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CE: Preventing, Assessing, and Managing Skin Tears A Clinical Review

Baranoski, Sharon MSN, RN, CCNS-APN, CWCN, FAAN; LeBlanc, Kimberly MN, RN, CETN(C); Gloeckner, Mary MS, RN, APN, CWON

AJN The American Journal of Nursing: November 2016 - Volume 116 - Issue 11 - p 24–30
doi: 10.1097/01.NAJ.0000505581.01967.75
Feature Articles

Although skin tears are common, particularly among older adults and neonates, they are often inadequately documented and poorly managed, resulting in complications, extended hospital stays, and negative patient outcomes. In this article, the first in a series on wound care in collaboration with the World Council of Enterostomal Therapists (www.wcetn.org), the authors describe the complications that developed in an elderly patient whose skin tear was improperly dressed and discuss best practices for preventing, assessing, documenting, and managing skin tears.

In this first article in a series on wound care in collaboration with the World Council of Enterostomal Therapists, the authors describe the complications that developed in an elderly patient whose skin tear was improperly dressed and discuss best practices for preventing, assessing, documenting, and managing skin tears.

Sharon Baranoski is an advanced practice nurse and president of Wound Care Dynamics, Inc, Shorewood, IL. Kimberly LeBlanc is a PhD student and a fellow in the School of Nursing, Faculty of Health Sciences, Queen's University, Ottawa, Ontario, Canada. Mary Gloeckner is an ostomy wound clinical nurse specialist in the Wound Outreach Department at UnityPoint Health–Trinity in Bettendorf, IA. Sharon Baranoski and Kimberly LeBlanc are cochairs, and Mary Gloeckner is a member, of the International Skin Tear Advisory Panel. Contact author: Sharon Baranoski, nrsebear@aol.com. The authors and planners have disclosed no potential conflicts of interest, financial or otherwise.

RF, an 83-year-old man who resided in a long-term care facility, was admitted to an acute care facility with pneumonia and possible aspiration at 3 pm on a Wednesday. (This is a real case; some identifying details have been changed to protect the patient's privacy.) RF presented with multiple comorbid conditions, including hypertension, congestive heart failure, coronary artery disease, arthritis, chronic obstructive pulmonary disease, and anemia. The admitting physician documented the presence of “skin sores” in RF's medical record, but did not indicate their severity or location. A nurse in the ED had covered the skin tears with dry gauze dressings, which tend to adhere to wounds. The removal of the dressings caused further trauma. RF described the skin tears as very painful.

Figure 1.

Figure 1.

The following morning, the RN caring for RF on the medical–surgical unit called in a wound ostomy continence nurse (WOCN) to assess and treat the tears. Approximately 24 hours after RF's admission, the WOCN (one of us, SB) assessed his skin tears. RF told her that he believed the injuries occurred the day before his admission to the acute care facility when he tripped and a personal support worker in the long-term care facility grabbed him to prevent him from falling. The first tear, on RF's left shoulder, measured 10 × 6 × 0.1 cm; the second, on his upper back, measured 7 × 5 × 0.1 cm (see Figure 1). Both were type 3 tears, as defined by the International Skin Tear Advisory Panel (ISTAP),1 indicating total flap loss that exposed the entire wound bed. The bleeding from both tears was profuse, probably exacerbated by the anticoagulant medication RF took for coronary artery disease, which was neither discontinued nor reduced during hospitalization. As a result of the bleeding, by day 3 of his hospital stay, RF's hemoglobin level had dropped to 8 g/dL, necessitating a blood transfusion.

Because the WOCN was concerned about the risk of infection, once the bleeding was under control, she treated the tears with a nonadherent topical antimicrobial dressing and a soft silicone foam dressing. Since RF had been vaccinated with tetanus toxoid within the past 10 years, no tetanus prophylaxis was administered.

Figure 2.

Figure 2.

Figure 3.

Figure 3.

Initially, the dressings required daily changes because of excessive bloody discharge; as the drainage subsided, the frequency of dressing changes decreased. Eight days after RF's admission, the skin tears were progressing toward closure (see Figure 2). Within four weeks of the original injury, they were healed (see Figure 3). As a result of RF's skin tears and the subsequent need for a transfusion, the treating physician extended RF's hospital stay by one week.

RF's experience underscores several crucial facts about skin tears:

  • Although they are often perceived as minor injuries, skin tears can become painful, costly, complex wounds that negatively affect patient outcomes.
  • Wound care nurses should be involved in their management.
  • Skin tears must be documented and properly classified in order to ensure that best practices are followed in their treatment.

This article describes skin tears, their frequency, and the classification system used in their documentation. It also discusses risk factors for developing skin tears, prevention strategies, and best practices for assessing and managing skin tears.

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CHARACTERISTICS AND FREQUENCY OF SKIN TEARS

A consensus panel of internationally recognized opinion leaders has defined a skin tear as “a wound caused by shear, friction, and/or blunt force resulting in separation of skin layers [that] can be partial-thickness (separation of the epidermis from the dermis) or full-thickness (separation of both the epidermis and dermis from underlying structures).”2 Skin tears tend to be jagged and irregular in shape. Some are dry; others are exudative. In most cases, skin tears are painful and slow to heal.

While skin tears are often found on the arms, legs, and dorsal aspect of the hands of older adults, they can occur anywhere on the body. In ambulatory independent older adults, the majority of skin tears occur on the lower extremities as a result of wheelchair injuries or trauma sustained when bumping into objects, during falls or patient transfers, or with inappropriate removal of dressings.2, 3 In neonates with immature skin, tears tend to occur with adhesive- or device-related trauma.2, 4

Skin tears are relatively common, particularly in long-term care facilities. Some research suggests that in the long-term care setting, the prevalence of skin tears is similar to or greater than that of pressure ulcers, affecting 8% to 22% of residents.5-7 In one Australian hospital study, the overall skin tear prevalence rate was 11%, but rates varied widely within the hospital, ranging from 4% in the orthopedic unit to 27% in the palliative care unit.8

Despite the tremendous clinical burden and costs associated with skin tears, they have been largely neglected in nursing and medical literature until recently. Over the past few years, however, there has been a substantial rise in research related to skin tear prevention and management.2, 9-11 Since 2011, ISTAP members have worked to review research; develop a new nomenclature and classification system1, 3; and establish consensus statements that provide a simpler means of assessing, documenting, and managing skin tears.2, 12

Figure 4.

Figure 4.

The ISTAP classification system, adapted from the work of Payne and Martin13 and Carville and colleagues,14 defines three types of epidermal and dermal loss (see Figure 4)1:

  • Type 1–No skin loss
  • Type 2–Partial flap loss
  • Type 3–Total flap loss

After having been shown to have internal and external validity as well as test–retest and intrarater reliability, the system was incorporated into practice.

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RISK FACTORS FOR SKIN TEARS

Table 1

Table 1

Populations at greatest risk for skin tears include those at the extremes of age (neonates and adults over 75), critically ill patients, chronically ill patients, and those who need assistance with personal care.2 Both intrinsic and extrinsic factors may put patients at risk for skin tears (see Table 1).

Box.

Box.

Advanced age affects both the healing process and the patient's susceptibility to skin tears.1 (See Changes That Occur in Aging Skin.2) Older patients undergo dermal and subcutaneous tissue loss, epidermal thinning, and changes in serum composition that reduce skin surface moisture. As these changes occur, the skin loses elasticity and tensile strength, elevating the risk of skin tears. Other characteristics common among elderly patients, such as dehydration, nutritional deficiencies, cognitive impairment, limited mobility, and reduced sensation, may exacerbate this risk.

Neonates. The incomplete epidermal-to-dermal cohesion seen in neonates predisposes them to skin tears when medical devices are secured to the skin. The adhesive bond between tape and skin is greater than that between the epidermis and dermis. As tape is removed, the epidermis remains attached to the tape, resulting in a painful tear. Other factors that put neonates at risk for skin tears include limited stratum corneum, skin surface alkalinity, and nutritional deficiencies.15

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PREVENTION STRATEGIES

When skin is fragile, any forceful movement or pull can cause tearing. Caregivers and family members need to take great care when positioning, turning, lifting, or transferring patients with vulnerable skin. The key to preventing skin tears is to recognize patients at high risk and to implement a prevention protocol that incorporates the following strategies3:

  • Identify and remove potential sources of injury, such as unnecessary equipment.
  • Ensure that lighting is sufficient.
  • Use lift sheets to move patients in bed.
  • Pad bedside rails, as well as wheelchair arm and leg supports.
  • Encourage patients to wear long sleeves and pants.
  • Consider shin guards for those who repeatedly experience skin tears.
  • Keep fingernails short when providing care.
  • Trim and file patients’ fingernails and toenails regularly.
  • Use moisturizing creams and no-rinse or pH-neutral skin cleansers.
  • Use lukewarm water for bathing.
  • Avoid using adhesive products on frail skin. If dressings are needed, use paper tapes or nonadherent dressings.
  • Reinforce the importance of gentle care with all caregivers and family members. Fragile skin can sustain injury through improperly moving or repositioning a patient.
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ASSESSING AND MANAGING SKIN TEARS

When assessing and developing a skin tear treatment plan, nurses must address several issues, including nutritional support, pain management, local wound conditions, and dressing selection. Assessment and treatment should proceed as follows3, 12:

  • Examine the skin tear flap.
  • Control the bleeding.
  • Support the integrity of fragile skin surrounding the wound by providing gentle care, avoiding adhesive products, and moisturizing as needed.
  • Clean the wound with normal saline or wound cleanser.
  • Irrigate the wound, flushing out any clots, debris, or dead tissue.
  • Realign the skin flap over the wound, approximating the wound edges. Do not remove the flap unless it is necrotic.
  • Classify and document the tear as type 1, 2, or 3.
  • In accordance with institutional practice and protocol, administer tetanus immunoglobulin (TIG) to patients who have not been inoculated with tetanus toxoid within the past 10 years. TIG should be administered before wound debridement to prevent the potential release of exotoxin.16
  • Address the underlying reason the tear occurred (for example, cognitive, sensory, or visual impairment; nutritional deficiency; or polypharmacy), if known.
  • Implement and document a prevention protocol to protect patient from further trauma.
  • Promote healing, wound drainage, and patient comfort with an appropriate moist, nonadherent dressing.
  • Provide ongoing assessment for infection, discomfort, or pain at the wound site.
  • Manage any infection that develops.
Table 2

Table 2

Appropriate dressings. Numerous moisture-retentive dressings are available in various shapes and sizes. These include dressings made from mesh, silicone, foam, acrylic, hydrogel, calcium alginate, and hydrofiber (see Table 2 for a list of products).12 Prevention is the primary focus in skin tear management, but using the right nonadherent product can aid in the healing process and prevent further insult with dressing changes.

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REFERENCES

1. LeBlanc K, et al. Validation of a new classification system for skin tears Adv Skin Wound Care 2013 26 6 263–5
2. LeBlanc K, et al. Skin tears: state of the science: consensus statements for the prevention, prediction, assessment, and treatment of skin tears Adv Skin Wound Care 2011 24 9 Suppl 2–15
3. LeBlanc K, et al. International Skin Tear Advisory Panel: a tool kit to aid in the prevention, assessment, and treatment of skin tears using a simplified classification system Adv Skin Wound Care 2013 26 10 459–76
4. LeBlanc K, et al. Skin tears: best practices for care and prevention Nursing 2014 44 5 36–46
5. Carville K, Smith J A report on the effectiveness of comprehensive wound assessment and documentation in the community Primary Intention: The Australian Journal of Wound Management 2004 12 1 41–9
6. LeBlanc K, et al. Prevalence of skin tears in a long-term care facility J Wound Ostomy Continence Nurs 2013 40 6 580–4
7. Santamaria NM, et al. Woundswest: identifying the prevalence of wounds within western Australia's public health system EWMA Journal 2009 9 3 13–8
8. McErlean B, et al. Skin tear prevalence and management at one hospital Primary Intention: The Australian Journal of Wound Management 2004 12 2 83–8
9. Carville K, et al. The effectiveness of a twice-daily skin-moisturising regimen for reducing the incidence of skin tears Int Wound J 2014 11 4 446–53
10. Lewin GF, et al. Identification of risk factors associated with the development of skin tears in hospitalised older persons: a case-control study. Int Wound J 2015 Sep 24 [Epub ahead of print].
11. Newall N, et al. The development and testing of a skin tear risk assessment tool. Int Wound J 2015 Dec 22 [Epub ahead of print].
12. LeBlanc K, et al. The art of dressing selection: a consensus statement on skin tears and best practice Adv Skin Wound Care 2016 29 1 32–46
13. Payne RL, Martin ML The epidemiology and management of skin tears in older adults Ostomy Wound Manage 1990 26 26–37
14. Carville K, et al. STAR: a consensus for skin tear classification Primary Intention: The Australian Journal of Wound Management 2007 15 1 18–28
15. Quigley S Baranoski S, Ayello EA Pressure ulcers in neonatal and pediatric populations Wound care essentials: practice principles. 2016 4th ed. Philadelphia Lippincott Williams and Wilkins 528–42
16. Carden DL Tintinalli JE Tetanus Emergency medicine: a comprehensive study guide. 2004 6th ed. Irving, TX American College of Emergency Physicians 34–7

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Keywords:

skin tear; skin tear classification system; wound care

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