Skin Diagnosis - Nursing Experts Only

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Assessing and managing skin tears in older people

Annie Clothier

Abstract The skin is the largest and most visible organ in the body, comprising of two principal layers, the dermis and epidermis (Timmons, 2006). Skin tears are acute, traumatic injuries, presenting predominantly in the extremities of the elderly, as a result of friction and shearing forces which separate the principal layers of the skin (Baranoski, 2005). Skin tears cause significant pain and adversely affect quality of life. It is essential that health professionals ensure they are confident and competent in the management of skin tears. This article discusses how to assess and manage skin tears in older people and provides an overview of factors to consider when choosing an appropriate dressing.

Annie Clothier is a tissue viability nurse, at Aneurin Bevan University Health Board, South Wales

Skin tears are acute, traumatic injuries, presenting predominantly in the elderly. They occur mainly on the extremities as a result of friction and shearing forces which separate the principal layers of the skin (Baranoski, 2005).

Skin tears were first defined in 1993 (Payne and Martin, 1993). Some are unavoidable, but many are considered preventable (Payne and Martin, 1993; Leblanc et al, 2013). Although they are perceived to be common among the elderly, these types of wounds often go unreported, especially in the community setting (Stephen-Haynes and Carville, 2011).

The majority of prevalence and incidence data originate from the USA and Australia. To date, there is no robust prevalence data available for the UK. Therefore the financial impact of skin tears on the NHS is not fully known (Bianchi, 2012).

The main causes of skin tears are mechanical trauma, often from wheelchair injuries, removal of adhesive tapes or dressings, transfers and falls (Baranoski, 2005; Battersby, 2009; Beldon, 2006; Groom et al, 2010), though in some cases no apparent cause is found (Baranoski, 2005).

In older people, most skin tears are seen on the extremities, usually the arms, dorsal aspect of the hands, and the lower limbs.

Skin tears cause significant pain and adversely affect quality of life. With an ageing population, it is essential that health professionals ensure they are confident and competent in the management of skin tears.

Physiology of ageing skin The skin is the largest and most visible organ in the body, comprising of two principal layers, the dermis and epidermis (Timmons, 2006).

As the skin ages, the amount of elastin and collagen reduces, resulting in visible changes, such as sagging and wrinkling, along with dryness, which is a result of lower levels of the dermal proteins which retain moisture (Battersby, 2009; Nazarko, 2007; Fleck, 2007).

The epidermis thins over time, leaving it more susceptible to mechanical trauma (Baranoski, 2005). Given the ‘tissue paper’ appearance of the skin, even the slightest bump or knock can cause tissue damage (Stephen-Haynes and Carville, 2011; Fleck, 2007).

Maintaining skin integrity can pose a challenge for health professionals working with older people. The occurrence of skin tears may reflect poorly on the quality of care provided by care homes and other healthcare facilities, so collecting data is considered essential to understand the magnitude of the problem (Leblanc and Baranoski, 2011).

Assessment and classification Assessment must follow a comprehensive and holistic approach. Underlying factors which may have contributed to the injury should be determined (Battersby, 2009). Conditions such as diabetes, anaemia or postural hypotension need to be addressed to prevent further tears occurring (Beldon, 2008).

A common sense approach to patient care should focus on addressing the risk factors associated with the development of a skin tear (Box 1), and modifying risks, for example by employing safer manual handling techniques, while assisting older adults with routine activities such as bathing, dressing and repositioning (Payne and Martin, 1993).

Creating a safe environment is essential to avoid unnecessary trauma from any bumps or knocks from

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Tissue Viability Nurse Forum, 2011; Carville et al, 2007).

The clinician must thoroughly assess the wound to determine the extent and depth of the damage (Battersby, 2009).

When assessing a skin tear, it is important to document the position of the skin tear; pain levels; size of the tear; description of the wound bed; level and appearance of exudate; and the integrity of the surrounding skin.

The All Wales Tissue Viability Forum recommends that assessment of the skin tear should include (All Wales Tissue Viability Nurse Forum, 2011):

■ Underlying disease process (e.g. diabetes, peripheral vascular disease)

■ Cause of the injury ■ Time of the injury ■ Previous skin injury ■ Status of surrounding skin ■ Nutritional status ■ Medication ■ Wound location ■ Size and category of the wound. There is no universally accepted classification for the

assessment of skin tears (Stephen-Haynes and Carville, 2011; Battersby, 2009; Leblanc and Baranoski, 2011; All Wales Tissue Viability Nurse Forum, 2011). The most widely documented is the Payne and Martin tool (Payne and Martin, 1993) (Box 2).

In recent years however, the formation of the International Skin Tear Advisory Panel (ISTAP) has initiated consensus statements and further work towards an internationally recognised and validated classification system (Payne and Martin, 1993). The ISTAP system is concise in that it focuses on three types of skin tear (Groom et al, 2010).

■ Type 1: Linear or flap tear that can be repositioned to cover the wound bed

■ Type 2: Partial flap loss that cannot be repositioned to cover that wound bed

■ Type 3: Total flap loss exposing the entire wound bed. In 2007, Carville et al published the STAR

classification system (Box 3) and it is interesting to note that in recent years it has been disseminated outside of Australia (Leblanc and Baranoski, 2011; Carville et al, 2007).

Managing skin tears The main aim of managing a skin tear is preserving the skin flap and protecting the surrounding tissue (Stephen-Haynes and Carville, 2011). As with any wound, the focus is on encouraging healing and preventing infection.

The All Wales Tissue Viability Forum Best Practice Statement is a useful tool for any practitioner and gives clear guidelines for assessing and managing skin tears

low lying furniture. Nurses can advise on the padding of sharp corners on furniture. Patients can be encouraged to wear some degree of protective clothing such as long sleeves and trousers in an attempt to cover the vulnerable areas (Payne and Martin, 1993; Leblanc et al, 2013; Fleck, 2007).

Care should also be taken when removing tapes and adhesive dressings. Gently grasping one edge and slowly peeling the dressing back, rather than up, in the direction of the hair growth will help reduce the trauma of removing adhesive dressings and tapes that are difficult to remove (All Wales Tissue Viability Nurse Forum, 2011). The use of a barrier film or cream can help to moisturize and protect the skin, and using a silicone-based adhesive remover for dressings will minimize trauma to fragile skin (Leblanc et al, 2013).

The importance of keeping the skin hydrated has been recognized and the use of topical emollients advocated, in conjunction with ensuring an adequate oral fluid intake (Fleck, 2007). This can be the difference between a bump resulting in a bruise or a skin tear (Fleck, 2007). There are many skin care products available that provide pH-balanced cleansing which further reduces drying effects on the skin (Payne and Martin, 1993).

It is essential that the cause of a skin tear is established to enable effective care planning that takes into account the risk factors involved (Stephen- Haynes and Carville, 2011; Fleck, 2007; All Wales

Box 1. Risk factors for skin tears ■ Age >75 years ■ Gender (more common in females) ■ History of previous skin tears ■ Dehydrated skin ■ Impaired mobility ■ Reliance on others for personal needs such as bathing or transferring

■ Cognitive or sensory impairment (diabetes, dementia) ■ Visual impairment ■ Poor nutrition and hydration ■ Medications that can have a thinning effect on the skin (e.g. steroids).

Box 2. Payne and Martin classification ■ Category 1: A skin tear without loss of tissue, either linear or with a flap that closes the tear to within 1 mm of the wound edges

■ Category 2: Partial tissue loss, scant when tissue loss is <25%. Moderate or large when the tissue loss is >25%

■ Category 3: Complete tissue loss with no epidermal flap covering the injury.

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(All Wales Tissue Viability Nurse Forum, 2011). It is freely available to download.

With any skin tear, it is essential that treatment is prompt in order to ensure the viability of the skin flap. The initial treatment process includes (Stephen-Haynes and Carville, 2011; Battersby, 2009; All Wales Tissue Viability Nurse Forum, 2011):

■ Control bleeding—apply pressure and elevate the limb

■ Cleanse the wound—use warm tap water or saline to irrigate and remove any debris or remaining clots

■ Approximate the flap—without pulling or applying pressure, gently unfold the flap and smooth it out over the wound. This can be done using a moistened, gloved finger or cotton tip

■ Dress the wound with an atraumatic wound contact layer to keep the flap in place. The atraumatic dressing should remain in place for several days to allow the flap to adhere to the wound bed. Ensure that the atraumatic layer is removed in the direction of the skin flap, and not against it

■ Sutures and staples are not recommended due to the fragile nature of the tissue

■ The wound should be monitored regularly for signs of infection (redness, heat, odour and increased pain and exudate). Particular care should be taken in the immunocompromised and people with diabetes

■ If the skin flap becomes necrotic, a specialist opinion should be sought from a tissue viability nurse or medical practitioner.

Choosing a dressing Dressing selection is important, but due to limited knowledge among some practitioners, inappropriate choices can be made. The ideal dressing should (Stephen-Haynes and Carville, 2011; Leblanc and Baranoski, 2011):

■ Maintain a moist environment (Stephen-Haynes and Carville, 2011; Battersby, 2009; Leblanc and Baranoski, 2011; All Wales Tissue Viability Nurse Forum, 2011; Carville et al, 2007)

■ Protect the surrounding skin ■ Control and manage exudate levels ■ Prevent trauma on removal ■ Give the patient comfort and security and optimize their well-being

■ Be easy to apply and cost effective. The All Wales Tissue Viability Forum advocates

the use of an atraumatic contact layer such as Silflex (Advancis Medical) or Mepitel (Molnlycke), or an atraumatic all in one dressing like Mepilex Border (Molnlycke) or Allevyn Gentle Border (Smith and Nephew) (All Wales Tissue Viability Nurse Forum, 2011). If using an all-in-one dressing, then it is advisable to mark the dressing with an arrow to

indicate the direction in which the dressing is to be removed.

In some cases, the patient may need to be referred to secondary care for further treatment and possible plastic surgery. This is particularly important if there has been full thickness tissue loss or a haematoma has formed.

Preventing skin tears As with all things, prevention is better than cure. The ISTAP guidelines specify that care needs to be planned and that a comprehensive assessment of the risk factors for skin tears must be conducted for all individuals at risk within the context of their environment (Leblanc and Baranoski, 2011).

The need to ensure that care giving staff are aware of proper handling techniques required for providing care without traumatizing the skin in vulnerable older adults is essential and should form part of an annual educational review.

Involvement of the multidisciplinary team should be considered to advise on a number of factors such as safer handling equipment that minimizes trauma to the skin, and consulting a dietician for advice on maintaining an adequate nutritional and hydration level. Most importantly, the individual patient and their family should be involved in deciding on and adopting prevention strategies (Leblanc and Baranoski, 2011).

Conclusion Skin tears present a challenge for the health practitioner. Care home establishments have a duty to ensure staff are educated in managing the skin of older adults.

Registered nurses should be aware of the risk factors for skin tears (Box 1) and, where possible, work to eliminate these. Environmental factors can

Box 3. STAR classification ■ Category 1a: A skin tear where the edges can be realigned to the normal anatomical position (without undue stretching) and the skin or flap colour is not pale, dusky or darkened

■ Category 1b: A skin tear where the edges can be realigned to the normal anatomical position (without undue stretching) and the skin or flap colour is pale, dusky or darkened

■ Category 2a: A skin tear where the edges cannot be realigned to the normal anatomical position and the skin or flap colour is not pale, dusky or darkened

■ Category 2b: A skin tear where the edges cannot be realigned to the normal anatomical position and the skin or flap colour is pale, dusky or darkened

■ Category 3: A skin tear where the skin or flap is completely absent.

(Baranoski, 2005)

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be implicated in the aetiology of skin tears. However, education and the enforcement of protocols for managing skin care can result in a reduction in the occurrence of skin tears (Baranoski, 2005).

A better understanding of the classification and treatment required will enable nurses to feel confident and aid decision-making, improving and enhancing the outcomes for the patient.

This article was originally published in Independent Nurse, 5 May 2014.

All Wales Tissue Viability Nurse Forum (2011) Best Practice Statement. The Assessment and Management of Skin Tears. MA Healthcare: Dulwich; 2011. Available from: http://bit. ly/1pnYA1q.

Baranoski S (2005) Meeting the challenge of skin tears. Adv Skin Wound Care 18: 74–5

Battersby L (2009) Exploring best practice in the management of skin tears in older people. Nurs Times 105: 22–6

Beldon P (2006) Best practice for the assessment and management of superficial skin tears. Wound Essentials 1: 108–9

Beldon P (2008) Management options for patients with pretibial lacerations. Nurs Standard 22: 53–8

Bianchi J (2012) Preventing, assessing and managing skin tears. Nurs Times 108: 12–6

Carville K, Lewin G, Newall N et al (2007) STAR: a consensus for skin tear classification. Primary Intention 15: 18–28

Fleck C (2007) Preventing and treating skin tears. Adv Skin Wound Care 20: 315–20

Groom M, Shannon RJ, Chakravarthy D, Fleck CA (2010) 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. J Wound Ostomy Continence Nurse 37: 46–51. doi: 10.1097/WON.0b013e3181c68c89.

Leblanc K, Baranoski S, Holloway S, Langemo D (2013) Validation of a new Classification system for Skin Tears. Adv Skin Wound Care 26: 263–5. doi: 10.1097/01.ASW.0000430393.04763.c7.

Leblanc K, Baranoski S (2011) Skin tears: state of the science: consensus statements for the prevention, prediction, assessment and treatment of skin tears. Adv Skin Wound Care 24(9 Suppl 1): 2–15. Available from: http://bit.ly/1gOJGrO.

Nazarko L (2007) Maintaining the condition of aging skin. Nursing and Residential Care 9: 160–3

Payne RL, Martin ML (1993) Defining and classifying skin tears: need for a common language. Ostomy Wound Manage 39: 16–22

Stephen-Haynes J, Carville K (2011) Skin tears Made Easy. Wounds International 2(4): 1–6

Timmons J (2006) Skin function and healing. Wound Essentials 1: 8–17

Key Points ■ Skin tears are acute, traumatic injuries, presenting predominantly in the elderly—the majority are thought to be preventable

■ Care should be taken when removing adhesive dressings and tapes

■ It is important to keep the skin hydrated, and topical emollients have been advocated, along with ensuring an adequate fluid intake

■ The main aim of managing a skin tear is preserving the skin flap and protecting the surrounding tissue

■ Dressings should maintain a moist environment, protect the surrounding skin, control and manage exudate levels, and prevent trauma on removal.

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