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Skin tears

Prevention and management

Langemo, Diane K., PhD, RN, FAAN; Williams, Ann, BSN, RN, BC, CWOCN; Edwards, Karen, MSS, BSN, RN, CWOCN

doi: 10.1097/01.NURSE.0000554309.45660.ca
Department: WOUND & SKIN CARE
Free

Diane K. Langemo is president of Langemo & Associates in Grand Forks, N.D., Ann Williams is a wound/ostomy coordinator at Inova Fair Oaks Hospital in Fairfax, Va., and Karen Edwards is an ostomy-continence nurse at UAB Hospital in Birmingham, Ala.

The authors have disclosed no financial relationships related to this article.

SKIN TEARS have historically been unrecognized by patients and caregivers in most circumstances, but they can become chronic and difficult to manage when left untreated.1,2 As the skin becomes drier, less elastic, and more vulnerable as one ages, skin tears become more common, particularly in older adults.1,2 This article reviews the prevalence, prevention, assessment, and management of skin tears with the goal of reducing misdiagnosis and promoting evidence-based management.

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Prevalence

Some experts consider skin tears to be more prevalent than pressure injuries.3,4 Despite this, literature on this acute skin wound was sparse until recent years. The International Skin Tear Advisory Panel (ISTAP) defines a skin tear as a wound caused by shear, friction, and/or blunt force resulting in separation of skin layers.1 A skin tear can be partial-thickness (separation of the epidermis from the dermis) or full-thickness (separation of both the epidermis and dermis from underlying structures). Skin tears can occur in any age group, including neonates. Long-term care prevalence has been reported at over 50% in the US, Canada, and Australia.3,5-7

Prevalence in the community is nearly 20% in Australia, Canada, and Latin America, and in acute care, prevalence has been over 20% in the US and Latin America.8,9 Prevalence in the palliative care setting is 30% and about 17% in the pediatric acute care setting in the US.10 In US patients with spinal cord injuries, prevalence is nearly 26%.11

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Risk assessment and prevention strategies

Skin tears occur far more frequently in patients who are either very young or very old. These patients tend to have thinner and more fragile skin, making them more vulnerable to skin tears from shear, friction, and/or blunt force.1,3,5 In addition, because sensation decreases with age, skin becomes more vulnerable to mechanical trauma.12 Along with older adults, critically and chronically ill patients are also at higher risk. Other risk factors include cognitive impairment, photoaging from the sun, aggressive behavior, and the need for assistance with activities of daily living (ADL). These factors can delay healing and need to be addressed in any plan for preventing and managing skin tears.12

Completing an assessment of your patient's risk for developing skin tears will guide your prevention measures.6,13 Just as each patient's risk for developing skin tears is unique, so is the individual prevention strategy for each patient. Preventing skin tears requires collaboration between nursing, physical therapy, occupational therapy, speech therapy, dietetics, primary care providers, pharmacy, and the patient and his or her significant others to provide a safe environment for the patient.

Establishing a risk reduction program for your facility will provide staff members the tools needed. These tools offer a clear and consistent evidence-based guideline to ensure that the plan of care for each patient includes all risk prevention strategies available.1

When assessing a patient's risk for skin tears, consider these issues.

  • Cognitive status. Patients who are cognitively impaired may not be able to comprehend or cooperate with their prevention program, which can increase their risk. A leading cause of skin tears is trauma during ADL.2 Staff must maintain a calm environment while providing care to prevent pulling or shearing of the skin. If a patient becomes agitated or combative, the caregiver may have difficulty applying such preventive garments as protective sleeves or shin guards. Agitation can also cause the patient to lash out, striking his or her hand, arm, legs, and feet on nearby objects. Caregivers can inadvertently cause skin tears on the extremities while trying to calm the combative patient.

Look for triggers that increase the patient's agitation and try to avoid them. Minimize noise and distractions when performing care, speak slowly and calmly, and repeat directions as needed. If the patient becomes upset or combative, move away until he or she calms down.1,2,4,5,7,13

  • Nutrition and hydration. Adequate nutrition and hydration are necessary to maintain healthy skin. Many older adults, even those whose body mass index is above normal, are malnourished and/or dehydrated.5,12 Diarrhea, vomiting, increased body temperature, and draining wounds require increased fluid intake.2 Calcium and vitamin D supplementation addresses nutritional deficits and reduces the risk of falls in older adults by improving bone strength, body sway, and muscle function.5

Occupational and speech therapy can help patients who have difficulty eating and drinking. The dietitian should be made aware of any food consistency requirements and prolonged illnesses that can impair the patient's nutrition and hydration status. If the patient's clinical status allows, offer at least 6 ounces of liquid with each medication administration and each meal.

  • Medications. Polypharmacy can lead to drug interactions, cognitive decline, unsteady gait, and cutaneous reactions. Corticosteroids are the most common medications that can affect skin integrity12,14 High-risk drugs such as antidepressants, dopaminergic drugs used to treat Parkinson disease, and antipsychotics can cause dizziness and confusion, leading to falls. Ensure that the patient's medication regimen is being monitored by the healthcare provider, nurse, or a pharmacist, and discuss any adverse reactions with the primary prescriber.1-3,6,7,14-16
  • Repositioning and transfers. Use lift sheets or patient lifts during transfers to reposition the patient in bed, and use proper techniques when transferring patients to a wheelchair, chair, or commode. When appropriate, use a lift system or sliding board. The physical therapist can provide individual patient guidelines for safe transfers.4,13,16
  • Fall risk. Falls can be caused by patient factors such as unsteady gait and urge incontinence; health disorders such as hypotension, stroke, arthritis, and Parkinson disease; or environmental factors such as poor lighting, slippery floors, loose rugs, clutter, shoes that do not fit properly, and showers or toilets without handrails.2 A comprehensive fall reduction program can address these factors and provide staff with best-practice guidelines. Padding the patient's arms and legs with long sleeves or trousers, knee-high socks, gloves, and skin/elbow pads, and maintaining an uncluttered environment can assist with skin protection.6 Be aware that patterned floors/rugs can be visually distracting and contribute to falls.
  • Risk for mechanical trauma. Mechanical trauma to the skin can be caused by dry skin, long and jagged fingernails and toenails, sharp edges of furniture, assistive mobility devices, and adhesives. Keep skin moist by applying a moisturizer after bathing while the skin is still damp. Because hot water can burn the skin and strip away protective oils, monitor bath water temperature. Keep nails trimmed and smooth. Pad the edges of furniture and mobility devices that have pieces that project outward. Avoid the use of adhesive products on the skin because they tend to strip fragile skin.1,4,13,14,16
Figure

Figure

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Data collection

Accurate assessment, description, and documentation of a skin tear are essential for appropriate treatment. Routinely assess for skin tears as part of the daily head-to-toe skin assessment. Differentiating skin tears from other types of skin injuries, such as gluteal cleft wounds, incontinence-associated dermatitis, and pressure injuries, can be challenging.4,6,17 The introduction of the Payne-Martin Skin Tear Classification System offered healthcare providers the first widely recognized system for classifying skin tears.18 ISTAP revised the classification system in 2013 and also developed the Skin Tear Decision Algorithm as a resource for assessment and treatment (see Skin tear decision algorithm and classification system).6,13,19 ISTAP also developed an assessment and treatment algorithm (see Pathway to assessment and treatment of skin tears).

Figure

Figure

Six components are important for data collection related to a skin tear: location on the body, type, cause, the environment in which the tear occurred, whether it occurred in a healthcare facility, and the presence of intrinsic and extrinsic factors. Intrinsic factors to consider include presence of edema; use of anticoagulants, steroids, or chemotherapy agents; urine and/or stool incontinence; senile purpura ecchymosis, hematoma; inability to reposition independently; and coexisting pressure injury. Senile purpura are nonpalpable, purple bruises with small red patches that fade to brown over a span of a few weeks. Found on the legs and forearm, they are caused by a loss of subcutaneous tissue with aging.20 Extrinsic factors include removal of tape or stockings, skin cleansers, prosthetic devices, blood draws, use of assistive devices, polypharmacy, transfers and/or falls, and inadequate nutrition.

Education is a key component in any skin tear prevention program. The patient, caregivers, and loved ones should be aware of the patient's risk factors and injury prevention strategies. Review the individualized prevention measures in all healthcare settings at least once per year and update as needed.17

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Managing a skin tear

Skin tears should be managed using a holistic, systematic approach.13 The goals of treatment include identifying and treating the underlying cause, implementing the appropriate prevention protocol, applying an appropriate dressing to initiate moist wound healing, avoiding further trauma, managing pain, protecting periwound tissue, managing exudate, and avoiding infection.

Control bleeding by applying gentle pressure with a dressing and elevating the extremity if appropriate. Cleanse the wound with a noncytotoxic solution such as 0.9% sodium chloride solution or potable water. Irrigate the wound with gentle pressure at or less than 8 pounds per square inch.13 Then, realign the skin flaps to the extent possible. For a Type 1 skin tear without skin loss, reposition the edges to cover the wound bed. For a Type 2 skin tear with a partial flap loss, reapproximate the wound edges. In a Type 3 skin tear with total flap loss and the wound bed entirely exposed, cover the entire area, preferably with a nonadhesive dressing.19

Select a dressing that will maintain wound bed moisture for healing without maceration, protect the periwound skin, control or manage exudate, prevent or manage infection, and optimize caregiver time.4 Sutures, staples, and adhesive strips are not recommended because they damage fragile skin.1 Apply a barrier or skin protectant product to protect periwound tissue.

Select a dressing that addresses the wound's specific characteristics. Dressing choices can include hydrogels, calcium alginates, hydrofibers, acrylics, foams, and nonadherent mesh.13,21 Soft silicone or low-contact foams are recommended as they prevent further skin damage and minimize pain during removal.13,19 Avoid films and hydrocolloids due to their adhesive properties. During dressing removal, use care and remove the dressing in the direction of the flap to maintain flap viability.22

The wound closure adhesive 2-octyl cyanoacrylate is another option. Applied once, it maintains a moist wound bed for healing and does not require removal.13

A topical antimicrobial agent can be used to manage infection.21,23 Tetanus immunoglobulin should be administered if the patient has not had it administered in the previous 10 years.24

For further guidance on the prevention, assessment, and management of skin tears, visit www.ISTAP.com.

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