Steps

Rationale/Points of Emphasis

1 Perform hand hygiene. Don gloves.

Standard precaution to reduce transmission of microorganisms.

2 Place infant/child on firm clean surface, such as changing table or crib/bed mattress. Keep your hand on infant and do not turn away from infant during the procedure.

Prevents injury and falls.

3 Remove soiled diaper and assess contents of diaper for unusual appearance or odor of urine or stool. If indicated, set diaper aside to determine output calculation after diapering is completed.

The average newborn urinates about 20 times a day. Unusual characteristics of urine or stool may indicate a gastrointestinal or urinary disturbance.

caREminder

If diaper sticks to circumcision site, use warm water to loosen diaper gently from area. Presence of a small amount of bloody discharge in the newly circumcised male may be normal. Excessive bleeding is abnormal. Female infants may have a small amount of vaginal, pink-tinged, mucoid discharge appearing 3-6 days after birth. This is from sloughing of endometrial lining caused by withdrawal from maternal estrogens.

4 Assess infant/child’s perineal area for redness, rash, or excoriation.

Prolonged contact with irritants such as moisture from urine and feces, fecal enzymes (urease, protease, lipases), soaps, detergents, ointments, or friction, is a major contributing factor in diaper dermatitis. Wet skin is more easily abraded and more permeable, and it has an increased microbial count. This situation can be exacerbated by alkaline soaps used to clean cloth diapers. The wet diaper also increases friction with the wet skin. Irritated, cut, or chapped skin is a contributing factor to diaper dermatitis.

When lesions or open wounds become infected, candidiasis may be a major culprit. Candida albicans can be cultured or recovered from the skin of up to 80% of infants with diaper dermatitis. It is rarely found in infants with healthy unbroken skin.

Clinical evidence does not support that the use of disposable diapers increases incidence of diaper rash. Disposable diapers are constructed for optimal absorption to effectively capture liquid and help avoid rewetting the infant’s skin.

5 Cleanse the skin with disposable wipes or a wet, warm washcloth with mild soap if necessary. Avoid soap contact with the newly circumcised glans penis as irritation may occur. Dry the perineal area.

Cleanses perineal area of urine and feces and prevents skin irritation.

caREminder

If the skin is clean under the diaper cream or ointments placed earlier on the child, the cream does not have to be removed completely with each diaper change; rather, lightly wiping the area to remove stool with a washcloth and mild cleanser is sufficient.

6 For the child with diaper dermatitis, consider one of the following:

Barrier creams assist in preventing further breakdown due to the friction of the diaper against the sensitive skin.

6a Apply a simple barrier cream (such as petroleum or 40% zinc oxide paste) to the noninfected diaper rash.

Medicated ointments may be used to treat infections that have developed on the genital and buttocks area.

6b If candidal infection is present, apply topical anticandidal agent (nystatin, lotrimin, micatin, nizoral) to diaper area per healthcare prescriber’s orders.

Topical steroids are useful to suppress significant inflammatory response. However, high-potency steroids are rapidly absorbed through the infant’s thin skin and can cause systemic toxicity. Special care should be taken by the nurse to avoid combination products (e.g., antifungals and steroids) without verifying that the steroid is of the low-dose type.

6c If severe inflammation is present, per healthcare prescriber’s orders, apply a topical, low-potency, nonfluorinated, 1% hydrocortisone cream to rash site for 7-10 days.

6d Children with recurrent diarrhea may be prescribed an oral anticandidal agent (nystatin) to sterilize the gastrointestinal tract and prevent systemic infection.

caREminder

Do not apply talcum powder or cornstarch to the diaper area. Although these products may reduce friction, absorb moisture, and eliminate chaffing in the diaper area, these products are not recommended because of the infant’s risk of aspirating air-borne particles and developing severe pneumonitis.

7 For the newborn, if the umbilical stump is dirty or sticky, clean the umbilical area with mild soap and water. Observe umbilicus for redness or drainage. Lift cord and clean base; do not wet the umbilical cord. Rinse and dry the area. Leave site open to air; do not apply alcohol, antiseptics, or antibiotics to umbilical cord stump.

Promotes drying of the stump. Prevents infection (omphalitis) that can be life-threatening. Studies have shown that natural drying of the umbilical cord does not result in increased incidence of infection.

8a For the infant with a Gomco-type circumcision, open petroleum jelly packet and apply liberally around penis, then and cover with sterile gauze, or use petroleum gauze packet.

Keeps area moist, decreasing irritation of circumcision site and promoting healing.

8b For the infant with a Plastibell-type circumcision, apply antibiotic ointment as ordered by healthcare prescriber, and cover with sterile gauze.

9 Apply new diaper securely, folding front of diaper to avoid irritation of umbilical cord. Fold plastic away from skin.

Prevents accidental soiling and prevents unnecessary irritation of umbilical cord. Irritation to circumcised area can occur if diaper is secured too tightly.

10 Determine the infant’s output by weighing the diaper and converting the gram weight into millimeters (see Chapter 5 ). Depending on the child’s condition, it is appropriate to wait until the end of an 8-hour shift to weigh all of the child’s wet disposable diapers.

Output measurements provide essential data about the child’s fluid status. Normal fluid balance is evidenced by a urine output of 1 to 2 mL/kg/hr.

Research shows that delaying weighing of disposable infant diapers for up to 8 hours will not result in any clinically significant differences in the weighed volume of the diapers.

11 Dispose of diaper and waste in appropriate receptacle. Remove gloves and perform hand hygiene.

Standard precautions. Reduces transmission of microorganisms.

12 Wrap infant in blanket and place in crib with side rails up. Return child to safe position in bed with side rails up.

Enhances infant thermoregulation and ensures patient safety.