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Words on Wounds

A forum to discuss the latest news and ideas in skin and wound care.

Monday, April 15, 2019

Wound CSI
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Matt is a 62-year-old male with a history of musculoskeletal degenerative disease. Recently, he was treated with antibiotics for a urinary tract infection and developed diarrhea

Upon assessment, his skin in the coccyx area is extremely fragile because of exposure to moisture from incontinence and accumulated heat secondary to immobility. The skin is irritated and inflamed from chemical irritants in the fecal matter and mechanical trauma from frequent cleansing. Small, discrete skin tears, attributable to frictional force from the washcloth, are apparent in the injured area, evidenced by partial skin loss. Over the next week, the area continues to deteriorate and acquires a dark, purplish appearance with evidence of tissue necrosis and deep tissue injury. 

His care team knows that in combination, excess moisture and increased heat and subsequent metabolic demand of the skin create a favorable microclimate for skin breakdown, so several interventions are implemented. Matt's standard hospital mattress is replaced with a low air loss mattress, and he is frequently turned to provide pressure redistribution and minimize shearing

It is a clinical challenge for healthcare professionals to identify and classify skin tears when they occur in areas of the body where pressure injuries also typically occur, such as over bony prominences. Skin tears and superficial stage 2 pressure injuries may be precipitated by similar risk factors. According to the updated definition proposed by the International Skin Tear Advisory Panel in 2018, a "skin tear is a traumatic wound caused by mechanical forces, including removal of adhesives. Severity may vary by depth (not extending through the subcutaneous layer).” 

Proper description of the skin lesion is important for care planning to address primary causative factors. However, as illustrated in this case, skin tears can rapidly evolve into pressure-related tissue injury because to skin fragility including skin atrophy, loss of elastin, and weakening of the epidermal junction.
Bundled approaches to care allow healthcare professionals to prevent and manage wound etiologies (pressure injuries, moisture-associated injuries, and skin tears) with one prevention program. This can potentially save money and time, but more importantly, also enhances patient comfort. The prevention and management of skin tears in frail older adults is available and can be accessed online here.