Running head: CHECKLIST SKIN ASSESSMENT FOR NEONATES 1

Checklist Skin Assessment for Neonates

Erica Pass

Brigham Young University Idaho

Nursing 420

Sister Hawkins

December 8, 2016
CHECKLIST SKIN ASSESSMENT FOR NEONATES 2

Checklist Skin Assessment for Neonates

Nasal continuous positive airway pressure (NCPAP) has evidence-based implications in

managing pulmonary diseases in neonates by reducing mortality and disease rates; however,

there is a strong correlation between the length of time for intubation therapy and nasal trauma

(Newnam, 2015). Early extubation has shown a reduction in complications and mortality rates,

but this could be avoided by assessing neonatal skin more thoroughly (Al Faleh, 2011). The

pressure necrosis, resulting from NCPAP, can lead to infection, patient discomfort, morbidities,

and extended intubation time. A study revealed that out of 989 neonates, 420 indicated nasal

trauma; this resulted during the first six days of treatment with NCPAP, which also could have

been avoided had adequate neonatal skin assessments been performed (Fischer, 2010).

Grosvenor, OHara, and Dowling (2016) performed a study and identified a gap of knowledge

throughout the practice of neonatal skin assessments. Are nurses performing adequate and

thorough skin assessments on neonates who are intubated during NCPAP therapy? Should a

checklist be provided for nurses when performing neonatal skin assessments?

Methods

As this study examines the quality of care and focuses on optimizing the effectiveness of

nursing assessments, it will be performed by way of an outcomes research; it will include a pre-

and post-intervention study to determine the desired proximal outcome: reduction of pressure

necrosis (Doran, 2015, p. 467). This design will consist of 200 nurses in the NICU throughout

the state of Idaho, for convenience. The sample of NICU nurses will not be randomly selected in

order to achieve reliability, validity, and representativeness.

Each nurse will participate in a pre-intervention by assessing the neonates once they are

admitted into the NICU. Nurses will assess for the incidences of pressure necrosis and any

exacerbations that could lead to it; this can be considered a baseline assessment and be used as a
CHECKLIST SKIN ASSESSMENT FOR NEONATES 3

comparison. The nurses will receive a brief explanation of the checklist and how to implement it

into their plan of care; they will use this checklist throughout the length of stay of the neonate.

The post-intervention would then take place; each nurse would receive a questionnaire once the

neonate is discharged to determine the efficiency of the skin assessments by measuring the

incidence of pressure necrosis. It will consist of yes or no questions asking if they identified

early manifestations of pressure necrosis (redness, dryness, heat, lesions, etc.), the interventions

they implemented to prevent pressure necrosis (change position, applied moisturizer/protective

skin barrier, raised cannula tubing off of neonate, etc.), and whether the neonate developed an

infection, felt discomfort, needed to be intubated longer, or was discharged successfully without

complications. The completed questionnaires will then be collected to determine the efficacy of

the administration of checklists and whether or not they helped achieve the proximal outcome.

Ethics

The nurses working in the NICU would be informed of the study prior to administering

the checklist and questionnaire. When the study is proposed to the nurses, informing them that

they can refuse to participate in the study at any time will preserve self-determination. Privacy

will be maintained by giving the nurses the opportunity to provide consent to not only participate

in the study, but to also share the questionnaire which they completed. Anonymity will not be

violated since personal information will not be linked back to a particular nurse and his or her

care. The researcher will not disclose the results of the questionnaire completed by the nurses

without consent to avoid a breach of confidentiality. NICU nurses were selected to observe the

quality of skin assessments in neonates; they were not selected for any other reason that may

violate the right to fair selection and treatment. Both NICU nurses and neonates alike will

experience no discomfort or harm from execution of this study.

One ethical issue that may arise is that neonates are classified as persons of diminished
CHECKLIST SKIN ASSESSMENT FOR NEONATES 4

autonomy. In order to combat this, the study will need to be reviewed for specific guidelines.

Research has been done to recognize that NCPAP therapy can lead to detrimental outcomes for

neonates; this study is designed to prevent those risks. It is specifically designed to improve the

safety and survival of neonates; therefore, the results of this study are unable to be obtained by

other means. Researchers will only be observing the nurses questionnaires and have no

participation in the viability of the neonate, protecting their safety. Both parents of the neonate

will need to be informed of the study during the consent process, similar to how the nurses were

notified (Grove, 2015, p. 102).

This study is identified as minimal risk to both the nurses and neonates since it is merely

observing the care nurses give and evaluating the influence of implementing or not implementing

a checklist. The only risk identified would result from the lack of assessment in a neonate,

performed by a NICU nurse, if there is a lack of assessment. Since there is minimal risk, the

study would be qualified as an expedited review once the institutional review board (IRB)

approves it.

Theory

The Nursing Role Effectiveness Model of Irvine, Sidani, and McGillis Hall, based off

of Donabedians theory, and as cited by Doran (2015), is the most representative to this research

study. It was designed to depict the factors that influence the way the nurse performs quality care

and how that leads to nursing-sensitive patient outcomes. The model is divided into three

components: structure, the nurses role, and the nursing-sensitive patient outcomes. Irvine and

theorists explain that the structure in outcomes (i.e. the nurses experience, knowledge, and

skills; the staff mix, workload, and assignment pattern; the patients health status, severity, and

morbidity) affects the nurses role and how he or she performs quality care, which determines the

health outcomes of the patient (Doran, 2015, p. 470). The research proposed is accurately
CHECKLIST SKIN ASSESSMENT FOR NEONATES 5

portrayed through this model. The nurses abilities (the structure) are exemplified in how he or

she provides quality care through skin assessments, with implementation of a checklist (nurses

independent and interdependent role), and consequently determine the incidence of skin

deterioration in neonates (patient/health outcomes).

Patient/Health
Structure Nurses' Role
Outcomes

Nurse Independent Role

Clinical/symptom
Experience Assessment control
Knowledge Diagnosis Freedom from
Skills Intervention complications
Follow-Up Care Functional status/self-
care
Knowledge of disease
and its treatment
Organizational Dependent Role satisfaction costs
Staff Mix Execution of medical orders
Workload Physician-initiated
Assignment pattern treatments

Adverse Events
Patient Interdependent Role
Health Status Communication
Severity Case management
Morbidity Coordination of care
Continuity/monitoring and
reporting
Team functioning

Figure 1. Nursing Role Effectiveness Model. The nurse, organizational, and patient structures
influence the nurses' roles. The patients health outcomes are contingent on the successfulness of the
nursing roles (Doran, 2015, p. 470).

Framework

The below diagram describes the process that can reduce these fatalities. The Nursing

Role Effectiveness Model components are indicated below the concepts in bullet points to

portray the relationship.

CHECKLIST SKIN ASSESSMENT FOR NEONATES 6

Reduced intubation
time, morbidities,
infection, and
Quicker reaction discomfort
time to prevent
Patient/Health
pressure necrosis Outcomes
Quicker assessment
Nurses' Independent
Nurses' Independent Role
Role
Thorough checklist
for skin assessment
in neonates
Nursing and
Organizational
Structure

Annotated Bibliography

Vance, D. A., Demel, S., Kirksey, K., Moynihan, M., & Hollis, K. (2015). A delphi study for the

development of an infant skin breakdown risk assessment tool Advances in Neonatal

Care : Official Journal of the National Association of Neonatal Nurses, 15(2), 150-157.

doi:10.1097/ANC.0000000000000104 [doi]

These authors earned an array of degrees and certifications consisting of MSN, RNC-

NIC, RNV, CNS, PhD, ACNS-BC, FAAN, and CWON. Vance and her cohorts realized

that skin breakdown is a major problem in the neonate population and decided to conduct

a study, for nurses, to examine the effectiveness of implementing a risk assessment tool,

in addition to the routine skin assessment. Their study, performed at institutes in Texas,

was comprised of an online survey, using the format of the Delphi technique, then

followed by a 5-point Likert scale. The study proved to be successful and the Seton Infant

Skin Risk Assessment Tool was created for evaluation of skin integrity in neonates

(Vance, 2015).

This study supports the fact that neonatal skin breakdown is of pressing concern and

interventions need to take place to reduce the incidence of morbidities. It analyzes the

current methods of assessing skin integrity and offers a risk assessment tool for
CHECKLIST SKIN ASSESSMENT FOR NEONATES 7

prevention of skin breakdown. This article is supplemental and reliable but fails to

examine the population of neonates under intubation therapy.

Grosvenor, J., O'Hara, M., & Dowling, M. (2016). Skin injury prevention in an irish neonatal

unit: An action research study Journal of Neonatal Nursing, 22(4), 185 <last_page> 195.

doi:10.1016/j.jnn.2016.01.004

Grosvenor, OHara, and Dowling obtained different degrees and certifications such as

RCN, MHS, PhD, MSc, RGN, RM, RNT, and BNS. These researchers performed a study

aimed towards nurses who perform skin assessments and other skincare practices on

neonates in Ireland. The qualitative study evaluated the implementation of a skin risk

assessment tool and whether it improved the quality of care for neonates in the NICU. A

total of 308 skin assessments were performed and 90 infants were assessed while using

the risk assessment tool. Infants were then categorized into very high risk, high risk,

at risk, and low risk groups; depending on which classification they fell under, nurses

would asses them twice daily, daily, twice weekly, or weekly. After the course of the

three-month study, nurses expressed their opinions about the risk assessment tool and

how it helped raise awareness in the importance of improving the quality of practice they

give to neonates; they felt that the tool encouraged them to give a more efficient skin

assessment, improved documentation, and improved communication amongst the health

care team. One barrier, though, to this study is the understanding of the risk assessment

tool; if there is confusion about documenting and assessing the neonate, then the scores

may be recorded differently and reduce the validity of the assessment quality (Grosvenor,

2016).

This qualitative study supports the need for an additional tool when evaluating neonatal

skin integrity. The results of the study, although performed in Ireland, provided positive
CHECKLIST SKIN ASSESSMENT FOR NEONATES 8

feedback for the implementation of a risk assessment tool. It did not necessarily discuss

the reduction of neonatal pressure necrosis and the subsequent fatalities, but rather

examined the opinions of the nurses who provided the skin care for the neonates.

Newnam, K. M., McGrath, J. M., Salyer, J., Estes, T., Jallo, N., & Bass, W. T. (2015). A

comparative effectiveness study of continuous positive airway pressure-related skin

breakdown when using different nasal interfaces in the extremely low birth weight

neonate Applied Nursing Research : ANR, 28(1), 36-41. doi:10.1016/j.apnr.2014.05.005

[doi]

The authors earned their licenses and became neonatal nurse practitioners throughout

universities and medical centers in Connecticut and Virginia. This journal is appropriate

for all nurses alike, but specifically nurses who care for neonates experiencing intubation

therapy. Newnam and other nurses investigated the relation between nasal injuries and

the different types of interfaces to administer CPAP; they identified a positive correlation

and specific risk factors, which lead to the nasal injuries. The nurses randomized 78

neonates into three different groups; the groups were categorized by the types of

interfaces that deliver CPAP (continuous nasal mask, nasal prongs, and alternating

between the mask and prongs). The end of the study manifested reduced skin injuries in

the group of alternating the mask and prongs, as compared to the mask and prong groups.

Some factors that may have skewed the results are the mask and prong size, positioning

of the CPAP device, and the degree of nursing intervention when skin breakdown is

identified (Newnam, 2015).

This journal is pertinent as it recognizes that although a focused skin assessment is

necessary and may reduce the amount of skin injuries in neonates, the type of delivery for

CPAP therapy may be a supplemental consideration for prevention of skin breakdown.

CHECKLIST SKIN ASSESSMENT FOR NEONATES 9

Fischer, C., Bertelle, V., Hohlfeld, J., Forcada-Guex, M., Stadelmann-Diaw, C., & Tolsa, J. F.

(2010). Nasal trauma due to continuous positive airway pressure in neonates Archives of

Disease in Childhood.Fetal and Neonatal Edition, 95(6), F447-51.

doi:10.1136/adc.2009.179416 [doi]

The authors of this article received their MD and work in the division of neonatology and

the pediatrics unit at a hospital in Switzerland. The audience is geared towards nurses in

Switzerland as the study takes place in Switzerland. Rather than performing a

quantitative or qualitative study, the authors decided to conduct an observational study.

All neonates who had been admitted between 2002 and 2007 were observed and deemed

eligible for the study. As the patients received CPAP therapy, they were placed into three

stages of skin breakdown (erythema, superficial ulceration, and necrosis). Close to 1,000

neonates were observed throughout this study and 42.5% of the neonates reported to have

experienced nasal trauma; there was a strong correlation between the severity of trauma

and the birth weight/gestational age of the neonate. This study did not identify prevention

mechanisms but rather proposed a staging system to identify the severity of nasal trauma

(Fischer, 2010).

The conducted research study suggests a method to identify the degree of injury that the

neonate may experience throughout CPAP therapy. It focused on a staging system, which

could potentially assist prevention strategies and treatments for neonatal pressure

necrosis.

Findings

This study is feasible as well as practical and can potentially reduce the exacerbations,

which result from pressure necrosis in neonates. It correlates with QSEN as it is focused on

patient-centered care, increasing safety for the neonate, and improving the quality of care being
CHECKLIST SKIN ASSESSMENT FOR NEONATES 10

given. As mentioned earlier, if a checklist for a skin assessment is implemented, it can ensure

safety for the neonate and improve the quality of care by reducing infection, intubation time,

discomfort, and possible morbidities.

Implications for Research

The implications for this research are safe patient outcomes, quality nursing care, analysis

of current care methods, and research for proposing a novel method of skin assessments. This

study recognizes the current complications with neonatal skin integrity in the NICU and intends

to reduce the amount of morbidities, infection, patient discomfort, and intubation time. By

performing this study, it will not only increase awareness in nurses but also to serve as a self-

check system to ensure the quality of care is both sufficient and efficient. As there is a gap in

knowledge, in regards to neonatal skin integrity throughout NCPAP treatment, this research

analyzes the current care methods as insufficient and proposes a more thorough method of the

assessment process.

Recommendations

This study and the findings thereof may be enhanced with additional research by

contributing the following: alternate methods of delivering NCPAP therapy to eliminate pressure

necrosis, analysis of the quantity of nursing assessments throughout a shift and its effects on the

patients skin integrity and overall health, the correlation between gestational age of neonate and

likelihood of developing more severe complications, and emphasizing the logistics of a thorough

neonatal skin assessment.

CHECKLIST SKIN ASSESSMENT FOR NEONATES 11

References

Al Faleh, K., Liew, K., Anabrees, J., Thevathasan, K., & Paes, B. (2011). Success rate and

neonatal morbidities associated with early extubation in extremely low birth weight

infants Annals of Saudi Medicine, 31(6), 577-580. doi:10.4103/0256-4947.87092 [doi]

Doran, D. (2015). Outcomes research. In S. K. Grove, J. R. Gray & N. Burns, Understanding

nursing research: Building an evidence-based practice (6th ed., pp. 466-499). St. Louis,

MO: Elsevier/Saunders.

Fischer, C., Bertelle, V., Hohlfeld, J., Forcada-Guex, M., Stadelmann-Diaw, C., & Tolsa, J. F.

(2010). Nasal trauma due to continuous positive airway pressure in neonates Archives of

Disease in Childhood.Fetal and Neonatal Edition, 95(6), F447-51.

doi:10.1136/adc.2009.179416 [doi]

Grove, S. K., Gray, J. R., & Burns, N. (2015). Understanding nursing research: Building an

evidence-based practice (6th ed.). St. Louis, MO: Elsevier/Saunders.

Grosvenor, J., O'Hara, M., & Dowling, M. (2016). Skin injury prevention in an irish neonatal

unit: An action research study Journal of Neonatal Nursing, 22(4), 185 <last_page> 195.

doi:10.1016/j.jnn.2016.01.004

Newnam, K. M., McGrath, J. M., Salyer, J., Estes, T., Jallo, N., & Bass, W. T. (2015). A

comparative effectiveness study of continuous positive airway pressure-related skin

breakdown when using different nasal interfaces in the extremely low birth weight

neonate Applied Nursing Research : ANR, 28(1), 36-41. doi:10.1016/j.apnr.2014.05.005

[doi]

Vance, D. A., Demel, S., Kirksey, K., Moynihan, M., & Hollis, K. (2015). A delphi study for the

development of an infant skin breakdown risk assessment tool Advances in Neonatal

Care: Official Journal of the National Association of Neonatal Nurses, 15(2), 150-157.
CHECKLIST SKIN ASSESSMENT FOR NEONATES 12

doi:10.1097/ANC.0000000000000104 [doi]