alcohol wipes to remove buildup of secretions / oil from the mask to help create a seal
Assess all areas of skin where medical device encounters the skin and underneath the bonnet/headgear
Ways of Preventative Skin Care for Intubated:
Apply ETT stabilizer:
Clean the area with sterile water
Pat the area dry with gauze
Apply approved skin protectant (No Sting Barrier Film). Let dry
Mastisol may be appropriate (WITH DISCRETION) on the following patients:
Critical airways
Copious secretions
When frequent (more often than daily) re-taping is required
Apply Elastikon to secure ETT. Ensure ETT does not pinch the skin between tape and ETT
Apply ETT stabilizer device; Cut the device to prevent pressure on the skin, as needed. Round the edges so that it does not rub into the septum
Use appropriate holding device to secure ventilator tubing so that it does not create skin tension
Use solvent (i.e., adhesive remover) when removing the ETT stabilizer
Peel tape slowly and gently
Clean the area with sterile water
Pat the area dry with gauze
Assess the upper lip, septum, and anywhere the approved securing device (i.e. Neo-Fit) touches the skin. A more detailed assessment (skin under the device) will be required when the ETT is re-secured
Skin Care Intervention for ANY intact non-blanchable erythema:
RN will initiate Neonatal Skin Care Nursing Order Set
Gently clean area with sterile water, pat dry, and apply Sween Cream to non-blanchable erythema or irritated skin every 6-8 hours and as needed and allow complete drying before placing patient interface.
Do not place Sween Cream directly under device
Rotate mask and Sween Cream locations (If mask in place, Sween Cream can go on septum, if prongs in place, Sween cream can be applied to the bridge of the nose
Enter Wound Care Nurse consult and document referral number on the Kardex
Do not use any barrier devices under the mask / prongs unless ordered by physician
Avoid the device contacting the area(s) of breakdown by changing device interface (i.e. mask to prongs, etc.)
Re-assess skin and off load new area interface every 2 hours