Download Best Practices for Preventing and Managing Skin Tears

Best Practices for
Preventing
and
Managing Skin Tears
Clay E. Collins
BSN, RN, CWOCN, CFCN, CWS, DAPWCA, FACCWS
Objectives
Identify and Discuss normal skin anatomy
Understand the physiologic changes in the
skin associated with aging
Discuss the Risk Factors associated with
skin tears
Discuss Assessment and Prevention
strategies
Understand treatment of skin tears based
on Assessment findings
Statistics
In 2000, 420 million people, 7% of world population,
were 65 and older.
According to the 2000 US census, 1 in 8 people are over
the age of 65
11 fold increase since 1900
July, 2003, 35.9 million in the US (12% of the population)
were 65 and older. Of these 4.7 million were 85 and
older
By 2030, 1 in 5 Americans is expected to be 65 years or
older
Projections indicate that by 2030 the number of elderly in
the world will rise more than 70%
Skin Tears
What is a Skin Tear?
Skin Tear Definition – The inadvertent removal of the
epidermis with or without the dermis by mechanical
means.
Trauma such as tape removal or blunt trauma such as
bumping into furniture can lead to skin tears.
Primarily on the extremities (80% on arms)
Result of friction alone or shearing and friction
Separates the epidermis from the dermis = Partial
thickness wound
Separates both the epidermis and the dermis from the
underlying skin = Full thickness wound
Skin Tears
Skin tears are a major problem affecting
the elderly and compromised individuals
Estimated 1.5 million skin tears occur in
institutionalized elderly each year
Prevalence rates 14 -24%
Painful
May lead to infection
Increase caregiver time and facility costs
The Skin
Dynamic, Regenerating organ
Comprises 15% of the total body weight
The body’s primary defense mechanism
Skin Anatomy and Physiology
3 Functional and
Anatomical Layers
Epidermis - outermost layer
comprised of five separate strata
Dermis – Thicker layer that
houses the hair follicles, sweat
glands, and nerves
Hypodermis/Subcutaneous
Tissue – fatty layer beneath
the skin that provides cushioning
and protection
Epidermis
Outermost layer
5 layers of stratified
epithelium
Under age 60
Over age 60
No blood vessels
nourishment and oxygen
originates from capillaries
in the dermis
Up to 7 mm thick
Merck Manual,2006
Skin Anatomy and Physiology
Dermal-Epidermal Junction
(Basement Membrane)
Provides structural support
Exchange of fluid and cells between
skin layers
Rete ridges/pegs - Epidermal
downward, finger-like projections
Dermal Papillae – upward
projections
Fit together like “tongue and
groove” wood to anchor the
epidermis to the dermis
Skin Anatomy - Epidermis
5 Sublayers of Epidermis:
1. Stratum Corneum – outermost layer, also called the
“horny layer”. Composed of dead keratinocytes. This
layer is constantly being sloughed off and
replenished from below
2. Stratum Lucidum – present in areas where skin is
thick (i.e. soles of feet) and absent where skin is thin
(i.e. eyelids, tympanic membrane)
3. Stratum Granulosum – only 1-5 cells thick
4. Stratum Spinosum – also called the “prickly layer”
5. Stratum Germinativum – single layer of cells that are
dividing and reproducing and migrate outward.
Skin Anatomy - Epidermis
Stratum Corneum
Stratum Lucidum
Stratum Granulosum
Stratum Spinosum
Stratum Germinativum
Basement Membrane
Stratum Corneum
Dead cells held together
by lipids (creates
waterproofing)
“Brick and mortar” of skin
A healthy stratum
corneum provides the best
line of defense against
invasion
Skin Anatomy - Epidermis
Absence of Blood Vessels
The cells that are alive get their nutrients via
osmosis and diffusion from the capillary
loops in the underlying dermis
Immune System –
Langerhans cells migrate from bone marrow
and reside in the epidermis.
Epidermal turnover rate – 28 days
Major function is PROTECTION
Dermis
Mesh of collagen and
elastin fibers
provide bulk, strength,
support, elasticity
Sweat and sebaceous
glands
Hair follicles
Rich in nerve and blood
supply
Hill MJ, 2003
Skin Anatomy - Dermis
Dermis – the inner layer of the skin
The thickest layer of the skin
0.3mm on the eyelids to 3.0mm on the back
Dermal papillae interlock with the epidermal rete
ridges and contain capillary loops that supply
oxygen and nutrients to the overlying epidermis.
Contains vascular plexus, lymphatics, and collagen
Nerve endings penetrate into the epidermis
Abnormal nerve function affects the skin because the lack
of nerve stimulation slows keratinocyte mitosis and
produces a shiny, atrophic skin (i.e. SCI)
Skin Anatomy - Dermis
Epidermal Appendages
Subcutaneous Tissue
Layer of fat
Providing cushioning,
insulation, and support
for other tissue
Nutritional storage
Vascular supply
Skin Anatomy Subcutaneous Tissue
Hypodermis
Contains adipose tissue, connective tissue,
blood vessels, lymphatics, and nerve
endings
Adipose tissue provides protection from
pressure and padding against shear forces
The pt with inadequate subcutaneous
tissue is at High Risk for deep tissue
damage caused by shear force and
pressure, especially if allowed to slide
Age Associated Changes
Elderly Skin
Prolonged epidermal turnover time
Collagen bundles shrink and cause wrinkling
Rete ridges and Rete pegs flatten causing
decreased cohesion of the layers which
leads to increased risk for skin tears and
epidermal stripping
Reduced activity of sebaceous and sweat
glands leads to dry skin
Age Associated Changes
Erratic loss of melanin production leads to
gray hair and age spots
Decreased sensory receptors = Increased
risk of trauma/burns (pt less likely to
recognize impending breakdown related to
friction, pressure, etc…)
Loss of Subcutaneous tissue = Increased risk
of shear/pressure injury and reduced thermal
insulation
Age Associated Changes
Decreased Immunocompetence of the skin =
increased risk of skin cancer, fungal
infections, other infections (Fx of Langerhans
cells are decreased by up to 50%)
Reduced blood flow to the skin = delayed
wound healing
Age Associated Changes
Reduced cellular competence/increased
senescence = cells are less able to carry out
activities essential to repair = increased risk
that wound will not heal
Increased capillary fragility = capillaries will
burst with light pressure causing purpura and
bruising
Problems Associated with Chronologically Aged Skin
Decrease Strength
Susceptibility to blister formation
Increased bruising
Skin Tears
Nail fragility and ridges
More severe blistering response
Purpura
Disruption of skin from friction and shear
Skin laxity
Increased wound dehiscence and infection
Increased formation of ulcers due to trauma and
pressure
Senescence
Slow cell turnover with slow and incomplete skin and
wound healing
Lack of response to growth factors
Abnormal DNA with cellular atypia and cancerous
neoplasms
Abnormal cell growth with development of non-cancerous
neoplasms
Incomplete repair to cellular damage like UV light,
oxidative stress
Lack of normal apoptosis
Osteomalacia and Osteoporosis due to Vitamin D
deficiency
Impaired Skin Barrier
Increased risk for irritant contact dermatitis
Dryness
Pruritis
Scaling, Fissuring, Cracking
Increased injury from tape stripping
Increased absorption of chemical/drugs through the
skin
Increase in transepidermal water loss
Maceration of skin occurs more easily
Tendency towards dermatitis due to dry skin irritation
Skin Appendage and Vascular Problems
Graying of hair and thinning
Sebaceous hyperplasia and decrease in sebum
Lack of thermoregulation from reduced sweating
Reduced capillary perfusion with difficulty in
thermoregulation and vascular reserve
Decrease in Skin Protective Function
More susceptible to sun damage due to melanocyte
problems
Irregular pigmentation
Dermal capillary skin flow dysregulation and decreased
dermal clearance
Less aware of pending skin damage from decrease in
nerve function and density
Reduced skin lymphatic activity
Increase in contact dermatitis and reaction to topical
Ostomy/Wound Management 2006;52(9):24-35
irritants
Altered Immunity
Cancers
Increase in Bacterial, Viral, and Fungal Skin and Deep
Tissue infection
T-Cell Lymphomas
Risk for Autoimmune problems
Assessment and Prevention
Studies show that once a skin tear –
related problem is identified ,
implementation of a prevention program
aimed at identifying at-risk individuals and
measures to protect the skin from injury
will reduce the rate of skin tears
Risk Factors
Advanced Age (>85 yrs)
Female
Caucasian
History of previous skin
tears
Compromised nutrition
Dehydration
Dry Skin
Cognitive Impairment
Altered Sensory Status
Immobility (bed or chair
bound)
Vision Impaired
Use of Assistive Devices
ADL Dependence
Total Care
Resists Care
Ecchymotic or bruised skin
(Senile Purpura)
40% of skin tears
associated with senile
purpura
Senile Purpura often
causes a decrease in
pain perception
Long Term Corticosteroid
use
Risk Factors
50% of all skin tears are of unknown origin
Skin Tears of known causes:
25% result from Wheelchair/Geri-chair injuries
25% from accidents involving bumping into
objects
18-24% occur due to transfers and falls
Skin Assessment
All patients at risk for skin tears should have their skin
assessed regularly. Good Lighting is needed. A good
time is during bathing.
Assess Skin for:
Dryness
Ecchymosis (bruising)
Edema
Erythema
Pruritis (itching)
Pain
Assess extremities for:
Color
Warmth
Edema
Ulcerations
Assess Environment
Assess clothing for:
Tightness
Rubbing
Prevention Strategies
Staff education
Identify patients at risk
Recognize that aged skin is impaired
Recognize fragile, thin, vulnerable skin,
especially when associated with ecchymotic
skin (senile purpura)
Prevention Strategies
Use care when providing full or partial
assistance with ADL’s since these tasks
increase contact with the skin thus increasing
potential for the skin to tear
Use of appropriate equipment (i.e. lifts, walkers,
transfer and turning aides, etc..) to assist with
toileting and transferring
Prevention Strategies
Keep pt well hydrated
Nutritional Support
Implement measures to protect skin from injury
such as:
Skin sleeves
Padded side rails
Gentle skin cleansers
Skin moisturizers
Prevention Strategies
Skin Cleansing
Measures to Keep Skin Healthy
Utilize pH balance cleansers and avoid
alkaline soaps
Alkaline products remove skin lipids which
increases water loss and compromises the
barrier function of the skin
Use non-alkaline soaps for patients with dry
skin
Cleanse
Goals of Skin Care Program
Bathe qd or less
Soap & water?
Use pH balanced, lipid-based
cleansing lotions
Use tepid, not hot water
Bathing systems & shampoo
cap
Incontinence cleansing
Immediately and after each
episode
32
Moisturize
Skin normally transpires
moisture (1 liter per day)
often leading to
excessively dry skin
Products should prevent
e-TEWL (excessive
transepidermal water
loss)
Dimethicone/silicones
prevents e-TEWL
Prevention Strategies
Skin Moisturizers
The most important factor for healthy skin is adequate
moisture
Emollients moisten and lubricate the skin
Lotions are suspensions of oily chemicals in alcohol and
water and contain two major ingredients:
Humectants such as glycerin that draw moisture into the skin’s
surface
Barrier ingredients that trap moisture in the skin
Prevention Strategies
Skin Moisturizers
Emollients (Natural Oils – sunflower, safflower,
olive and canola oils)
Emollients penetrate into the stratum corneum to
increase the lipid component and add softness plus
they leave an oily film on the epidermis to retard
water loss and help to rehydrate the stratum
corneum
Moisture Barriers (Dimethicone and other
silicones)
Help to retard water loss and to retain lipids and
water within skin cells
Prevention Strategies
Skin Moisturizers
Humectants ( Glycerin, urea, propylene
glycol)
These act as “water attractants” – they pull water
from environment
They increase the water component of the
stratum corneum
Protect and Nourish
Ideally, products should be breathable
and not occlude the pores
Improve skin integrity with nutrients,
amino acids, vitamins, antioxidants
Protect and Nourish
Primary barriers
Sealants
Ointments
Creams
Protect
Second generation
barriers
Remains in contact with
skin, is not absorbed
Allows for healing even
with repeated chemical
assault
May contain zinc oxide,
starch powders,
dimethicone, and other
silicones
Decreasing the Incidence of Skin
Tears…
An Evaluation of Costs and Effects of a Nutrient-Based Skin Care Program as a Component of Prevention of
Skin Tears in an Extended Convalescent Center. Marge Groom, BSN, MSHCA, RN, CWOCN, Ronald E.
Shannon, MPH, Debashish Chakravarthy, PhD, Cynthia Fleck, BSN, RN, CWS
Decreasing the Incidence of Skin
Tears…
Switched to Nutrient-Based skin care regimen
Education included staff, resident and family
One LTC facility
100 residents
Decrease from 180 to 2 skin tears
Skin Tear Study
Treatment
Nutrient-Based
Skin Care
PetrolatumBased Skin Care
6-Month
Labor and
Supply Cost
of Wound
Treatment
2
Average
Labor and
Supply Cost
of Skin Tears
(2-week
treatment)
$21.96
180
$21.96
$3,866.40
Difference
$3,822.48
Number of
Skin Tears
$43.92
Skin Tear Study
Conclusion
The analysis proved fiscally responsible
Decreased the number of skin tears
Provided comfort to the residents
Empowered staff
Prevention Strategies
Skin tears resulting from adhesives:
Appropriate application and removal of tape
Stabilize skin while peeling tape away slowly
Skin prep/liquid barriers
Solvents (adhesive remover) – may dry skin
Use of solid wafer skin barriers, thin
hydrocolloids, low adhesion foam dressings,
or skin sealants under dressings
Use of porous tapes
Avoidance of unnecessary tape use
Prevention Strategies
Protection of ecchymotic skin:
Keep arms and legs covered with rolled gauze
Long sleeves and pants
Transparent dressings*
Thin hydrocolloids*
Low-adhesion foam dressings
*Anytime adhesive dressings are used on intact
skin to prevent skin tears, the dressing should
not be changed routinely but should be left
undisturbed and allowed to fall off.
Skin Tear Classification
Payne-Martin Classification System
Most commonly used instrument to classify or
describe skin tears
Based on level or amount of tissue loss
Payne-Martin Classification
System
Category I: Skin Tear can fully approximate wound
Linear Skin Tear - Full thickness wound that occurs in wrinkle or
furrow of skin. Both epidermis and dermis are pulled apart as if
an incision has been made, exposing tissue below.
Flap-type skin tear – Partial thickness wound in which the
epidermal flap can be completely approximated or approximated
so that no more than 1mm of dermis is exposed
Category II: Skin Tear with partial thickness loss
Scant Tissue Loss – Partial Thickness wound in which 25% or
less of the epidermal flap is lost and as least 75% of underlying
dermis is covered by flap.
Moderate to Large tissue loss – More that 25% of the epidermal
flap is lost and more than 25% of the dermis is exposed
Category III: Skin Tear with complete tissue loss
A Partial Thickness wound in which an epidermal flap is absent
Payne-Martin Classification
System
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.
Payne-Martin Classification
System
Category I
This is a linear
type skin tear.
Note areas of
senile purpura
Payne-Martin Classification
System
Category I
This flap type skin
tear has an
epidermal flap
covering the
dermis to within 1
mm of the wound
margin.
Payne-Martin Classification
System
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.
Payne-Martin Classification
System
Category II
Less than 25% of
the epidermal flap
has been lost in
this scant tissue
loss type skin tear
Payne-Martin Classification
System
Category II
More than 25% of
the epidermal flap
has been lost in
this moderate to
large tissue loss
type skin tear.
Payne-Martin Classification
System
Category III--skin
tears with
complete tissue
loss. The
epidermal flap is
absent in this type
of skin tear.
Payne-Martin Classification
System
Category III
The epidermal
flap is absent in
this skin tear
Treatment of Skin Tears
Skin Tear treatment should be based on:
Fragility of the person’s skin
Need to protect surrounding skin
Utilization of moist healing principles
Extent of tissue injury
Treatment of Skin Tears
Traditional dressings:
Transparent Films
Do not handle fluid well
Pooling and leaking of fluid onto surrounding skin
Adhesive - can cause epidermal stripping or tearing of the
skin upon removal
“Non-adherent” pads with topical antibiotics
Adhere to skin and wound and can cause damage with
removal
Do not provide an optimal moist environment for healing
Require more frequent changes
More costly and labor intensive
Treatment of Skin Tears
Experts generally discourage use of transparent
and hydrocolloid dressings because their
removal can cause more skin damage and pain
Alternatives include:
Hydrogel sheet dressings (DermaGel, Elasto Gel)
Petroleum based dressings (Xeroform, Vaseline
Gauze)
Non-adherent gauze (Adaptic, Oil emulsion
dressings, Mepitel, etc..)
Non-adherent Foam dressing
Zinc Oxide
Sample Skin Tear Protocol
Treatment of Skin Tears
Gently cleanse with Normal Saline or Wound cleanser
*Remove blood from underside of flap before re-positioning over the
wound bed
Using a Cotton tipped applicator, Gently roll skin flap into place,
unrolling edges so as to cover as much of exposed wound bed as
possible.
*Important to replace all viable skin as this is the best dressing
available and will protect the wound while new skin grows
Secure edges with Steri-strips – (Caution: traction on periwound skin
can cause further damage)
Cover with Hydrogel sheet Dressing (DermaGel)
Secure with roll gauze and Self Adherent bandage (Co-Flex) or
tubular wraps (Medigrip) or net stockings
Avoid taping directly on skin
Place an arrow on dressing to indicate the direction of the skin tear
Change dressing q 3-5 days depending on amount of drainage
Treatment of Skin Tears
Minimize dressing changes to decrease risk of
trauma to wound
Most dressings can be left in place for up to 5
days
Treatment of Skin Tears
Important to choose dressings that allow
you to:
Avoid adhesives
Decrease dressing changes
Maintain an optimally moist wound healing
environment
Treatment of Skin Tears
No tissue loss and minimal exudate: (q 3-5 days)
Cyanoacrylate Liquid Skin Protectant
Hydrogel Sheet Dressing + Wrap/Elastic Tubular
Gauze
Petroleum based gauze + Wrap Gauze
Non-adherent gauze (Adaptic, Oil emulsion
dressings, Mepitel, etc..) + Wrap Gauze
Zinc Oxide + wrap gauze
Cyanoacrylates
Hydrogel Sheet Dressings
Treatment of Skin Tears
Tissue Loss and moderate amount of exudate
(q 1-5 days)
Hydrogel Sheet Dressing + Wrap/Elastic tubular
gauze
Non-Adhesive Foam Dressings + Wrap/Elastic
tubular gauze
Polyacrylate Dressing + Wrap/Elastic tubular
gauze (q 24 hours)
Documentation
Skin tears are typically noted by thickness
(Partial Thickness or Full Thickness) or by
Category
Document:
CATEGORY or TYPE of the skin tear
wound care treatment interventions
measures implemented to prevent further
skin tears
Conclusion
Skin Tears are common in the elderly with more than 1.5
million each year in adults in health care facilities
Age related skin changes increase the risk of skin tears
in the elderly
Identifying those at risk for skin tears and implementing
prevention strategies can reduce the incidence of skin
tears
Studies indicate that the majority of skin tears will heal in
7 to 21 days depending on the severity of the skin tear
Skin tear treatment should be based on the fragility of
the person’s skin, the need to protect the surrounding
skin and utilization of non-adherent dressings
References
Ayello EA. Preventing pressure ulcers and skin tears. In: Mezey M, Fulmer T, Abraham I,
Zwicker DA, editor(s). Geriatric nursing protocols for best practice. 2nd ed. New York (NY):
Springer Publishing Company, Inc.; 2003. p.165-84. National Guideline Clearinghouse.
www.guideline.gov.
Bank D, Nix D. Preventing Skin Tears in a Nursing and Rehabilitation Center: An
Interdisciplinary Effort. OWM. 2006; 52(9):38-46. Baranoski S. Skin Tears: Staying on
Guard against the enemy of frail skin. Nursing2000. 2000; September.
Bryant R, Clark R A. Skin Pathology and Types of Damage. Acute and Chronic Wounds:
Current Management Concepts. 3rd edition. Mosby. 2007.
Fleck CA. Preventing and Treating Skin Tears. Advances in Skin & Wound Care.
2007;20(6):315-321.
Flemister B. A Compendium of case studies on the management of a variety of chronic
wounds utilizing a breakthrough in interactive wet therapy. Presented at the 15th Annual
Clinical Symposium on Advances in Skin & Wound Care. Nashville, TN. 2000.
Fore J. A Review of Skin and the Effects of Aging on Skin Structure and Function. OWM.
2006; 52(9):24-35.
Jones JL. Understanding Skin Tears: the “Whys” and “Hows”. ECPN. 2007; Jan/Feb.
Milne CT and Corbett LQ. A New Option in the Treatment of Skin Tears for the
Institutionalized Resident: Formulated2-Octylcyanoacrylate Topical Bandage. Geriatric
Nursing. 2005;26(5):321-325.
Payne RL and Martin ML. Defining and classification skin tears: need for a common
language. OWM 1993;39(5)16-26.
Ratliff CR, Fletcher KR. Skin Tears: A Review of the Evidence to Support Prevention and
Treatment. Ostomy Wound Management. 2007; 53(3):32-42.
Roberts M. Preventing and Managing Skin Tears. JWOCN 2007;34(3):256-259.
Thank You
Questions?
Clay E. Collins
BSN, RN, CWOCN, CFCN, CWS, DAPWCA, FACCWS