9.3 Infiltration, Wounds, Diaper Dermatitis, and Skin Infection

Infiltration, Wounds, Diaper Dermatitis, and Skin Infection

Quick Answer: Peripheral intravenous infiltration and extravasation (PIVIE) is a healthcare-acquired skin emergency: stop the infusion, mark the border, elevate, notify, and use hyaluronidase conceptually to disperse many non-vasoconstrictor infusates. Vasopressor extravasation uses alpha-blockade (phentolamine) thinking, not hyaluronidase. Wounds are surgical or not; negative-pressure wound therapy (wound VAC) is a surgeon-directed tool for selected defects, not a nurse-invented suction trick. Pressure reduction and honest device rotation prevent hospital-acquired pressure injury. Ostomy wafers fail at the leak, not at a clock. Irritant diaper dermatitis is moisture and enzymes on convex skin; candidal dermatitis is beefy with satellite lesions in the creases. Skin infection is bacterial, viral, or fungal—HSV is not erythema toxicum.

This section covers diaper dermatitis, infection, IV infiltration/extravasation, and wounds on the current Neonatal CCRN Test Plan (exams on or after November 12, 2025). OpenExamPrep independent teaching; it does not claim endorsement by AACN Certification Corporation. PIVIE also appears among healthcare-acquired conditions in the multisystem domain; here you own the skin response. Practice: /practice/ccrn-neonatal.

PIVIE

A peripheral IV infiltrates when fluid leaves the vein. Infiltration usually names non-vesicant leak; extravasation names vesicant leak. Neonatal vesicants and irritants you will actually see: calcium, parenteral nutrition (especially high osmolality), sodium bicarbonate, potassium, vasopressors (dopamine, epinephrine), some antibiotics, and hypertonic saline. The site is swollen, cool, blanched, or tense; the infant is irritable with handling; later there are blisters and necrosis. Staging systems exist; the nursing action is the same at the start: stop the infusion.

Next actions that are testable:

• Attempt aspiration of residual drug through the catheter if still in place
• Remove or retain the catheter per antidote protocol
• Outline the area with a marker and the time
• Elevate the limb
• Photograph per policy, notify the provider, complete HAC documentation
• Do not wrap so tightly that you add compartment pressure
• Do not apply a random heating pad as a personality preference

Hyaluronidase is an enzyme that temporarily loosens hyaluronic acid in the subcutaneous matrix so many non-vasoconstrictor infusates can disperse and be absorbed. It is given as small subcutaneous injections around the injury per protocol. It is not the drug for dopamine or epinephrine in the tissue. Those injuries are ischemic from alpha constriction; phentolamine (an alpha blocker) is the conceptual antidote many protocols use, sometimes with nitroglycerin paste as an adjunct. Warm versus cold compresses depend on the agent and the protocol: vasoconstrictors are often warmed to encourage dilation; some vesicant protocols use cooling. Memorize the fork—hyaluronidase versus vasoactive antidote—not a single folklore compress.

Prevention: the right cannula in the right vein, hourly (or more frequent) site visualization, transparent dressings, no circumferential tape tourniquets, avoid the scalp when you have a better site, and move long-term TPN to a PICC or central line when indicated. Joints flex and blow veins. Parents should be taught to call for swelling, not to let the nurse sleep. Typical term resting heart rate 120–160 and preterm 140–180 will not diagnose PIVIE; a sudden pain response when the pump beeps occlusion, plus a tight hand, will.

Surgical versus non-surgical wounds

Surgical wounds follow laparotomy, stoma creation, PDA ligation, neurosurgical drains, and cutdowns. You want approximated edges, a dry or appropriately dressed incision, and no dehiscence. Evisceration (bowel at the skin) is an emergency: cover with moist sterile saline dressings, keep NPO, call surgery, support perfusion—do not shove bowel back as a bedside hobby. Non-surgical wounds are pressure injuries, device-related injuries (CPAP interfaces, nasal probes, saturation sensors, splints), skin tears, thermal and chemical burns, and congenital defects already managed on other services.

Negative-pressure wound therapy (NPWT, wound VAC) appears in testable action lists as an advanced dressing: continuous or intermittent suction through a foam and occlusive drape into a canister. Indications are selected open wounds, dehiscence, and some abdominal-wall defects after a surgeon decides the viscera and vessels are safe. Nursing work is a sealed drape, correct pressure setting as ordered, canister changes, alarm response, and pain control when foam is removed. Do not put NPWT on untreated osteomyelitis, an unexplored fistula, or exposed great vessels because a video made it look easy. Do not use a VAC as the first cover when bowel is already on the abdomen—that infant needs a moist sterile emergency dressing and a surgeon, not a foam island.

Pressure reduction: reposition on a schedule the skin can tolerate, use pressure-redistributing mattresses, keep linens smooth, rotate oximeter sites every few hours, relieve CPAP prong pressure, and avoid doughnut rings that concentrate load at the rim. Hospital-acquired pressure injury is both integumentary and a healthcare-acquired condition. Occiput, ears, nares, and heels are neonatal favorites because devices live there.

Ostomy appliances

Ileostomies and colostomies after NEC or anorectal malformation fail first at the wafer-skin junction. Cut the wafer to the stoma with a small clearance, use paste as needed, change for leakage rather than for a ritual hour that leaves enzyme-soaked skin in place, and treat peristomal irritant versus candidal disease the same way you treat the diaper space. High-output ileostomy is a fluid and sodium problem for chapter 13; here you recognize denuded peristomal skin and bag failure. Teach families before discharge, not at the elevator. Measure output; a bag that is full and peeling is already a wound.

Diaper dermatitis: irritant versus candida

Irritant contact diaper dermatitis is moisture, friction, urea, and stool enzymes. It prefers convex surfaces—buttocks, mons, prominent thighs—and may spare the inguinal folds if those folds stayed dry. The skin is red, shiny, and sore. Treatment: frequent changes, super-absorbent diapers, zinc oxide or similar thick barrier, brief air exposure, and stop the wipe that is stripping lipid. Powders that aerosolize are a lung problem; they are not modern NICU standard.

Candidal diaper dermatitis is a beefy red eruption that involves the folds and shows satellite papules and pustules beyond the main plaque. It follows antibiotics, humidity, and yeast in the stool. Treatment is an antifungal (nystatin or another unit agent) plus barrier, and look in the mouth for thrush. Bacterial superinfection (honey crust, bullae, expanding cellulitis) needs a different pathway.

Bacterial, viral, and fungal skin infection

Bacterial: Omphalitis is spreading erythema, induration, or purulence from the umbilicus—a portal to the abdominal wall and portal vein, a true emergency. Bullous impetigo and staphylococcal scalded skin syndrome (SSSS) produce tender erythroderma and superficial blistering; Nikolsky sign may be positive in SSSS; the infant is miserable and needs antistaphylococcal therapy and fluid attention (fluids here mean support of a denuded burn-like surface, not chapter 13’s anion gap). Cellulitis and abscess follow breaks in ELBW skin.

Viral: HSV in a neonate can be a few vesicles or a sepsis picture with no rash. Any suspicion—maternal history, vesicles, unexplained seizures or hepatitis—starts acyclovir while you test; do not wait for a dermatology photograph. Do not call clustered vesicles erythema toxicum in a sick or at-risk infant. VZV and enterovirus also vesiculate.

Fungal: Candida is the everyday organism (diaper, intertriginous, congenital cutaneous candidiasis with widespread macules and desquamation in a preterm infant). Malassezia can colonize oily preterm skin. Filamentous fungi (Aspergillus) invade ELBW skin breaks in humid environments—another reason humidity is weaned and skin is protected.

Culture when the diagnosis drives isolation and drugs. Isolation and hand hygiene are infection control, not optional courtesy.

Worked examples

Example A. Calcium gluconate extravasates into a hand. Stop the line, mark the time, elevate, notify, and use the unit hyaluronidase pathway if that is the listed antidote for calcium—not phentolamine. Watch for blistering over hours.

Example B. Dopamine extravasates. Hyaluronidase is the wrong conceptual antidote. Use phentolamine thinking, keep the limb visible, and involve the surgical team early if perfusion is lost.

Example C. A beefy red diaper rash with satellites after a week of antibiotics is candida, not more zinc alone. A red, shiny buttocks with spared folds in a diarrheal infant is irritant until satellites appear.

Example D. Abdominal wound edges separate and bowel is visible. Moist sterile cover, surgery now. A wound VAC is a later, ordered tool, not the first move for evisceration.

Example E. Spreading redness from the umbilicus in a 5-day-old is omphalitis. Do not treat it as irritant diaper dermatitis because the diaper touched the cord.

Exam traps: hyaluronidase for vasopressors; bagging a vesicant site in heat because it feels better; calling HSV erythema toxicum; treating candidal satellite rash with barrier cream only; delaying omphalitis treatment; peeling VAC foam without analgesia; inventing a pressure-ulcer doughnut. Independent study material covering these listed problems is here; mixed questions live at /practice/ccrn-neonatal. Pediatric wound pages at /study-guides/ccrn-pediatric assume older children, not ELBW barrier physiology.