ARTHUR MITCHELL, 83, has been transferred from a rehabilitation facility, where he was recovering from a stroke, to your home health care agency for follow-up care. As you're reviewing the admitting paperwork, you notice that while he was at the facility, Mr. Mitchell had two skin tears, one on his right forearm and one on the dorsal aspect of his left hand. The tear on his hand hasn't healed, and it's covered by a transparent film dressing.
Monica Carson, 72, was admitted to your medical/surgical unit 3 days ago with an acute inflammation of her right lower leg. Her admitting diagnosis is cellulitis. Cultures reveal that she has a Staphylococcus aureus infection. She's been receiving oxacillin intravenously since admission, and now the physician has written an order to discontinue the I.V. drug. As you gently loosen the dressing covering the site, Ms. Carson moans. You look more closely and see that a small piece of her skin has been pulled off with the dressing.
Martha Ellis, 78, a resident at your long-term-care facility, has Alzheimer's disease, but had been doing well until about a week ago. Now her confusion has worsened and she's started wandering the halls at night. One morning, the nursing assistant informs you that Ms. Ellis has a sore on her right leg that she didn't have the day before. You assess the leg and discover that Ms. Ellis has a skin tear, probably from bumping into a piece of furniture the night before.
Mr. Mitchell, Ms. Carson, and Ms. Ellis represent a significant nursing challenge in caring for elderly patients: preventing skin tears. Put simply, a skin tear is a separation of the epidermis from the dermis. A classification system for skin tears developed in the late 1980s (which I'll discuss later) goes into more detail. It defines a skin tear as a traumatic wound occurring principally on older adults' extremities as a result of friction alone or shearing and friction forces that separate the epidermis from the dermis (partial-thickness wound) or that separate both the epidermis and the dermis from underlying structures (full-thickness wound).
No matter how it's defined, a skin tear is a painful but preventable injury. In this article, I'll help you meet the challenge skin tears present by providing insights on how the skin changes with age, offering tips for recognizing risk factors for skin tears, suggesting a way for you to identify and classify skin tears, and recommending strategies for prevention and management.
As you know, the skin is the largest organ of the body (see Anatomy of the Skin). It has eight primary functions:
* protection. Skin is a physical barrier against infection and excessive fluid loss.
* thermoregulation. Body temperature is regulated through vasoconstriction, vasodilation, and sweating.
* excretion. Certain products, electrolytes, and water are secreted through the skin, assisting in thermoregulation.
* storage. About 15% of the body's water is contained in the skin. The skin also acts as an important depository of body fat.
* metabolism. The skin synthesizes vitamin D on exposure to light, activating the metabolism of calcium and phosphate.
* absorption. The skin can absorb certain drugs and deliver them into the bloodstream (percutaneous drug delivery).
* sensation. Nerve endings in the skin let us feel pain, pressure, heat, and cold.
* body image. The skin plays cosmetic, identification, and communication roles.
The skin has two layers: the epidermis (the outermost layer) and the dermis (the innermost layer). They're separated by the epidermal-dermal junction, often referred to as the basement membrane zone. A layer of loose connective tissue, called subcutaneous tissue or hypodermis, lies underneath the dermis. Let's look at the function of these layers in more detail.
The epidermis is a thin, avascular layer that regenerates every 4 to 6 weeks. The primary function of the epidermis is protection: It's responsible for maintaining skin integrity against such physical insults as shearing, friction, and toxic irritants.
The dermis, the thicker layer of the skin, is divided into the papillary dermis and the reticular dermis. The dermis provides strength, support, blood, and oxygen to the skin.
The subcutaneous tissue or hypodermis attaches the dermis to underlying structures and promotes an ongoing blood supply to the dermis for regeneration.
Thinner and less elastic
As we age, the layers of our skin begin to change. The epidermis gradually thins, making the skin more vulnerable to mild mechanical trauma like shearing stress. This allows blister formation and skin tears.
The skin is more easily stretched because the amount of elastin fibers decreases with age. Like a worn rubber band, it doesn't snap back as quickly or have as much elasticity as it used to have.
The barrier function of the skin becomes less effective with age, leaving the skin more susceptible to water loss, bruising, and infection. Certain drugs and irritants could be more easily absorbed, possibly causing adverse or allergic reactions.
Thermoregulation is impaired, as are tactile sensitivity and pain perception. Blood vessels become thinner and more fragile, leading to the appearance of hemorrhaging known as senile purpura. You'll often find skin tears at sites of senile purpura.
Numerous age-related changes occur in the dermis. The most striking is the approximately 20% loss in dermal thickness, which may account for the paper-thin appearance of elderly skin. Losses in the dermal cells, blood vessels, nerve endings, and collagen lead to altered or reduced sensation and thermoregulation, rigidity, and moisture retention; skin sagging occurs as well.
The subcutaneous fat below the dermis provides protection and insulation. With losses in subcutaneous fat related to aging, parallel losses occur in these protective functions.
Subcutaneous tissue tends to undergo site-specific atrophy in the face, dorsal aspect of the hands, shins, and plantar aspects of the foot. These atrophied areas will absorb more energy when traumatized (such as striking the leg against a piece of furniture), resulting in a greater chance of an injury, such as a skin tear or bruise. At the same time, decreased pain perception may make elderly people even more vulnerable to trauma.
Who's at risk?
As you can see, age-related alterations in skin integrity challenge you to protect your patients' frail skin. Even the simplest movement, such as turning or lifting, can create friction and shearing forces that may injure the skin. An adhesive dressing that you intended to protect a patient's wound or intravenous line can tear her delicate skin when removed. Even ambulating or transferring a patient may present a problem if she inadvertently bumps into a chair, a table, or the bed.
In general, fragile skin, advanced age, use of assistive devices, cognitive/sensory impairment, and history of previous skin tears can put your patient at risk for a skin tear. Research has shown that dependent patients who require total care for all activities of daily living are at greatest risk. Their injuries tend to result from such routine activities as dressing, bathing, positioning, and transferring.
Even independent, ambulatory patients aren't without risk; they sustain the second-highest number of skin tears, primarily on the lower extremities. Many of these patients also have edema, purpura, or ecchymosis. Sight-impaired patients are in the third-highest risk category.
Nearly half of all skin tears have no apparent cause. The other half can be caused by wheelchair injuries, accidentally bumping into objects, transfers, falls, and tape injuries.
Although nearly 80% of skin tears occur on the arms and hands, other areas of the body also are at risk. Be careful about skin tears on the back and buttocks; they could be mistaken for Stage II pressure ulcers. The etiology of a pressure ulcer is different from the etiology of a skin tear. A pressure ulcer is any lesion caused by unrelieved pressure resulting in damage to underlying tissue.
Pressure ulcers are usually located over bony prominences and are staged to classify the degree of tissue damage. Pressure may be a related cause for a skin tear, but it's not the primary cause. Also, a patient with a pressure ulcer may need a special support surface and possibly debridement of the wound or surgical intervention to close it; these aren't necessary for a skin tear. And a pressure ulcer will take much longer to heal than a skin tear.
Classifying skin tears
Developed in the late 1980s, the Payne-Martin Classification for Skin Tears addresses assessment, prevention, and treatment of skin tears. Although relatively new and not well known, this classification tool can help you assess, document, and track patient outcomes.
The classification system is divided into three categories:
* Category I—skin tears without tissue loss. In a linear type Category I skin tear, the epidermis and dermis have been pulled apart, as if an incision had been made. In a flap type Category I skin tear, the epidermal flap completely covers the dermis to within 1 mm of the wound margin.
* Category II—skin tears with partial tissue loss. With a scant tissue loss type Category II skin tear, 25% or less of the epidermal flap is lost. When more than 25% of the epidermal flap is lost, the Category II skin tear is referred to as a moderate to large tissue loss type skin tear.
* Category III—skin tears with complete tissue loss. The epidermal flap is absent in this type of skin tear.
Although research to validate this tool is ongoing, it's being used in clinical practice. You may want to consider combining it with other risk assessment and documentation tools to round out your policies and procedures on skin and wound care.
An ounce of prevention
A commonsense protocol may be the best approach to preventing skin tears. If your patient is at risk, consider the following points:
* Use proper positioning, turning, lifting, and transferring techniques to prevent friction or shear. A lift sheet should be used to move and turn patients. If the patient is being cared for at home, make sure home health care assistants and her family caregivers understand these techniques.
* Make sure nursing assistants and home health care assistants know the importance of carefully handling elderly patients with frail skin. Any harsh movement or pulling can create a skin tear.
* Pad bed rails, wheelchair arm and leg supports, and any other equipment that may be used; this will protect the patient from accidentally bumping into a hard surface.
* Use pillows and blankets to protect and support arms and legs.
* Recommend that your patients wear long sleeves and pants to add a layer of protection.
* Use paper tape or a nonadherent dressing on frail skin and remove it gently. Or use stockinette, gauze wrap, or any other similar type of wrap instead of tape to secure dressings and drains.
* Apply a moisturizing agent to dry skin to keep it adequately hydrated. Creams are better than lotions.
* Provide a well-lit environment to minimize the risk of patients bumping into equipment or furniture.
If a patient develops a skin tear despite your efforts at instituting preventive measures, your goal is to help the injury heal with the least amount of trauma. Research has yet to show us the optimum treatment for skin tears, so most institutions develop their own protocol based on existing research. Many types of skin and wound care products can be used to promote a healing environment, including petrolatum ointment, nonadherent dressings, hydrogels, petroleum-based gauze and collagen dressings, transparent films and foams, hydrocolloids, and Steri-Strips.
The following interventions are suggested:
1. Gently clean the skin tear with 0.9% sodium chloride solution or a nontoxic wound cleaner.
2. Let the area air dry or pat carefully to dry.
3. Approximate the skin tear flap/tissue, if present, as closely as possible.
4. Provide appropriate topical wound care, such as a moist wound dressing. Remove any product with an adhesive backing with utmost care to avoid further trauma.
5. Secure nonadherent dressings with a gauze or tubular nonadhesive wrap.
6. Change dressings according to the manufacturer's recommendations. For example, hydrogels generally are changed every day; hydrocolloids, weekly or as needed; and foams, weekly or as needed.
7. Educate the patient and family (and staff, if necessary) on how to avoid skin tears in the future.
8. Make sure prevention strategies are initiated.
9. Document the type/category of the skin tear and your interventions. Skin tears generally aren't measured; they're noted as partial-thickness or full-thickness or by the categories I discussed earlier. If your institution's protocol allows it, consider photographing the skin tear for the patient's record.
On the mend
Skin tears are common in the elderly, with more than 1.5 million occurring each year in adults in health care facilities. Proper documentation is vital to understanding the extent of the problem: Skin tears should be documented as such and not grouped into pressure ulcer categories.
By knowing how to recognize patients at risk for skin tears, prevent skin injuries, and use dressings appropriately to help heal them, you can save your patient undue pain and suffering.