Skin tears

At a glance…

Long-term care providers must ensure that their skin tear procedures and practices reflect the current literature and clinical practice guideline recommendations. This article outlines the latest clinical information.

In the United States alone there are more than 1.5 million skin tears per year in institutionalized adults.

1 Eighty percent occur on the arms and hands. Over the past 20 years, clinicians, researchers, and regulators have focused their attention on the problem of skin tears, especially in older adults. The result is a better understanding of the problem with excellent demographic data and understandings of underlying etiologies. Long-term care providers must ensure that their skin tear procedures and practices reflect the current literature and clinical practice guideline recommendations.

Classification, risk assessment, demographics, etiologies

In 1993, Payne and Martin published their definitive work on skin tears, formally defining “skin tears” and introducing a three-category system that remains the gold standard today.2 In 1994, White, Karam, and Cowell introduced a Skin Tear Risk Assessment Tool.3 Following two decades of research it is now clearly recognized that skin tears in the elderly occur due, in part, to physiologic changes in the skin as we age and to certain medications that thin the skin (e.g., corticosteroids). Research shows that the major causative etiologies for skin tears are:

• Wheelchair injuries 25%

• Bumping into objects 25%

• Transfers 18%

• Falls 12.4%4

Skin tears are often associated with falls and fall events5 and with low-quality lotions and bathing products (lotions and soaps).6,7,8,9 This is where good prevention and treatment strategies come into play.

Clinical practice guidelines

To help direct clinical practice, a number of tools and clinical practice guidelines for skin tears have been developed in recent years. In 2004, the Patient Safety Authority of the Commonwealth of Pennsylvania began a statewide skin tear initiative. Their data and skin tear toolkit can be downloaded from the Patient Safety Authority of the Commonwealth of Pennsylvania Web site at https://www.patientsafetyauthority.org.5

Many of the clinical practice guidelines that have been developed can be downloaded from the Internet via search engines. These documents can help you update your facility’s skin tear procedures and practices (see sidebar, pg. 32).

Prevention strategies

Identify individuals at high-risk for skin tears. Just as pressure ulcer risk assessment may reduce the prevalence of pressure ulcers, identifying those individuals at high risk for skin tears and instituting prevention strategies may reduce the risk of skin tears. One skin tear risk assessment tool has been published.

3 Many facilities use their own admission skin assessment forms for this purpose. Once a high-risk resident is identified, an individualized skin tear prevention plan of care should be developed, implemented, and documented.

Maintain a safe environment. Tactics include preventing falls and bumps, providing good lighting, ensuring an uncluttered environment, and upholstering or covering sharp edges of furniture. Educating patients, caregivers, and staff on preventive strategies and transfer techniques is critical.

Prevention strategies

• Identify individuals at high-risk for skin tears

• Maintain a safe environment

• Use soaps and lotions with emollients

• Use protective clothing and devices

Use soaps and lotions with emollients. Use of moisturizers or emollients on a daily basis reduces skin tear risk, lowers the incidence of skin tears, and is cost-effective. Avoid the use of aggressive adhesives-such as tapes and certain dressings. Thousands of dollars can be saved annually per facility.9

Use protective clothing and devices. Long-sleeved shirts, stockings, and clothing modifications are effective strategies for preventing skin tears. Skin sleeves and leg protectors are useful preventive devices, especially for individuals who experience recurring skin tears.

Treatment strategies

The goals of skin tear treatment include stopping bleeding, recovering skin integrity, preventing infection, minimizing pain, and promoting comfort.10,11

A variety of primary dressings are available, in both plain and silver formats, that promote healing and reduce pain including alginates, amorphous hydrogels, foams, hydrofibers, sheet hydrogels, silicone net dressings (contact layers), and silicone-coated foams. Secondary dressing options for skin tears include gauze, roll gauze, transparent film, dressing retention sheet, and abdominal pad.

Outdated options include transparent films (as primary dressings; okay as secondary dressings), Telfa-type nonadherent dressings, sutures, and removal of a viable flap immediately post-injury.

Conclusion

Check your facility skin tear procedures and practices to make sure that they reflect the current literature and clinical practice guideline recommendations. Never has the old adage been more true: An ounce of prevention is worth a pound of cure.

Additional Clinical Practice Guidelines Resources

• Nursing Standard of Practice Protocol: Pressure Ulcer Prevention & Skin Tear Prevention. Ayello EA, Sibbald RG. January 2008. Hartford Institute for Geriatric Nursing. Available at: https://hartfordign.org

• Preventing Pressure Ulcers & Skin Tears. In evidence-based geriatric nursing protocols for best practice. Capezuti et al, Springer, 2008. National Guideline Clearinghouse. Available at: https://www.guideline.gov

• Best Practice Recommendations for the Prevention and Treatment of Skin Tears. Leblanc et al. Wound Care Canada 2008;6(1):14-30. Available at: https://www.cawc.net/index.php/professional/resources

• Exploring best practices in the management of skin tears in older people. 23 April 2009. Nursing Times, UK. Available at: https://www.nursingtimes.net

• Focus on Five. Joint Commission. September 2007.

Diane Krasner PhD, RN, CWCN, CWS, MAPWCA, FAAN, is the WOCN/Special Projects Nurse at Rest Haven-York, a 159-bed long-term care facility in York, Pennsylvania. She is a wound and skin care consultant and serves as an expert witness in medical malpractice cases involving wound and skin care. Dr. Krasner is the lead co-editor of Chronic Wound Care: A Clinical Source Book for Healthcare Professionals, 4th edition (

https://www.chronicwoundcarebook.com) and the clinical editor of WoundSource (

https://www.woundsource.com).

To send your comments to the editor, please e-mail mhrehocik@iadvanceseniorcare.com.

References

1. Malone ML, et al. The epidemiology of skin tears in the institutionalized elderly. Journal of the American Geriatric Society 1991; 39:591-5.
2. Payne RL, Martin ML. Defining and classifying skin tears: Need for a common language. Ostomy Wound Management 1993; 39 (5): 16-20, 22-4, 26.
3. White MW, Karam S, Cowell B. Skin tears in frail elders: A practical approach to prevention. Geriatric Nursing 1994; 15 (2): 95-9.
4. Brillhart B. Preventive skin care for older adults. Geriatrics & Aging 2006; 9 (5): 334-9.
5. Patient Safety Authority. Commonwealth of Pennsylvania. Skin Tears. Available athttps://patientsafetyauthority.org.
6. Ratliff CR, Fletcher KR. Skin tears: A review of the evidence to support prevention and treatment. Ostomy Wound Management 2007; 53 (3): 32-42.
7. Mason SR. Type of soap and the incidence of skin tears among residents of a long-term care facility. Ostomy Wound Management 1997; 43 (8): 26-30.
8. Birch S, Coggins T. No-rinse, one-step bed bath: The effects on the occurrence of skin tears in a long term care setting. Ostomy Wound Management 2003; 49 (1): 64-7.
9. Groom M, et al. Decreasing the incidence of skin tears in the extended care setting with the use of a new line of advanced skin care products containing Olivamine. Journal of WOCN 2010; 37 (1): 46-51.
10. Krasner D. An approach to treating skin tears. Ostomy Wound Management 1991; 32:56-8.
11. Meuleneire F. Using a soft silicone-coated net dressing to manage skin tears. Journal of Wound Care 2002; 11 (10): 365-70.

Long-Term Living 2010 April;59(4):30-32