beginning of the diaper dermatitis

8/11/2019 Beginning of the Diaper Dermatitis

1/7

Abstract

Diaper dermatitis (DD), an acute inflammatory reaction of skin in the

perineal area, is an extremely common pediatric condition. Nurses

practice of preventing and treating DD is inconsistent and often not

evidence-based. In addition, a 2008 Skin Injury Prevalence Study at

our hospital revealed that 24% of inpatients had DD. The authors

developed a project to determine a consistent and evidence-based

approach to DD prevention and treatment including the availabi lity of

products. A complete literature review was conducted in addition to

benchmarking with other pediatric hospitals, consultation with topic

experts, and evaluation of current nursing practice prior to revis-

ing the existing perineal skin care nursing standard. The evidence

supports frequent diaper changes, use of super absorbent diapers,

and protection of perineal skin with a product containing petrolatum

and/or zinc oxide. As supported by the literature, we revised the

standard to include improvements in practice as well as product

updates for prevention and treatment. Hospital-wide implementation

of the revised standard included training Skin Care Champions to

educate staff and support practice improvements. Ongoing education

and monitoring by the Skin Care Champions is necessary to further

improve the prevention and treatment of DD for our patients.

Key Words: Diaper dermatitis, Diaper rash, Infant, Pediatric patient.

Beginning

Bottom:at the

Evidence-Based

Care of

Diaper

Dermatitis

10

volume 37 | number 1 January/February 2012


2/7

expressed dissatisfaction with the lack of zinc-basedproduct availability. Additionally, medical care teams fre-quently ordered individual pharmaceutical ingredientsthat nurses mixed together at the bedside to create theirown concoctions. The Nursing Practice department

viewed these bedside concoctions asa patient safety issue and, therefore,a priority for the hospital to address.In addition, a 1-day Skin Injury Prev-alence Study conducted in our hospi-tal reported 24% of inpatients hadDD (unpublished data). This infor-

mation supports our hospitals incon-sistent approach toward preventionand treatment of this commonlyoccurring problem.

To address this issue, we formedan interdisciplinary team comprisedof a wound ostomy continence nurse,nurse researcher, pharmacist, and

clinical nurse specialists (CNSs) from surgery, oncology,complex chronic/integrated care, and neonatal intensivecare. With a team formed and problem areas identified,we extensively reviewed the literature to determine thebest evidence for DD prevention and treatment.

Synthesis of Literature andAdditional EvidenceThe team conducted a broad literature search throughCINAHL and Ovid, with no age or date limitations.Search terms included diaper rash, diaper dermatitis,nappy rash, irritant contact dermatitis, perineal skinbreakdown, oncology, neonatology, surgery, petrolatum,zinc oxide, cholestyramine, baby powder, and cornstarch.Incontinence-associated dermatitis (IAD), a term used forDD symptoms in older pediatric and adult patients, wasnot included in this search (Gray et al., 2007). A reviewof article reference lists provided additional sources. Wealso reviewed national neonatal skin care guidelines. Inaddition to the literature, we searched for additional evi-

dence by querying pharmacy and nursing listserves,consulting with topic experts in our hospital, andbenchmarking with other pediatric hospitals for theirDD prevention and treatment practices.

The literature search yielded 96 articles dating from1962 to 2011 of which we evaluated 82 that specifi-cally addressed DD prevention and treatment. We usedthe rating scale as described by Melnyk and Fineout-Overholt (2011) to level the evidence. Less than 12%of the articles were systematic reviews or randomizedcontrolled trials (Levels I & II) and the remaining ar-ticles were nonrandomized trials, single descriptivestudies, literature reviews, or expert opinions (Levels

Diaper dermatitis (DD), an acute inflammatoryreaction of skin in the perineal area, is anextremely common pediatric condition. Theetiology of DD is multifactorial and includes

moisture, warmth, friction, urine, and feces. Skin contactwith urine and feces plays an integralrole as moisture trapped against theskin causes increased permeabilityand susceptibility to damage fromfriction (Berg, Milligan, & Sarbaugh,1994). The skin therefore loses itsability to provide an effective barrier

against irritants and microbes. Urinecontact with diapered skin causes anincrease in skin pH thus increasingskin permeability and activating fecalenzymes, known irritants that cancause skin destruction. As the stratumcorneum becomes damaged, microbesare more likely to cause inflamma-tion and can lead to the development of a secondaryinfection (Shin, 2005). The signs and symptoms of DDrange from generalized erythema to skin breakdownleading to an open wound. Above all, DD causes discom-fort for the child as well as significant caregiver distress.

Age and health status influence DD risk. DD can occurin diapered and/or incontinent patients of varying ages.Neonates, specifically premature neonates, are at in-creased risk (Lund et al., 2001), as well as patientsbetween 9 and 12 months of age (Jordan, Lawson, Berg,Franxman, & Marrer, 1986). DD commonly affectshealthy children; however, acutely and chronically illchildren may be at higher risk due to factors includingmedications that can cause diarrhea, underlying diagno-ses such as cancer, gastrointestinal anomalies, neurologi-cal disorders, genetic syndromes, and malnutrition. In apoint prevalence study, Noonan, Quigley, and Curley(2006) found 60% of hospitalized children less than 18years of age incontinent of urine and/or stool with 16%of these patients having hospital-acquired DD. McLane,Bookout, McCord, McCain, and Jefferson (2004) found

excoriation/DD as the most common type of skin break-down (42%) in their prevalence study of hospitalizedchildren aged birth to 17 years old.

The DD frequency cited in the literature, the suspicionthat our hospitals rate was high, and observed practicevariations encouraged us to look at our own prevalencerates and prevention and treatment tactics. We utilizedthe Iowa Model of Evidence-Based Practice (EBP) as theframework for our project (Titler et al., 2001). Problem-focused triggers included nursing and physician requestsfor barrier products not carried by the hospital and fre-quent changes to the treatment plan from shift to shift.Nurses, physicians, and pharmacists, as well as families,

Lauren M. Heimall, MSN, RNC-NIC, PCNS-BC, Beth Storey, MSN, RN, CPON,Judith J. Stellar, MSN, CRNP, PNP-BC, CWOCN, and Katherine Finn Davis, PhD, RN, CPNP

Diaper dermatitis

causes discomfort for

the child as well assignificant caregiver

distress.

January/February 2012

MCN 11


3/7

found petrolatum to be an effective barrier against skinbreakdown.

Other factors to consider include the type of diaperand frequency of diaper changes. A Cochrane Review didnot find definitive evidence to support or refute the useand type of disposable diapers for prevention of DD(Baer, Davies, & Easterbrook, 2006). However, multipledescriptive and expert opinion articles recommend usingsuper absorbent diapers containing gelling materials,which keep moisture away from skin (Davis, Leyden,Grove, & Raynor, 1989; Lund et al., 1999; Nield & Ka-mat, 2007; Scheinfeld, 2005). Caregivers should changediapers frequently, as often as every 2 hours or soonerif the diaper is wet and/or soiled (AWHONN, 2007;Atherton, 2004; Borkowski, 2004; Nield & Kamat;Visscher, 2009).

The literature supports certain processes for cleansingthe diaper area and subsequent application of diaper areaproducts. Some authors encourage the use of soft clothsand water for cleansing the diaper area due to preserva-tives in baby wipes that have the potential to cause skinirritation (AWHONN, 2007; Borkowski, 2004). How-

ever, many authors continue to supportthe use of baby wipes due to advancesin manufacturing that have decreasedthe number of additives that they con-tain (AWHONN, 2007; Atherton, 2004;Ehretsmann, Schaefer, & Adam, 2001;Nield & Kamat, 2007; Odio, Streicher-Scott, & Hansen, 2001). Appropriateapplication of prevention and treatmentproducts is also an important factor toconsider. Several experts (Lund et al.,1999, 2001; Taquino, 2000) advisecaregivers to apply barrier productsthickly and refrain from rubbing offcompletely during diaper changes toprevent further skin damage. Coveringbarrier products with a thin layer of pet-rolatum may help prevent the diaperfrom sticking to the product (Borkowski,2004). When a fungal infection is pres-ent, caregivers should apply the anti-fungal first with the barrier productlayered on top. Antifungal powder can

also be layered with skin protectant/sealant, referred to as crusting (Gray,2007).

Current PracticeIn conjunction with searching for evi-dence, our team developed a survey tocollect baseline data prior to any prac-tice changes (Titler et al., 2001). Thissurvey included data regarding diaperedstatus, DD products at the bedside,and presence and type of DD as de-scribed by Noonan et al. (2006). The

IIIVII). See Table 1 for a summary of select recom-mendations from the literature.

Although the literature supports that DD is a commoncondition in the hospitalized child, definitive Levels I andII evidence supporting the most effective prevention andtreatment options is not available (Rowe, McCall, &Kent, 2008). However, there is some consensus of lowerlevels of evidence around effective barriers. The literaturesupports that petrolatum and/or zinc oxide provide effec-tive barriers against potential perineal skin irritants andmaceration (Association of Womens Health, Obstetricand Neonatal Nurses [AWHONN], 2007; Hoggarth,Waring, Alexander, Greenwood, & Callaghan, 2005;Lund, Kuller, Lane, Lott, & Raines, 1999; Nield &Kamat, 2007). Baldwin et al. (2001) studied disposablediapers that delivered a continuous zinc oxide- and

petrolatum-based formulation to the skin. Infants wear-ing these diapers had reduced DD and skin erythemacompared to the control group wearing regular diapers.Baldwin also found that an increased concentration ofzinc oxide in an impregnated diaper led to an increasedtransfer of zinc oxide to the skin. Hoggarth et al. (2005)

Table 1.Summary of Literature Recommendations for

Diaper Dermatitis Prevention and Treatment.

Positive recommendations

Zinc oxide AWHONN, 2007; Baldwin, et al., 2001;Hoggarth et al., 2005;Lund et al., 1999; Nield & Kamat, 2007;Wananukul et al., 2006

Petrolatum AWHONN, 2007; Atherton, 2001;Hoggarth et al., 2005; Lund et al., 1999;Odio et al., 2000

Ilex Lund et al., 1999

Antifungal products Lund et al., 1999

Frequent Diaper Changes AWHONN, 2007; Atherton, 2004; Borkowski, 2004;Kazaks & Lane, 2000; Nield & Kamat, 2007;Visscher, 2009

Super Absorbent Diapers Atherton, 2001a; Atherton, 2004

a; Baer et al., 2006a;

Davis et al., 1989a; Lund et al., 1999;Nield & Kamat, 2007; Scheinfeld, 2005

a

Application proceduresfor use of barrierproducts & antifungalproducts

Borkowski, 2004; Gray, 2007; Lund et al., 1999, 2001;Taquino, 2000

a

Diaper Wipes Atherton, 2001a; Atherton, 2004

a; Borkowski, 2004;

Ehretsman et al., 2001a; Nield & Kamat, 2007,

Odio et al., 2001a

Neutral or Negative Recommendations

Open to Air Lund et al., 1999

Antibacterial Products AWHONN, 2007; Lund et al., 1999

Powder Darmstadt & Dinulos, 2000a; Farrington, 1992

a

aThese references are also included in AWHONNs Neonatal Skin Care Evidence-BasedClinical Practice Guidelines (2007)

12



4/7

4. What do you like/dislike about the revised standard?5. What would make the revised standard more adapt-

able to practice? More user-friendly? More helpful oraccessible?Based on the feedback, many nurses were unaware of

our current standard or had read it once during orientationand had not accessed it again. Primary obstacles were inac-cessibility, including difficulty searching the nursing intranetor having no direct links to the standard. Regarding feed-back on the revised standard, nurses commented positivelyabout the inclusion of photos of DD, as well as the algo-rithm for prevention and treatment. The nurses offeredmany ideas to improve the revised standard, chiefly sur-rounding clarification of product application and removal.

Product SelectionUsing the evidence, we moved forward to update ourcurrent products. We consulted our hospital allergy,dermatology, and infection control experts regardingcommon additives and tubs versus tubes for prod-uct containers. Following the EBP process, we also con-

sidered caregiver preferences and availability of productsin the community so treatment could be continued athome (Melnyk & Fineout-Overholt, 2011). Next, weobtained approval from the hospital product evaluationcommittee and collaborated with materials distributionto plan product availability, location, and switch-out.Titler et al. (2001) recommends piloting an EBP changein a small sample, such as a single unit; however, this wasnot feasible with our hospitals system for changingproducts house wide. The hospital stocked petrolatum(Vaseline), but did not designate it as a DD product. Pet-rolatum, the first-line product for prevention, is nowavailable on each units open supply cart. We replaced

survey included 195 patients from six in-patient units specifically chosen due to

their high risk of DD as shown in ourhospitals previous Skin Injury PrevalenceStudy. Results filtered for only diaperedand incontinent patients showed that16% had DD, of which 76% were Type Iand a variety of products existed at thebedsides (Figure 1, January 2010 data).

Changing PracticeChanging practice to reflect the currentevidence is not without challenge. Cullenand Titler (2004) state that initiating aproject and effectively changing practicecan take 18 to 24 months. This is especially

true regarding the prevention and treat-ment of DD because many clinicians haveset ideas based on past experiencebothas clinicians and as parents. In addition,caregivers have opinions on how to pre-vent and treat DD for their child. EBPmodels do account for these patient andfamily preferences along with clinical exper-tise and research evidence (Melnyk & Fineout-Overholt,2011). Despite these challenges, nursing practice needs toreflect the evidence. Therefore, our team forged aheadwith updating our perineal skin care standard based onthe current evidence.

New Practice GuidelinesAfter a comprehensive review of the evidence, we revisedour nursing standard. The new perineal skin care stan-dard focuses on prevention and the importance of clearlyidentifying patients at risk for DD in order to employprevention strategies early in the hospitalization. Forpatients with DD, a clear time frame was developed todiscourage constant changing of products and allowone particular product time to exhibit effectiveness. Inorder to improve user-friendliness, we added a single-page, step-by-step algorithm (Figure 2) with photos andproduct application instructions. Detailed instructionselaborating on the algorithm and routine diaper care areincluded in the body of the standard.

Prior to implementation, we sought feedback from

frontline staff as end users regarding use of the currentstandard as well as information on format, understand-ability, and ease of use for the revised standard (Titleret al., 2001). To gather this information, we conductedfocus groups with key stakeholders. Forty-three nursesand one advanced practice nurse across six units fre-quently caring for diapered patients participated in thediscussions. We drafted a standard script to guide thediscussion. Questions included:1. Were you aware of the current Perineal Skin Care

Standard?2. How do you use the current standard?3. What are the obstacles to using the current standard?

Figure 1. Diaper Dermatitis Prevalence & Severityin High-Risk Units

Type 1: erythema, intact skin, no Candida; Type 2: erythema, intact skin, Candida;Type 3: erythema, denuded skin, no Candida; Type 4: erythema, denuded skin, Candida.

0%2008Dec 2010Jan 2010June 2010Sept 2010Dec

5%

10%

15%

20%

25%

30%

TotalDiaperDermatitisRate

% Type IV

% Type III

% Type II

% Type I

New Standard Released March 2010


MCN 13


5/7


6/7

practice changes. In light of our initial finding of 24%prevalence of DD, we reassessed our high-risk units prior

to implementing our revised standard and found a 16%prevalence rate. These rates from high-risk units closelymirror hospital-wide data. Following implementationof the revised standard, our prevalence rate was 15% at3 months, 18% at 6 months, and 11% at 9 months.Therefore, over a 2-year period, the prevalence rate forhigh-risk units dropped from 24% to 11%. Preimple-mentation, prevalence assessments of Type IV DD were11% and 5%. In the 9 months following implementa-tion, the prevalence of Type IV DD decreased to 0% (seeFigure 1). To capture compliance with the standard, wecollected information regarding products at the bedside.

Prior to implementation of the revised standard, 14% ofhigh-risk patients had other products at the bedsidenot currently identified in the standard. Postimplementa-tion, data revealed a decrease of other products to6% potentially reflecting increased compliance with therevised standard.

Clinical ImplicationsThe hospital Skin Care Champions were integral inbringing DD prevention and treatment to the forefront ofnursing care. They will continue with this work as nurs-

ing staff needs frequent reminders of the importance ofperineal skin care within the busy demands of bedsidecare. Routine collection of skin condition data serves as areminder and offers another opportunity for Skin CareChampions to discuss perineal skin care with nurses. Uti-lizing multiple avenues for information disseminationhelps ensure that the message is heard.

DD continues to affect hospitalized children andshould remain a priority for nurses caring for diaperedand incontinent patients. DD is often a preventable con-dition if appropriate attention and care are provided.Most importantly, nurses have the opportunity to influ-ence DD rates through preventative evidence-based care.

our second-line product with a 40% zinc-based product(Desitin Maximum Strength Original Paste), which is

available in each units Pyxis MedStation. In addition tobeing evidence-based, this change saves the hospitalapproximately $8,000 per year. Nurses order products inthe third line of prevention and treatment (Triple Paste,etc.) from materials distribution for individual patients.Our algorithm encourages the use of first- and second-line products and reserves the use of third-line productsfor when frontline products fail or as determined bypatient needs.

Communication and DisseminationOnce we finalized revisions to the standard, we devised ahospital-wide rollout plan. This plan included presenta-

tions to the hospital CNS group, nursing departmentshared governance councils, and approximately 60 unit-based Skin Care Champions who are responsible for skincare education on their units. The team presented the en-tire EBP project during Nurses Week as both a poster andoral presentation. All nursing units received a tip sheethighlighting the major changes to the standard, color post-ers of the algorithm to post, and cameras to document DDvisually and see improvements with healing over time.

ChallengesAlthough DD is a common condition in the hospitalizedchild, definitive optimal prevention and treatment strate-gies are still debatable as there is a lack of randomizedcontrolled trials. This lack of high-level evidence makesrecommendations more difficult. Additionally, much ofthe evidence available is dated; therefore, more studiesare needed to identify the best options available.

The implementation of EBP changes proved to be achallenge in such a large pediatric hospital. Thousands ofstaff required education and training that spanned mul-tiple disciplines. The risk of staff information overloadwas ever present as there were many competing prioritiesthroughout the hospital at the time we disseminated thenew standard. Buy-in from staff and consistency in prac-tice were essential for the implementation of practicechanges and important for patients and families to haveconsistent, evidence-based care.

Clinicians often have preferences for DD prevention

and treatment based on clinical and personal experience.Straying from those preferences, especially when believedto be the best method or product, can be difficult. Addi-tionally, caregivers may also have personal preferencesfor their child and may want to continue with their ownprevention or treatment strategies. While acknowledgingclinician and caregiver preferences, we sought to educatethrough the evidence-based revision of the standard andpatient/family education materials.

EvaluationAs part of the EBP implementation process, Titler et al.(2001) recommend reevaluation after implementation of

Buy-in from staff and

consistency in practice were

essential for the implementation

of practice changes and important

for patients and families to have

consistent evidence-based care.


MCN 15


7/7

Our hospital demonstrated improvement in the preva-lence of DD and the severity of cases, but there is always

room for additional improvement.

Lauren M. Heimall is a Clinical Nurse Specialist in theNewborn/Infant Intensive Care Unit, The ChildrensHospital of Philadelphia, Philadelphia, PA. She can bereached via e-mail at [email protected].

Beth Storey is a Clinical Nurse Specialist in the Inpa-tient Oncology/Blood and Marrow Transplant Unit, TheChildrens Hospital of Philadelphia, Philadelphia, PA.

Judith J. Stellar is a Wound, Ostomy, ContinenceAdvanced Practice Nurse at The Childrens Hospital ofPhiladelphia, Philadelphia, PA.

Katherine Finn Davis is a Nurse Researcher, TheCenter for Pediatric Nursing Research & Evidence-Based

Practice, The Childrens Hospital of Philadelphia, Phila-delphia, PA.The authors declare no conflicts of interest.

DOI:10.1097/NMC.0b013e31823850ea

References

Association of Womens Health, Obstetric and Neonatal Nurses. (2007).Neonatal Skin Care Evidence-Based Clinical Practice Guideline(2nded.). Washington, DC: Association of Womens Health, Obstetric andNeonatal Nurses.

Atherton, D. J. (2001). The aetiology and management of irritant diaperdermatitis. Journal of European Academy of Dermatology andVenereology, 15(Suppl. 1), 1-4.

Atherton, D. J. (2004). A review of the pathophysiology, prevention andtreatment of irritant diaper dermatitis. Current Medical Researchand Opinions, 20(5), 645-649. doi: 10.1185/030079904125003575

Baer, E. L., Davies, M. W., & Easterbrook, K. J. (2006). Disposable nap-pies for preventing napkin dermatitis in infants (Review). CochraneDatabase of Systemic Reviews 2006 (3), CD004262. doi: 10.1002/14651858.CD004262.pub2

Baldwin, S., Odio, M. R., Haines, S. L., OConnor, R. J., Englehart, J. S.,& Lane, A. T. (2001). Skin benefits from continuous topical adminis-tration of a zinc oxide/petrolatum formulation by a novel dispos-able diaper. Journal of the European Academy of Dermatology andVenereology, 15(Suppl. 1), 5-11. doi: 10.1046/j.0926-9959.2001.00002.x

Berg, R. W., Milligan, M. C., & Sarbaugh, F. C. (1994). Association of skinwetness and pH with diaper dermatitis. Pediatric Dermatology,11(1), 18-20. doi: 10.1111/j.1525-1470.1994.tb00066.x

Borkowski, S. (2004). Diaper rash care and management. PediatricNursing, 30(6), 467-470.

Cullen, L., & Titler, M. G. (2004). Promoting evidence-based practice: Aninternship for staff nurses. Worldviews on Evidence-Based Nurs-ing,1(4), 215-223. doi: 10.1111/j.1524-475X.2004.04027.x

Darmstadt, G. L., & Dinulos, J. G. (2000). Neonatal skin care. PediatricClinics of North America, 47(4), 757-782. doi: 10.1016/S00313955(05)70239-X

Davis, J. A., Leyden, J. J., Grove, G. L., & Raynor, W. J. (1989). Com-parison of disposable diapers with fluff absorbent and fluff plusabsorbent polymers: Effects on skin hydration, skin pH, and diaperdermatitis. Pediatric Dermatology, 6(2), 102-108. doi: 10.1111/

j.1525-1470.1989.tb01005.x

Ehretsmann, C., Schaefer, P., & Adam, R. (2001). Cutaneous tolerance ofbaby wipes by infants with atopic dermatitis, and comparison ofthe mildness of baby wipe and water in infant skin. Journal ofEuropean Academy of Dermatology and Venerealogy, 15(Suppl. 1),16-21.

Farrington, E. (1992). Diaper dermatitis. Pediatric Nursing, 18(1), 81-82.

Gray, M. (2007). Incontinence-related skin damage: Essential knowl-edge. Ostomy Wound Management, 53(12), 28-32.

Gray, M., Bliss, D. Z., Doughty, D. B., Ermer-Seltun, J., Kennedy-Evans,K. L., & Palmer, M. H. (2007). Incontinence-associated dermatitis: Aconsensus. Journal of Wound, Ostomy, Continence Nursing,34(1),45-54. doi: 10.1097/00152192-200701000-00008

Hoggarth, A., Waring, M., Alexander, J., Greenwood, A., & Callaghan, T.(2005). A controlled, three-part trial to investigate the barrier func-tion and skin hydration properties of six skin protectants. Ostomy/Wound Management, 51(12), 30-42.

Jordan, W. E., Lawson, K. D., Berg, R. W., Franxman, J. J., & Marrer, A.M. (1986). Diaper dermatitis: Frequency and severity among a gen-eral infant population. Pediatric Dermatology, 3(3), 198-207. doi:10.1111/j.1525-1470.1986.tb00513.x

Kazaks, E.L. & Lane, A.T. (2000). Diaper dermatitis. Pediatric Clinicsof North America, 47(4), 909-919. doi: 10.1016/S0031-3955(05)70248-0

Lund, C., Kuller, J., Lane, A., Lott, J. W., & Raines, D. A. (1999). Neonatalskin care: The scientific basis for practice. Journal of Obstetric,Gynecologic and Neonatal Nursing, 28(3), 241-254. doi: 10.1111/

j.1552-6909.1999.tb01989.x

Lund, C. H., Kuller, J., Lane, A. T., Lott, J. W., Raines, D. A., & Thomas, K.K. (2001). Neonatal skin care: Evaluation of the AWHONN/NANNresearch-based practice project on knowledge and skin care prac-tices. Journal of Obstetric, Gynecologic and Neonatal Nursing,30(1), 30-40. doi: 10.1111/j.1552-6909.2001.tb01519.x

McLane, K. M., Bookout, K., McCord, S., McCain, J., & Jefferson, L. S.(2004). The 2003 national pediatric pressure ulcer and skin break-down prevalence survey: A multisite study. Journal of WoundOstomy and Continence Nursing, 31(4), 168-178.

Melnyk, B. M., & Fineout-Overholt, E. (2011). Evidence-based Practicein Nursing and Healthcare: A Guide to Best Practice (2nd ed.).Philadelphia: Lippincott Williams & Wilkins.

Nield, L. S., & Kamat, D. (2007). Prevention, diagnosis, and manage-ment of diaper dermatitis. Clinical Pediatrics, 46(6), 480-486. doi:10.1177/0009922806292409

Noonan, C., Quigley, S., & Curley, M. A. (2006). Skin integrity in hospi-talized infants and children: A prevalence study. Journal of PediatricNursing, 21(6), 445-453. doi: 10.1016/j.pedn.2006.07.002

Odio, M. R., OConnor, R. J., Sarbaugh, F., & Baldwin, S. (2000). Con-tinuous topical administration of a petrolatum formulation by a

novel disposable diaper. Dermatology, 200(3), 238-243.Odio, M., Streicher-Scott, J., & Hansen, R. C. (2001). Disposable baby

wipes: Efficacy and skin mildness. Dermatology Nursing, 13(2),107-112, 117-118, 121.

Rowe, J., McCall, E., & Kent, B. (2008). Clinical effectiveness of barrierpreparations in the prevention and treatment of nappy dermatitisin infants and preschool children of nappy age. International Journalof Evidence-Based Healthcare, 6(1), 3-23. doi:10.1111/j.1479-6988.2007.00095

Scheinfeld, N. (2005). Diaper dermatitis: A review and brief survey oferuptions of the diaper area. American Journal of Clinical Derma-tology, 6(5), 273-281.

Shin, H. T. (2005). Diaper dermatitis that does not quit. DermatologicTherapy, 18(2), 124-135.

Taquino, L. T. (2000). Promoting wound healing in the neonatal setting:Process versus protocol. Journal of Perinatal and Neonatal Nurs-ing, 14(1), 104-118.

Titler, M. G., Kleiber, C., Steelman, V. J., Rakel, B. A., Budreau, G., Ever-ett, L. Q., , Goode, C. J. (2001). The Iowa Model of evidence-based

practice to promote quality care. Critical Care Nursing Clinics ofNorth America, 13(4), 497-509.

Visscher, M. O. (2009). Recent advances in diaper dermatitis: etiologyand treatment. Pediatric Health, 3(1), 81-98. doi: 10.2217/17455111.3.1.81

Wananukul, S., Limpongsanuruk, W., Singalavanija, S., & Wisuthsare-wong, W. (2006). Comparison of dexpanthenol and zinc oxide oint-ment with ointment base in the treatment of irritant diaper derma-titis from diarrhea: A multicenter study. Journal of MedicalAssociation of Thailand, 89(10), 1654-1658.

For 13 additional continuing nursing education articles onevidence-based practice, go to nursingcenter.com/ce

16


beginning of the diaper dermatitis

Documents