The Effectiveness of Skin Barrier on Medical Adhesive Related Skin

Injury in Neonates at Perinatology Dr. Cipto Mangunkusumo

Hospital Jakarta

Novardian

, Suhendar Sulaeman

, Nyimas Heny Purwati

and Widia Sari

Nurse at Neonatal Intensive Care Unit, Dr. CiptoMangunkusumo Hospital Jakarta, Indonesia

Lecture at Nursing Department, University of Muhammadiyah Jakarta, Indonesia

Lecture at Nursing Department, Esa Unggul University, Indonesia

Keywords: MARSI, Skin Barrier, Transparant Dressing, Neonates.

Abstract: Skin damage is one of the serious problems in neonates. One of causing of medical adhesive that is MARSI.

Skin damage on neonates will cause discomfort and affect the process of babies care. Based on AWHONN

recomended that skin barrier aplication to reduce MARSI The aim of this study are to identify the

effectiveness of transparant dressing with skin barrier and transparant dressing without skin barrier to

prevent MARSI in neonates attached infusion at Perinatology Dr. Cipto Mangunkusumo Hospital Jakarta.

The design of this study was pre experimental with non equivalent without control group. The sampling

methode used is total sampling. Total sample in this research are 80 neonates getting infussion (40 neonates

with gestational age ≤ 34 weeks, and 40 neonates with gestational age ≥ 34 weeks) who were divided into 4

groups. The data collected using NSCS (neonatal skin condition scale) questionaire with score 3-9. The

analysis used is Wilcoxon. The result of this research found that use of transparant dressing with skin barrier

in neonates with gestational age ≤ 34 weeks and neonates with gestational age ≥ 34 weeks is effective for

reducing MARSI incident (p< 0,05).Transparant dressing with skin barrier recomended use to prevent of

MARSI.

1 INTRODUCTION

Skin damage is one of the serious problems in

neonates. One of causing the using of medical

adhesive that is MARSI (Medical adhesive related

skin injury). MARSI has been defined as an

occurrence in which erythema and or other

manifestation of cutaneous abnormal (including but

not limited to vesicle, bulla, erosion, or tear) persists

30 minutes or more after removal of the adhesive

(McNichol, Lund, Rosen, & Gray, 2013)

In 2017, The Townsvile Hospital and health

service in the neonatal unit, found that prevalence of

skin damage in neonates was 9.25%-43%. This

result shows that prevalence of MARSI is high.

There are some factors that causing of skin

damage on neonates such as using of medical

adhesive, gestation age and birth weight. In 2013, a

study found that causing of skin damage were 22,4%

of the using of vascular catheter, 14% of non-

invasive continous positive airway pressure delivery

device, and 17,8% of oxygen saturation and

temperature. Based on the data that causing of skin

damage are using of medical devices.

Another factor causing of skin damage is

premature birth. Because of this condition will cause

distruption of the skin structure particularly stratum

corneum. Consequently, will increase

transepidermal water loss (TEWL) in neonates

which will cause termoregulation disturb,

dehydration and electrolite imbalance (Kuller et al.,

2006; Lambe, 2001; Lund, 2014; Nonato & Lund,

2001; M. O. Visscher, 2009).

The conditions require appropriately

management to prevent MARSI. One of them

management of MARSI is recomended by

Association of Women’s Health Obstetric and

Neonatal Nurses (AWHONN) and National

Association of Neonatal Nurse (NANN) is skin care

in neonates (Kuller et al., 2006).

The guideline skin care in neonates involve

assessment of newborn skin, umbilical cord care,

circumsision care, diaper rash, using medical

Novardian, ., Sulaeman, S., Purwati, N. and Sari, W.

The Effectiveness of Skin Barrier on Medical Adhesive Related Skin Injury in Neonates at Perinatology Dr. Cipto Mangunkusumo Hospital Jakarta.

DOI: 10.5220/0008222801870192

In Proceedings of the 1st International Conference of Indonesian National Nurses Association (ICINNA 2018), pages 187-192

ISBN: 978-989-758-406-0

187

adhesive, TEWL, skin damage, intravena

infiltration, and skin nutrition (Kenner & Lott,

2007). Skin damage on neonates will cause



discomfort and affect the process of babies care.

To increase comfort of babies is needed role of a

nurse according to theory of comfort by Kolcaba

(Alligood, 2014).

Based on Consensus AWHONN (Association of

Women Health, Obstetric and Neonatal Nurses) in

2007 recommended that medical adhesive choice

and skin barrier application are as alternative to

reduce MARSI (McNichol et al., 2013). Skin barrier

is a product to protect skin which will provide a

protective layer between epidermis and adhesive.

Skin barrier availables in liquid wipes, applicators,

or spray formulated from various substances such as

acrylic, polymer organic and anorganic, and silicon.

The aim of this study are to identify the

effectiveness of transparant dressing with skin

barrier and transparant dressing without skin barrier

to prevent MARSI in neonates attached infusion at

Perinatology Dr. Cipto Mangunkusumo Hospital

Jakarta.

2 METHODS

This study was pre experimental with non equivalent

without control group (non randomized without

control group pretest-postest). The studies using

research assistant. The result of interreliability test

was p<0,05. Participants were 80 neonates divided

into 4 groups. Group 1 were 20 neonates with

gestational age ≤34 weeks applied by transparant

dressing with skin barrier. Group 2 were 20 neonates

with gestational age ≤ 34 weeks applied by

transparant dressin without skin barrier. Group 3

were 20 neonates with gestational age ≥ 34 weeks

applied by transparant dressing with skin barrier.

Group 4 were 20 neonates with gestational age ≥ 34

weeks applied by transparant dressing without skin

barrier

Firstly, group 1 and 3 were evaluated using

NSCS (Neonatal Skin Condition Scale) observation

sheet before applied with medical adhesive, was

applied 3M Cavilon No Sting Barrier Film 3344E, 1

ml Product USA and then leave around 30 seconds.

Then, cover skin with using a transparant dressing

(3M Tegadern film 6cm x 7cm). Change of the

medical adhesive was done after 3 days or when skin

area looked dirty.

At the same time, for group 3 and 4 transparant

dressing is used. The skin was evaluated for

conditions using the NSCS observation sheet.

The data collected using Observation sheet with

NSCS (neonatal skin condition scale) with score 3-9.

The NSCS instrument is recommendation from

AWHONN. The data was analyzed using SPSS 2.0.

Since the data not normally distributed, Wilcoxon

was used for statistical analysis.

Ethical clearance for this study was granted from

ethics committe Cipto Mangunkusumo Hospital.

3 RESULTS

Table 1: Characteristics of Respondents in each group

based on gender (n=80).

Characteristics

Group

p value

I (n=20)

f (%)

II (n=20)

f (%)

III (n=20)

f (%)

(n=20)

f (%)

1.Male

2.Female

3.Ambiguos

9 (45)

(55)

0 (0)

11 (55)

9 (45)

0 (0)

8 (40)

11 (55.5)

1 (5)

11 (55)

8 (40)

1 (5)

0.701

Table 1 show that the majority of respondent

were female in group 1 and 3 (55% and 55.5%,

respectively) and male in group 2 and 4 (55% in

both group). The test of homogenity result shows

value of 0.701 which means that the characteristics

of respondent homogeneus.

Table 2: Characteristics of Respondents in each group

based on NSCS before intervention (n=80).

Characteristics

Group

p value

I (n=20) II (n=20) III (n=20) IV (n=20)

NSCS score

3.70

(0.73)

3.70

(0.57)

3.75

(0.85)

3.85

(0.75)

0.441

Table 2 shows that the test of homogenity NSCS

score from each group with p value =0.441. This

shows characteristics of respondent in each group

based on NSCS score before intervention is

homogeneus.

Table 3: MARSI score in neonates with gestational age ≤

34 weeks (n=80).

f (Score) Percentage(Score)

3 4 5 6 3 4 5 6

1.Transparant

dressing + skin

barrier

a. Before

. Afte

2.Without skin

barrier

a. Before

. Afte

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Table 3 show that MARSI score before and after

intervention transparant dressing with skin barrier no

increase MARSI incident. The majority of MARSI

score was 3 (45%) before intervention and after

intervention was 3 (60%).

The data show that there was a change in

MARSI score before and after intervention

transparant dressing without skin barrier. Before

intervention, MARSI score 5 only 1 respondent

(5.0%), but after intervention transparant dressing

MARSI score 5 becomes 7 neonates (35.0%).

Table 4: MARSI score in neonates with gestational age ≥

34 weeks.

Frequen

(Score) % (Score)

3 4 5 6 3 4 5 6

1.Transparant

dressing with

skin barrier

a. Before

. Afte

2.Transparant

dressing

without skin

barrier

a. Before

. Afte

Table 4 show that MARSI score before and after

given intervention transparant dressing with skin

barrier not increase MARSI incident. The majority

MARSI score is 3 (45%) before intervention and

after intervention is 3 (55%).

The data also shows that MARSI score before

and after intervetion transparant dressing there is a

change. Before intervention MARSI score 5 only 1

respondent (5%), but after intervention MARSI

score 5 to be 6 respondent (30%).

Table 5: Difference in average of MARSI score before and

after intervention in neonates with gestational age ≤ 34

weeks.

Mean SD

Mean

ran

Pv n

1.Transparant

dressing with

skin barrier

a. Before

b. After

c. (∆)

3.7

3.45

-0,25

0.733

0.605

3.00

0.02

2. Without

skin barrier

a. Before

b. After

c. (∆)

3.7

4.15

0.45

0.571

0.745

0.00

4.00

0.01

Table 5 shows that in the intervention group

given transparant dressing with skin barrier there

was no increase in the MARSI score with the

difference before and after the intervention was -

0.25. The statistical test results obtained p = 0.025

with 95% CI. It can be concluded that there is a

difference between the MARSI score before and

after skin barrier intervention.

The table also shows that in the group with

transparent dressing without skin barrier intervention

there was also an increase in the MARSI score. The

difference between before and after the intervention

is 0.45. This is shows that after transparent dressing

there is an increase in skin irritation in infants. The

statistical test results obtained a value of p = 0.014

so it can be concluded that there is a difference

between the MARSI score before and after given

transparantdressing.

Table 6: Difference in average of MARSI score before and

after intervention in neonates with gestational age ≥ 34

weeks.

Mea

Mean

ran

Pv n

1.Transparant

dressing with

skin barrier

a. Before

b. After

c. (∆)

3.75

3.55

-0.2

0.851

0.759

2.50

0.04

2.Transparant

dressing

without skin

barrier

a. Before

b. After

c. (∆)

3.85

4.20

0.35

0.745

0.835

4.00

4.57

0.03

Based on table 6, shows that in group III given

transparent dressing intervention with skin barrier

there was no increase in MARSI score. The

difference between before and after the intervention

is -0.2. The results of the statistical test obtained p =

0.046, it can be concluded that there is a difference

between the MARSI score before and after the

transparant dressing intervention with the skin

barrier.

The table above also explains that in group IV

given transparent dressing dressing without skin

barrier there was an increase in MARSI scores. The

difference between before and after the intervention

is 0.35. This shows that after the transparent

installation of the dressing without the skin barrier

there is a deterioration of the skin condition in the

baby. The statistical test results obtained p = 0.035,

so it can be concluded that there is a significant

difference between the MARSI score before and

after being given a transparant dressing intervention

without the skin barrier.

The Effectiveness of Skin Barrier on Medical Adhesive Related Skin Injury in Neonates at Perinatology Dr. Cipto Mangunkusumo Hospital

Jakarta

189

4 DISCUSSION

1. Gender

The majority gender of neonates in each group is

male. In theory, it was not found that gender affected

damage to skin integrity. The research conducted by

Alfiyanti (2012) stated that there was no significant

relationship between gender with the incidence of

compressive wounds in children treated in PICU.

The study showed that gender factors did not affect

the occurrence of damage to skin integrity

(Alfiyanti, Nurhaeni, & Eryando, 2012).

2. Gestational Age

In this research, each respondent was divided into

groups based on gestational age ≤ 34 weeks and ≥ 34

weeks. In premature babies, skin barriers have not

developed properly so that babies has damageskin

integrity (M. Visscher & Narendran, 2014). The

structure of skin integrity, especially the stratum

corneum, is associated with gestational age because

skin barriers develop 24 to 34 weeks after birth, so

that premature infants have a thin epidermal layer

and less stratum corneum (M. O. Visscher, 2009).

3. The effectiveness of transparant dressing with

skin barrier and transparant dressing without skin

barrier in neonates given infussion on MARSI

a. Transparant dressing with skin barrier

application

The average MARSI score before and after given

skin barrier decreases. So it can be concluded that

the use of an effective skin barrier to prevent skin

damage due to the use of medical adhesive or other

adhesive devices. The use of a skin barrier

application will provide a protective layer between

the epidermis and medical adhesive. This study the

barrier skin used was in the form of Cavillon no

sting barrier 3M product film. After the application,

the barrier liquid will evaporate and leave a

protective layer that is transparant and breathable for

up to 72 hours.

In the gestational age of ≥ 34 weeks, the use of

skin barriers also causes a decrease in the incidence

of MARSI with a difference in value (∆) The

statistical test results obtained p = 0.046 so that it

can be concluded that there are differences in the

average use of skin barriers before and after

intervention in infusion infants with a gestational

age of ≥ 34 weeks. In groups with a gestational age

of ≥ 34 weeks there was a greater difference in value

than gestational age ≤ 34 weeks. This is due to

gestational age of ≥ 34 weeks so that anatomically

the epidermis and stratum corneum have begun to

function so that the skin will be bluish pink and

smooth or white (Kenner & Lott, 2007).

The use of skin barriers has been recommended

to skin care for neonates who are treated (Telofski,

Morello, Mack Correa, & Stamatas, 2012). That was

because the structure of the baby's skin is different

from that of an adult. Research conducted by Kuller

et al., (2006) states that the use of medical adhesive

in infants is a major factor cause of skin damage in

infants treated at the NICU. Invasive procedure also

causes the baby to have iatrogenic injury. These

injuries can cause damage to the integrity of the skin

including burns and lesions due to the use of

disinfectants, erythema and hollows on the skin due

to the use of monitoring probe devices (Kenner &

Lott, 2007).

The difference value before and after being given

a skin barrier application thus indicating that the

skin barrier is more effective in preventing MARSI

incident or other skin damage. The use of skin

barriers in this study does not cause improvement in

the baby's skin, but prevents further damage to the

baby's skin due to medical adhesive.In addition to

the use of adhesives, skin damage in premature

babies is also caused by many things, one of which

is gestational age of ≤ 34 weeks. The gestational

age is associated with not yet developing the skin

layer perfectly, especially the stratum corneum is

still small.

This research is in line with research conducted

by Brondon et al., (2010) which states that the use of

skin protection such as the no sting barrier film will

reduce TEWL and maintain skin integrity in infants.

This study was conducted in 69 infants with a

gestational age ≤ 33 weeks for 18 months. Every

baby gets treatment for 2 weeks (Brandon, Coe,

Hudson-Barr, Oliver, & Landerman, 2010).

b. Transparant dressing without skin barrier

application

The average MARSI score before and after the

intervention was given using transparant dressing,

there was an increase in the MARSI score. The

statistical test results so that it can be concluded that

there are differences in the average before and after

the intervention using transparent dressings without

skin barriers to the incidence of MARSI in infants

with gestational age of ≤ 34 weeks given infusion.

The high difference value indicates that the skin

changes towards negative, where there is an increase

in skin irritation in the baby after being given

transparant dressing without the skin barrier. It can

be seen in Table 2 that after the use of transparent

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dressing, the score of MARSI 5 becomes 7

respondents, where before the intervention the

MARSI 5 score is only 1 respondent.

One of the recommended use of transparant

dressings is 3M Tegaderm. This Tegaderm film

consists of elastic film with adhesive that is free of

latex and hypoallergenic and is breathable which

allows the exchange of oxygen and water vapor well

so that the skin will remain moist. In addition to this,

conditions are transparant, making it easier to

observe skin conditions due to invasive actions that

occur.

The use of transparant dressings is often used

both in adults and children. Research conducted by

Inoue & Matsuda (2015) in 25 patients showed that

the use of transparant film dressings in press wounds

was more cost effective compared to hydrocoloid

dressings (Inoue & Matsuda, 2016). In premature

babies, recommends using transparant dressings to

maintain skin integrity in infants (Lund, 2014). This

is different from this study, where the use of

transparant dressing increases the incidence of

MARSI in premature infants. The increase is due to

the structure of the baby's skin that is still not fully

developed, so the use of transparant dressing will lift

the epidermis layer of the baby's skin and TEWL

increases so that the baby's skin will be more

damaged. Another possibility is that the increase in

MARSI scores on the use of transparant dressing

applications without skin barriers can also be caused

due to the wrong technique of releasing transparent

dressings, it is not using stretch methods so that the

risk increases MARSI.

In the infants with gestational age of ≥ 34 weeks

there was also an increase in the MARSI score

before and after the use of transparant dressing

without skin barrier with a difference. But the

difference in value is smaller when compared to the

infant with gestational age of ≤ 34 weeks. This is

due to the development of the skin structure in the

baby. The statistical test results so it can be

concluded that there was a significant difference in

the use of transparent dressings without skin barriers

before and after intervention in infants with

gestational age of ≥ 34 weeks given infussion. The

difference that occurs in neonatal skin is an increase

in the MARSI score, so the use of transparant

dressing without a skin barrier will worsen the

condition of the baby's skin.

The limitations of this study are the removal of

the medical adhesive in each babies is not the same

because several conditions, like dirty, contains blood

and babies move the room.

5 CONCLUSIONS

In this study, it was shown that the use of transparant

dressings with skin barriers was effective in prevent

of MARSI.

It is recommended that the use of transparant

dressings with skin barrier to prevent of MARSI as a

guidelines in infant skin care, especially in infants

with gestational age of ≤ 34 weeks.

The limitations of this study are the removal of

the medical adhesive in each babies is not the same

because of several conditions, like dirty, contains

blood and babies move the room.

ACKNOWLEDGEMENTS

The preparation of this paper was supported by

Magister of Nursing University of Muhammadiyah

Jakarta, Neonatology intensive care unit at Dr. Cipto

Mangunkusomo Hospital Jakarta and 3M Company.

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