Keeping Skin in the Game: Bringing Awareness to Neonatal Skin Injuries

Saturday, 7 November 2015

Media S. Esser, MSN, BSN, RN, APNP, NNP-BC
Neonatology, Children's Hospital of Wisconsin, Milwaukee, WI, USA
Christine A. Schindler, PhD, RN, CPNP-AC/PC, WCC
Pediatrics, Children's Hospital of Wisconsin, Milwaukee, WI, USA
Patricia Clinton, PhD, MSN, BSN, IA, ARNP, CPNP
College of Nursing, University of Iowa, Retired, Iowa City, IA, USA


Keeping Skin in the Game: Bringing Awareness to Neonatal Skin Injuries



The purpose of this project is to increase awareness of the broad range of neonatal skin injuries and to improve documentation of those injuries in a level 4 Neonatal Intensive Care Unit (NICU).


Skin injury is a significant problem in the neonatal population. Skin injuries in the neonatal population are suspected to be under reported and often overwhelming for healthcare professionals. Neonatal skin is very thin compared to adult skin, taking days to weeks to mature, thus predisposed to injury. Injuries are most commonly caused by daily bedside care and procedures performed during the neonate’s hospitalization. The advancement of technology in improving morbidity and mortality over the last 10 years has continued to result in the occurrence of skin injuries.

The most common skin injuries found in the neonatal population are skin tears, IV infiltrates, device related pressure injuries, diaper dermatitis, irritant dermatitis, and adhesive injuries. Every neonate in the NICU is considered high risk and several preventative measures are performed based on clinical triggers in daily care. As many as 4% of patients from the NICU may be discharged with significant scarring. Those infants of lower gestational age have had rates of unintentional skin injuries at 57% compared to their term counterparts with rates of 3%. Describing the scope of skin injuries seen in neonates is a first step in developing interventions to improve outcomes.


This QI project began in January 2015 following successful IRB approval. All infants admitted to the NICU were assessed and data were included on all infants except those with pre-existing incision sites, Gtubes, trachs, and other surgical sites that would be under the management of a specialty service.

Data collection included: basic demographics, description of injury, site of injury, date of resolution, and interventions. Nurses documented skin injuries in a specific section within the electronic health record providing a date of start/end and description.


Process measures included: the creation of a data collection tool, the provision of education for interdisciplinary teams, and improved documentation. Outcome measures included: the identification and characterization of skin injuries other than pressure ulcers.

Leadership Journey:

This journey started with the idea of promoting increased awareness related to neonatal skin injuries and the need for consistent standardized documentation related to those injuries. The project grew to become the compilation of many meaningful experiences leading to the generation of a stronger NICU presence in the conversations surrounding skin care initiatives within the organization.

            The KP model served to guide the work with each of the five steps exemplifying key points in this skin care journey. The five steps including modeling the way, inspiring a shared vision, challenging the process, enabling others to act, and encouraging the heart served as guides for the project.


Curley, M. A. Q., Quigley, S. M., & Lin, M. (2003). Pressure ulcers in pediatric intensive care: Incidence and associated factors. Pediatric Critical Care Medicine, 4(3), 284-290.

Migoto, MT., Souza, S., & Rossetto, EG. (2013). Skin lesions of newborns in a neonatal unit: descriptive study. Online Brazilian Journal of Nursing, 12(2). Retrieved from:

Reddy, M., Gill, S. S., & Rochon, P. A. (2006). Preventing pressure ulcers: A systematic review. JAMA, 296, 974-984.

Sardesai, S., Kornacka, M., Walas, W., & Ramanathan, R. (2011). Iatrogenic skin injury in the neonatal intensive care unit. The Journal of Maternal-Fetal and Neonatal Medicine,24(2), 197-203.