Download Skin Tears - Dermatuff

SKIN
TEARS
Staying on guard against the enemy of frail skin
Skin tears are a serious, painful problem for your older patients. Find out
how to recognize patients at risk, what you can do to prevent skin tears,
and how to manage them effectively if they occur.
By Sharon Baranoski, RN, APN, CWOCN, MSN
Administrative Director, Clinical Programs and Development and Administrator, Home Health
Silver Cross Hospital • Joliet, Ill.
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.
C
E
2.0
ANCC/AACN
CONTACT
HOURS
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.
14 Travel Nursing2003
www.nursingcenter.com
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 (fullthickness 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.
Largest organ
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
www.nursingcenter.com
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 epidermaldermal 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,
TravelNursing2003, October 15
Anatomy of the skin
The skin (also called the integument) is made up of two layers, the epidermis and the dermis. They’re separated by the
epidermal-dermal junction and supported by a layer of loose connective tissue, called subcutaneous tissue.
The epidermis (the outermost layer) can be as thick as 1 mm
on the palms of the hands and soles of the feet or as thin as 0.1
mm on the eyelids. This avascular layer is divided into five layers:
• The stratum corneum’s acid mantle helps prevent bacterial and
fungal growth and blocks water loss and injury.
• From one to five cells thick, the transparent stratum lucidum is
a transitional layer. It may be absent from thinner skin such as the
eyelids.
• Keratinization (movement of keratin-filled cells to the skin’s surface) occurs in the stratum granulosum.
• Also called the prickly layer or the spiny layer, the stratum spinosum is composed of polyhedral cells with intracellular bridges
that create a spiny appearance.
• Rete ridges are formed in the stratum germinativum. They
project downward to provide a sculpted surface for the epidermaldermal junction.
The dermis (the innermost
layer) is the thicker layer of
the skin, containing blood
and lymph vessels, elastic
and nerve fibers, hair
follicles, and sweat and
sebaceous glands. It’s
divided into the papillary
dermis and the reticular
dermis. The papillary dermis
forms rete ridges, which
project upward and contour
to the epidermis in the
epidermal-dermal junction.
The reticular dermis,
which forms the base of the
dermis, is composed of
the proteins collagen
(which provides strength)
and elastin (which gives
skin its recoil).
epidermis
epidermaldermal
junction
dermis
subcutaneous
tissue
Subcutaneous tissue, or hypodermis, attaches the dermis to underlying structures. This layer
includes adipose and connective tissue, blood vessels, and nerves.
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
www.nursingcenter.com
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.
TravelNursing2003, October 17
Classifying skin tears
The photos illustrate skin tears under the Payne-Martin Classification for Skin Tears.
Category I skin tear
This is a linear type skin tear.
Note areas of senile purpura.
• 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.
Management strategies
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, petroleumbased 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
18 Travel Nursing2003
Category I skin tear
This flap type skin tear has an
epidermal flap covering the
dermis to within 1 mm of the
wound margin.
Category II skin tear
Less than 25% of the
epidermal flap has been lost
in this scant tissue loss type
skin tear.
Category II skin tear
More than 25% of the
epidermal flap has been lost
in this moderate to large
tissue loss type skin tear.
Category III skin tear
The epidermal flap is absent
in this skin tear.
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.
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.
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.
Baranoski, S.: "Skin Tears: Guard Against this
Enemy of Frail Skin," Nursing Management. 32(8):
25-31, August 2001.
SELECTED REFERENCES
Baranoski, S.: "Skin Tears: The Enemy of Frail
Skin," Advances in Skin & Wound Care. 13(3, part
1):123-126, May/June 2000.
O’Regan, A.: "Skin Tears: A Review of the Literature," WCET Journal. 22(2):26-31, April/June 2002.
Machado, F.: "Mission: Skin Integrity," Remington
Report, (suppl):3-5, Nov/Dec 2001.
Meuleneire, F.: "The Management of Skin Tears,"
Nursing Times, 99(5):69-71, February 4-10, 2003.
Selden, S.T., Cowell, R.N.C., and Fenno, J.: "Skin
Tears: Recognizing and Treating this Growing
Problem," Extended Care Product News, p. 14-15.
May/June 2003.
CE Test
Skin tears: Staying on guard against the enemy of frail skin
Instructions:
• Read the article beginning on page 14.
• Take the test, recording your answers in the test answers
section (Section B) of the CE enrollment form. Each question
has only one correct answer.
• Complete registration information (Section A) and course
evaluation (Section C).
• Mail completed test with registration fee to: Lippincott
Williams & Wilkins, CE Dept., 16th Floor, 345 Hudson St.,
New York, NY 10014.
• Within 3 to 4 weeks after your CE enrollment form is
received, you will be notified of your test results.
• If you pass, you will receive a certificate of earned contact
hours and an answer key. If you fail, you have the option of
taking the test again at no additional cost.
• A passing score for this test is 12 correct answers.
• Need CE STAT? Visit http://www.nursingcenter.com for
immediate results, other CE activities, and your personalized
CE planner tool.
• No Internet access? Call 1-800-933-6525, ext. 331 or ext.
332, for other rush service options.
• Questions? Contact Lippincott Williams & Wilkins: 212886-1331 or 212-886-1332.
Provider Accreditation:
This Continuing Nursing Education (CNE) activity for 2.0 contact hours is
provided by Lippincott Williams & Wilkins, which is accredited as a
provider of continuing education in nursing by the American Nurses
Credentialing Center’s Commission on Accreditation and by the
American Association of Critical-Care Nurses (AACN 11696, CERP
Category A). This activity is also provider approved by the California
Board of Registered Nursing, Provider Number CEP 11749 for 2.0 contact hours. LWW is also an approved provider of CNE in Alabama, Florida,
and Iowa and holds the following provider numbers: AL #ABNP0114, FL
#FBN2454, IA #75. All of its home study activities are classified for Texas
nursing continuing education requirements as Type I.
Your certificate is valid in all states. This means that your certificate of
earned contact hours is valid no matter where you live.
Payment and Discounts:
• The registration fee for this test is $13.95.
• If you take two or more tests in any nursing journal published by
LWW and send in your CE enrollment forms together, you may deduct
$0.75 from the price of each test.
• We offer special discounts for as few as six tests and institutional bulk
discounts for multiple tests. Call 1-800-933-6525, ext. 332, for more
information.
Registration Deadline: October 2004
www.nursingcenter.com
TravelNursing2003, October 19
C E
2.0
ANCC/AACN CONTACT HOURS
Skin tears: Staying on guard against the enemy of frail skin
GENERAL PURPOSE To improve nursing practice and the quality of care by providing a learning opportunity that enhances a participant’s understanding of prevention, assessment, and intervention of skin tears. LEARNING OBJECTIVES After reading the preceding article and taking this test, you should be able to:
1. Identify the structure and function of normal skin anatomy and patterns of aging that increase the risk of skin tears. 2. Differentiate the assessment
criteria for the three skin tear categories. 3. Select effective nursing interventions for preventing and managing skin tears.
1. Skin tears usually involve the
a. extremities.
b. hypodermis.
c. subcutaneous fat.
d. bony prominences.
b. ambulatory.
c. sight-impaired.
d. those requiring total care.
7. Eighty percent of skin tears occur on the
a. back and buttocks.
b. face and legs.
c. arms and hands.
d. shins and feet.
2.The epidermis
a. is the thicker layer of the skin.
b. promotes ongoing blood supply to the
dermis.
c. regenerates every 4 to 6 weeks.
d. is divided into papillary and reticular layers.
14. Immediately after cleaning and drying a
skin tear, apply
a. a moist dressing.
b. stockinette
c. cream.
d. tape.
9. A flap type skin tear is
a. a linear skin tear.
b. a Category II skin tear.
c. a Category I skin tear.
d. a scant tissue loss skin tear.
4. Gradual epidermal thinning caused by aging
can be a primary cause of
a. a decrease in elasticity.
b. a pressure ulcer.
c. senile purpura.
d. shearing stress.
10.The epidermal flap is absent in
a. Category III skin tears.
b. scant tissue loss skin tears.
c. moderate to large tissue loss type skin tears.
d. Category II skin tears.
5.Which area of the body is at a great risk for
skin tears from site-specific subcutaneous
tissue atrophy?
a. back
b. hands
c. buttocks
d. bony prominences
11. A major way of preventing skin tears
includes
a. teaching caregivers safe position changes
and transfer techniques.
b. using friction.
c. allowing the patient’s arms and legs to
dangle.
d. using bed rails.
6. Patients at highest risk for skin tears are
a. independent.
ENROLLMENT FORM
13. Gently clean a skin tear with
a.. petrolatum ointment.
b. cream.
c. 0.9% sodium chloride solution.
d. lotion.
8. A Category II skin tear includes
a. no tissue loss.
b. partial tissue loss.
c. complete tissue loss.
d. absent epidermal flap.
3.The epidermis’s function is to
a. provide strength and support to the skin.
b. maintain skin integrity.
c. provide ongoing blood supply to the dermis.
d. attach the dermis to underlying structures.
✄
12.You can reduce the potential for skin tears
by using
a. bed rails.
b. wheelchair arms.
c. wheelchair leg supports.
d. pillows.
15.Which statement about dressing changes is
correct?
a. Change dressings according to manufacturer’s recommendations.
b. Change hydrogels weekly or as needed.
c. Change hydrocolloids daily.
d. Change foams daily.
16. Skin tear documentation should always
include
a. measurement.
b. thickness.
c. photography.
d. stage.
TravelNursing2003, October 2003, Skin tears: Staying on guard against the enemy of frail skin
✄
A. Registration Information:
❑ LPN ❑ RN ❑ CNS ❑ NP ❑ CRNA ❑ CNM ❑ other ___________________
Last name ____________________________ First name ________________________ MI _____
Job title __________________________________ Specialty _________________________________
Type of facility ____________________________________ Are you certified? ❑ Yes ❑ No
Address _______________________________________________________________________________
Certified by ___________________________________________________________________________
State of license (1) __________________________ License # ___________________________
City _______________________________________ State _________________ ZIP ______________
State of license (2) __________________________ License # ___________________________
Telephone ____________________ Fax ____________________ E-mail ____________________
Registration Deadline: October 2004
Contact hours: 2.0
Social Security # _____________________________________________________________________
❑ From time to time, we make our mailing list available to outside organizations to announce special offers.
Fee: $13.95
Please check here if you do not wish us to release your name and address.
B. Test Answers: Darken one circle for your answer to each question.
a
1.
2.
3.
4.
❍
❍
❍
❍
b
❍
❍
❍
❍
c
❍
❍
❍
❍
d
❍
❍
❍
❍
a
5.
6.
7.
8.
❍
❍
❍
❍
b
❍
❍
❍
❍
c
❍
❍
❍
❍
d
❍
❍
❍
❍
a
9.
10.
11.
12.
❍
❍
❍
❍
b
❍
❍
❍
❍
C. Course Evaluation*
1. Did this CE activity's learning objectives relate to its general purpose? ❑ Yes ❑ No
2. Was the journal home study format an effective way to present the material? ❑ Yes ❑ No
3. Was the content relevant to your nursing practice? ❑ Yes ❑ No
4. How long did it take you to complete this CE activity?___ hours___minutes
5. Suggestion for future topics __________________________________________________________
c
❍
❍
❍
❍
d
❍
❍
❍
❍
a
13.
14.
15.
16.
❍
❍
❍
❍
b
❍
❍
❍
❍
c
❍
❍
❍
❍
d
❍
❍
❍
❍
D. Two Easy Ways to Pay:
❑ Check or money order enclosed (Payable to Lippincott Williams & Wilkins)
❑ Charge my ❑ Mastercard ❑ Visa ❑ American Express
Card # _____________________________________________ Exp. date __________________
Signature _______________________________________________________________________
*In accordance with the Iowa Board of Nursing administrative rules governing grievances, a copy of your evaluation of the CE offering may be submitted directly to the Iowa Board of Nursing.