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The Effectiveness of Modified Child Bonnet to Decreased of Damage Skin Integrity in Children with
Noninvasive Ventilation (NIV) in the Cambodian Room, Sanglah Hospital

Suryaningsih, Eta Risnawati Nyoman

1
RSUP Sanglah Denpasar Surya_ras@yahoo.com
2
RSUP Sanglah Denpasar etaduta@yahoo.co.id

Article Info: ABSTRACT

Submitted: Noninvasive ventilation (NIV) is a mechanical ventilation technique without use the endotracheal tube
07-05-2022 in the airway. Damage to skin integrity caused by the installation of NIV devices is often ignored
Revised: because the priority in lifesaving for the installation of breathing apparatus is a top priority. This study
31-05-2022
aimed to analysed the effectiveness of modified child bonnets on the incidence of skin integrity
Accepted:
31-05-2022
damage in children who are installed with NIV (Noninvasive Ventilation) in the Cambodian Room of
Sanglah Hospital. Methods: This research is a quasi-experimental research with Posttest Only, Non-
equivalent Control Group Design. The population in this study were pediatric patients aged 1-24
months with NIV installation. The sampling technique in this study used purposive sampling, there
are 16 samples. The data analysis technique used in this study is the Mann Whitney test. Result: The
results of the study were Exact Sig. [2*(1-tailed Sig.)] i0.002 with a significance level of =0.01. This
shows that Exact Sig. < α, then the modified child bonnet is effectived in reduced the rate of damage
to skin integrity in pediatric patients who have NIV installed. Analysis: Based on these results, it is
expected that the used modified child bonnet can be applied in order to reduce the incidence of skin
integrity damage in pediatric patients.

Keyword: Modified Child Bonnet, Damage to Skin Integrity, NIV

DOI:

INTRODUCTION

Noninvasive ventilation (NIV) is a mechanical ventilation technique without using of a tracheal tube (endotracheal tube) in the airway.
Indications for the use of NIV are type 1 respiratory failure (hypoxemia), type 2 respiratory failure (hypercapnia), ventilator weaning,
and palliative care in patients who refuse intubation (McNeill, 2012). In the installation of noninvasive ventilation, there are several
drawbacks, namely it can cause delays in the installation of invasive ventilation, a higher risk of aspiration, suctioning of mucus in the
trachea cannot be carried out, can cause claustrophobia (fear of closed objects), pressure effects on the face and nose which can
cause damage to integrity skin, especially in children (Leclerc, 2011).
Children during treatment are very susceptible to various damage to the integrity of the skin because the structure, system, and
physiology of the skin are still in the adjustment stage and not yet optimal (Chang & Orlow, 2008 in Leksmana, et al. 2019). Damage
to skin integrity can be in the form of damage to skin integrity (pressure ulcers), namely local injuries to the skin or underlying tissue
as a result of pressure or combination of pressure and displacement (National Pressure Ulcer Advisory Pannel, 2009 in Leksmana,
2019). Damage to skin integrity in children can occur more quickly than expected. According to Yigit, et. al. (2009) in Suyami (2013),
damage to skin integrity in children can occur within 2-6 hours after admission to acute care.
The incidence of impaired skin integrity varies across hospitals and in different countries. Hospitals in the United States are
estimated to have 2.5 million skin integrity defects treated. A survey identified damage to skin integrity in hospitalized children as
high as 0.47%-13% (Kottner, 2012). Another study identified the incidence of impaired skin integrity in hospitalized children ranging
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from 3%-28%. Based on this figure, 27% of the incidence of damage to skin integrity during NIV installation in children occurred in
the PICU (Pediatric Care Unit), and 23% occurred in the NICU (Neonatal Intensive Care Unit) while in the acute care unit it was 7%-
17% (Drake, 2007). In Indonesia, according to Suryadi (2006) in Yusuf (2012), the incidence of skin integrity damage during NIV
insertion is still quite high, at 33.3%. This figure is the highest number compared to countries in ASEAN. In room infection of Building
A, 1st floor of RSUP Dr. Copto Mangunkusumo Jakarta in the last five months (January-May 2013) was 1.4%.
Damage to skin integrity caused by the installation of NIV devices is ignored because the priority in life saving for the installation of
breathing apparatus is of course a top priority. But the integrity of the patient's skin in this regard should also be given priority. The
impact caused by damage to the integrity of the skin is not only on the wound, but also has an impact on the quality of life, pain,
unpleasant odor, rest disorders, social interaction disorders, role disorders and infection if NIV installation is indicated for a long time
which is sometimes neglected. This condition is reinforced by the results of Suyami's research (2013), which identified that damage
to skin integrity affecting the epidermis, dermis, and subcutaneous layers can have an impact on physical and psychological aspects
including pain, systemic infection, increasing morbidity and mortality, increasing length of stay, increase the cost of care, and
negative psychosocial aspects such as impaired self-image, shame, and lack of self-confidence (Curley, et.al, 2009 in Suyami,
2013).
Based on a preliminary study conducted by researchers in the Cambodian Room of Sanglah Hospital Denpasar on July 1-December
31, 2020, there were 36 children who were treated, 22 of them using NIV aids. The average pediatric patients treated in the
Cambodia Room using NIV were in the age range of 1-24 months. Based on these data, all of these 22 patients had wounds on the
frontal head due to NIV installation due to the limited availability of the Child bonnet (there is no size that matches the size of the
child's head over the age of 2 months) so the nurse uses an alternative cloth or elastomul to replace the function of the Child bonnet.
the. In addition to these problems, sometimes the use of alternative elastomules also creates new problems, namely the
ineffectiveness of the NIV position in children and often causes the NIV circuit to be lapped or not properly positioned.
Based on this background, the researchers felt that it was necessary to conduct a study entitled "Effectiveness of Modified Child
Bonnet in Reducing the Incidence of Skin Integrity Damage in Children with Noninvasive Ventilation (NIV) in the Cambodian Room,
Sanglah Hospital".

METHOD
Research design
This study uses a quasi-experimental type of research, because there are still external variables that also influence the
formation of the dependent variable and because there are no control variables (Sugiyono, 2010). The research design
used was Posttest Only, Non-equivalent Control Group Design, namely the experimental group and the control group
were not chosen randomly so that the results of the treatment could be known accurately.

In the design of this study, the experimental group was given a modified Child Bonnet installation treatment, while the
control group was given elastomol or alternative bonnet installation treatment. The research design used can be
described in the following chart:

Treatment Post-test
Treatment group X1 O1
Control group - O2

Figure 3.1 Research design on the effectiveness of modified child bonnet in reducing the incidence of skin integrity
damage in children who have NIV installed in the Cambodian Room, Sanglah Hospital

Information:
X1 : Intervention (Child Bonnet modification)
O1 : Observation (observation of any damage to the skin integrity of the group
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intervention)
O2 : Observation (observation of any damage to skin integrity in the group
control)

Research Place and Time

The research was carried out in the Cambodian Room of Sanglah Hospital for two months, from May to June 2021.
Population and Research Sample
Research population
The population in this study were all pediatric patients who had NIV installed.
Sampling technique
The sample in this study were all pediatric patients who used NIV and met the inclusion criteria. The sampling
technique used in this research is purposive sampling. This sampling technique was used because the time and cases
sought were limited. The number of samples in this study were 16 pediatric patients indicated for the use of NIV which
were divided into 8 people in each treatment group and control group. In this study, researchers set the treatment group
and control group alternately. If one patient with NIV is treated with modified child bonnet, the next patient will be
given alternative treatment as a control group.

RESULT

Characteristics of Research Subjects

1. Characteristics of Respondents Based on Age
Table 4.1
Characteristics of Respondents by Age

Age (month) Frequency Percentage

(f) (%)
2-12 12 75,0
13-24 4 25,0
Total 16 100

Based on the data in the table above shows the age of most respondents is 2-12 months, namely 14 people (75%).
2. Characteristics of Respondents Based on Gender
Table 4.2
Characteristics of Respondents by Gender

Gender Frequency Percentage

(f) (%)
Man 7 43,8
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Woman 9 56,2
Total 16 100

Based on the data in the table above, it shows that the number of female respondents is 9 people (56.2%).

1. Observations on Research Objects Based on Research Variables

a. Results of Data Analysis on the Effectiveness of Using Alternative Methods on the Incidence of Skin Integrity Damage in the
Control Group
Table 4.3

Frequency Distribution of the Effectiveness of Using Alternative Methods on the Incidence of Damage to Skin Integrity in the Control
Group

Control Group Frequency Percentage

(f) (%)
No damage 1 12,5
There is damage 7 87,5
Total 8 100

Based on the data above, it can be concluded that the incidence of skin integrity damage in the control group was very high, namely
7 patients (87.5%).

b. Results of Data Analysis of the Effectiveness of the Use of Modified Child Bonnets on the Incidence of Skin Integrity Damage
in the Intervention Group
Table 4.5
Frequency Distribution of the Effectiveness of the Use of Modified Child Bonnets on the Incidence of Skin Integrity Damage
in the Intervention Group

Control Group Frequency Percentage

(f) (%)
No damage 8 100
There is damage - -
Total 8 100

Based on the data above, significant data were obtained, namely 8 patients (100%) with no damage to skin integrity in the
modified child bonnet intervention group.

c. Results of Comparative Analysis of the Effectiveness of the Use of Modified Child Bonnets on the Incidence of Skin Integrity
Damage in the Control and Intervention Groups
Table 4.6
Normality Test Data on the Effectiveness of Child Bonnet Modifications
against damage to skin integrity in children who are attached to NIV

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Kolmogorov-Smirnov Shapiro-Wilk
Statistic df Sign. Statistic df Sign.
Group .334 16 .000 .644 16 .000
Age .462 16 .000 .546 16 .000
Gender .366 16 .000 .638 16 .000
Comorbid .294 16 .001 .762 16 .001
Damage to Skin Integrity .366 16 .000 .638 16 .000
a. Lilliefors Significance Correction

Based on the data above, the significance value (p) in the Kolmogorov-Smirnov test for damage to skin integrity is 0.000 (p >
0.05) so that based on the normality test, the data distribution is not normally distributed. Thus, testing the effectiveness of
the modified Child Bonnet in the control group and the intervention group using the Mann-Whitney test was carried out.

Table 4.7
Effectiveness of Modified Child Bonnet against impaired skin integrity in
NIV-attached children in the control and intervention groups

Damage to Skin Integrity

Mann-Whitney U 4.000
Wilcoxon W 40.000
Z -3.416
Asymp. Sig. (2-tailed) .001
Exact Sig. [2*(1-tailed Sig.)] .002a

Furthermore, the data on the effectiveness of the modified child bonner was tested and the results of the Mann-Whitney test were
obtained, namely Exact Sig. [2*(1-tailed Sig.)] is 0.002 with a significance level of =0.01. This shows that Exact Sig. < 0.002,
meaning that the modified Child Bonnet is effective in reducing the rate of skin integrity damage in pediatric patients who have NIV
installed in the Cambodia Room.

Discussion of Research Results

Analysis of Research Results based on Characteristics of Respondents
The results of the characteristics of the respondents in this study showed that the most children were 2-12 months old as many as 14
people (75%). Age plays a role in contributing to nasal septal damage in children. In the study of Abedesso et al. (2012), the mean
age group was 7.25 months the rate of nasal septal damage was in the younger age group. This is in line with the research of
Mayordomo, et al. (2009) in Leksmana (2019), who found the average patient age of 6.1 months had a higher level of damage
compared to the average patient age of 11.6 months. This study is in line with several previous researchers, namely the
characteristics of respondents at a younger age, which is 75%.
In this study, there were more data on female sex, namely 9 people (56.2%). This study is not in line with previous research based
on the gender of the respondents. In the study of Abedesso et al. (2012), sex found 13 people (52%) boys and 12 people (48%) girls
at NIV installation who experienced damage to the nasal septum.

Analysis of Comparative Results of Skin Integrity Damage in the Control Group

Based on the data in this study, the data on skin integrity damage in the control group (using alternative methods of elastomol or
plaster) was very high, namely 7 patients (87.5%). According to research Asmarini (2020), states that the use of NIV in infants can
cause side effects that can make children injured, namely injury to the nose, for example erosion of the nasal septals, and nasal

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snubbing, while long-term use can cause pneumothorax. In addition, the use of non-standard NIV devices can cause damage to the
baby's skin. This is in line with this study, namely in the control group there were wounds after NIV installation with alternative
methods.

Analysis of Comparative Results of Damage to Skin Integrity in the Intervention Group

Based on the data obtained a significant result that is equal to 8 patients (100%) no damage to skin integrity in the intervention
group. These data are in line with the research. According to the research of Chen et al. (2017), Non-invasive respiratory support
(NIRS) bundle is an evidence-based clinical intervention from the literature for standardized care to improve the quality of
independent infants receiving NIV. The standard in question is the tool used in accordance with the standard so that complications
do not occur in children. This is in line with this study, namely that there was no damage to skin integrity that occurred in the modified
child bonnet treatment group.
Several NIRS Bundle intervention protocols according to Milligan et al. (2017), namely (1) Observe the baby every hour to check and
maintain the proper prong position. (2) Remove and replace the protective layer once every service to carry out a skin examination.
3) Reposition the baby every 3 or 4 hours using developmental care principles. 4) Assess for pain at least 3 or 4 hours after insertion
and assess the degree of skin injury after 24 hours of using NCPAP. In this study, the principles of the NIRS bundle protocol have
been considered so that modified child bonnets are highly recommended for the use of NIV for children, besides being effective,
modified child bonnets are also efficient in their manufacture and the materials used have been proven to be very safe and
comfortable on children's skin. Thus, it can be ensured that the modified child bonnet is safe and comfortable to use in the
installation of NIV in children.
Analysis of Comparative Results of Skin Integrity Damage in Control and Intervention Groups
The results obtained in this study explained that the data obtained were not normally distributed so that the Mann-Whitney test
obtained Exact Sig data. of 0.002 with a significance level of = 0.01 so it can be concluded that the modified Child Bonnet is effective
in reducing the number of skin integrity damage in pediatric patients who have NIV installed in the Cambodia Room.
The results of this study are supported by the theory proposed by Wellington, et. al. According to research Wellington, et. al (2014),
stated that one of the discomforts caused by NIV insertion is the damage to the integrity of the skin caused. This study also explains
that the length of time using NIV affects the damage to skin integrity that occurs in patients.
This research is also supported by research conducted by Khaterine, et. al (2013) who explained that one of the locations of damage
to skin integrity is in the nose and face area by 20% to 60%. An increased risk of skin injury was associated with smaller infant size,
gestational age, and duration of programmed therapy. Appropriate nursing care strategies are very supportive to improve skin
integrity during the use of NIV devices in children.
Based on the results of the study above, it is hoped that the discovery of a modified Child Bonnet can reduce the incidence of
damage to skin integrity in pediatric patients who are indicated for NIV installation. This is because the modified child bonnet is made
of sponge material and is covered with a soft, hypoallergenic cloth so it is safe and comfortable compared to alternative methods

CONCLUSION

Based on the results of research on the effectiveness of modified child bonnets in reducing the incidence of damage to skin integrity
in children who have NIV (Noninvasive Ventilation) installed in the Cambodian Room, Sanglah Hospital Denpasar, it can be
concluded as follows.
1. Characteristics of respondents based on age, namely age in the range of 2-12 months as many as 14 people (75%), female sex
as many as 9 people (56.2%).
2. Analysis of skin integrity damage data in the control group (using alternative methods of elastomol or plaster) was very high,
namely 7 patients (87.5%).

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3. Analysis of the data obtained significant results that is equal to 8 patients (100%) no damage to skin integrity in the intervention
group.
Analysis of the effectiveness of the modified child bonnet was tested and the results of the Mann-Whitney test were obtained, namely
Exact Sig. [2*(1-tailed Sig.)] is 0.002 with a significance level of =0.01. This shows that Exact Sig. < 0,002, then the modified child
bonnet is effective in reducing the rate of skin integrity damage in pediatric patients who have NIV installed in the Cambodia Room.

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