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Evidence-based skin tear protocol

June 1, 2008
by Judy Bolhuis, BS, NHA
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Don't neglect this important facet of wound care in your facility

A common experience:

Aresident's daughter comes to the front office wanting to see the administrator. She reports her mother has very fragile skin, cannot stand on her own, and requires total assistance for all transfers. The daughter claims the nursing assistants hit her mother's lower leg on the retracted bedrail when they put her to bed, causing a skin tear. She says the nurses usually just put steri-strips across the skin tears and drainage from the skin tear gets onto her mother's sheets and clothes. The daughter doesn't like to see the bruises from the skin tears and she is concerned because she feels her mother's skin tears occur frequently and take a long time to heal.

The nurses put “nonstick” gauze over the steri-stips to address the drainage concerns. Still the daughter questions the treatment. When the dressing is changed, the nonstick gauze adheres to the dried blood from the skin tear, which hurts her mother and sometimes causes another skin tear or reactive bleeding. She says she believes the nurses are not taking her mother's skin tears seriously and more needs to be done.

The daughter may be correct in saying that skin tears are not taken seriously in the nursing home setting. Long-term care regulatory requirements classify skin tears as accidents, which may contribute to the perception that skin tears are not “real” wounds, even though they're the most common wound type among the elderly. Reports show that more than 1.5 million skin tears occur each year in nursing homes.

Skin tears occur when the layers of the skin separate from one another, forming an open wound. Often caused by shear and/or friction against the skin, skin tears tend to be very painful and often become infected. Skin tears are common in the elderly because of thinning skin, flattened rete ridges, loss of natural skin lubrication, and increased capillary fragility. If a resident is on anticoagulants or corticosteroids, skin tears occur even more easily and take longer to heal. All clinical staff need training on the causes of skin tears to understand the necessary prevention strategies.

Facility wound care protocols often lack treatment guidelines for skin tears. When facilities have the benefit of a dedicated wound care nurse, it is generally not a part of the daily routine to treat skin tears; the treatment is done by the nurse at the bedside using what is available in the treatment cart.

Since skin tears are viewed as “accidents,” often facility administration may not even know the true extent of the skin tear presence in the facility, how they are actually managed, or how long they can take to close.

In addition to collecting data on skin tears in the facility, an evidence-based protocol will provide for both the prevention and treatment of skin tears. A protocol should be scientific enough to be accepted by physicians, but practical enough to be used by all members of the clinical care team.

When discussing a skin tear protocol with clinicians, the goal is to maximize healing while minimizing the complications and pain associated with them. Implementation of the protocol should also result in cost savings due to a smaller number of occurrences and lower treatment costs.

Developing a skin tear protocol

There should be four primary criteria in evaluating an appropriate treatment option for skin tears—the dressing should (1) continuously cleanse the wound to eliminate the need to cleanse during dressing changes, (2) fill and conform to the wound to maintain a healthy environment, (3) absorb exudate from the skin tear to increase wearing time, and (4) keep the wound bed moist and soothe the traumatized tissues to help reduce pain and provide comfort at the site of injury.

An ideal skin tear protocol goes beyond the specific treatment and addresses regulatory and in-servicing needs, facilitates the resident and family education offered by licensed staff, is evidence-based, and ensures outcomes consistent with the facility's quality of care standards.

Good facility communication about the process of evaluating and implementing an evidence-based skin tear protocol is very important. Prior to beginning to evaluate a skin tear protocol, staff should be trained in the primary preventive measures needed to reduce the opportunity for skin tears, which include improving skin health and reducing trauma. They should be educated on the steps that can be taken to minimize the potential for occurrence and to prevent recurrence, e.g., patting skin dry, applying moisturizing creams immediately after bathing, and correcting underlying dehydration and nutritional deficiencies.

An overview of the care planning steps to control recurrence of skin tears should include a review of the resident room and surrounding environment for safety hazards, as well as education of staff and family members related to lifting and turning techniques for nonambulatory residents. Care planning reviews for mobile residents should include the use of protective clothing and padding on wheelchairs and bedrails, as necessary, to prevent future injury. Also, facility requirements for documentation of skin tears should be reviewed with licensed personnel.

Protocol materials should include a review of the Payne-Martin Classification System, developed by R.L. Payne and M.L. Martin to identify the severity of a skin tear (figure); the classification code allows for a consistent description of the skin tear. This means that all clinical staff are communicating the assessment of the skin tear from the same frame of reference and no longer using subjective descriptions in their documentation.

Category I: Skin tears without tissue loss

A. Linear type