Skin Tears a review of current management therapies and their application therapies and their application Trudie Young 3m Road Show Care of the Older Person’s Skin: Meeting the Challenge

Skin Tear Definition Fleck 2007 “Skin tears are traumatic wounds that result from a separation of the two major layers of the human skin, the epidermis and the dermis.”“Skin tears are traumatic wounds that result from a separation of the two major layers of the human skin, the epidermis and the dermis.”

Skin Tears USA - mandatory reporting of skin tears (Pennsylvania)USA - mandatory reporting of skin tears (Pennsylvania) Residents identified as at risk for skin tears should be placed on a prevention protocol, treatment protocols should also be in placeResidents identified as at risk for skin tears should be placed on a prevention protocol, treatment protocols should also be in place

Skin Tear Classification System Payne Martin 1993 Category 1 – skin tears without tissue loss,Category 1 – skin tears without tissue loss, linear type or flap typelinear type or flap type Category 2 – skin tears with partial tissue loss, described as 25% more or less of skin lossCategory 2 – skin tears with partial tissue loss, described as 25% more or less of skin loss Category 3 – skin tear with full-thickness tissue loss. The epidermal flap or tissue is absent in this type of skin tearCategory 3 – skin tear with full-thickness tissue loss. The epidermal flap or tissue is absent in this type of skin tear

Skin Tears – sites and risk factors Malone 1991, McGough-Csarny 1998, Meuleneire 2002 Main site - upper extremities – forearmMain site - upper extremities – forearm Risk factors – medication (sedating, dehydrating or long term steroid use), sensory loss, history of previous skin tears, compromised nutrition, joint stiffness, contractures, cognitive impairment, dependency, poor lighting, low furnitureRisk factors – medication (sedating, dehydrating or long term steroid use), sensory loss, history of previous skin tears, compromised nutrition, joint stiffness, contractures, cognitive impairment, dependency, poor lighting, low furniture

Skin Tears – Causes Malone 1991, McGough-Csarny 1998, Meuleneire 2002 For many injuries the cause was unknown although some happened during episodes of nursing careFor many injuries the cause was unknown although some happened during episodes of nursing care Known causes – falls, wheelchairs, restraints, transfers, violent behaviour, bed rails, jewellery, fingernails, taking blood, tape removal, taking off and putting on socks and tights, tight clothing, bandage application and slippageKnown causes – falls, wheelchairs, restraints, transfers, violent behaviour, bed rails, jewellery, fingernails, taking blood, tape removal, taking off and putting on socks and tights, tight clothing, bandage application and slippage

Pretibial lacerations Davis 2004 Postal questionnaire to A & E unitsPostal questionnaire to A & E units Incidence 5.2 per 1,000 attendeesIncidence 5.2 per 1,000 attendees Treatments – adhesive tape, dressings (including dry dressings), sutures!!!!!!!!!!!!Treatments – adhesive tape, dressings (including dry dressings), sutures!!!!!!!!!!!!

Treatment Issues Historical options – drying the flap out, BactrobanHistorical options – drying the flap out, Bactroban Ritualistic options – antiseptic use despite no signs of infectionRitualistic options – antiseptic use despite no signs of infection

Best Practice Statement 2006 StatementReason How to demonstrate statement is being achieved Assessment should be carried out to determine the cause of the skin tear and this should be removed to prevent further injury Early detection of skin trauma through identification of the cause may prevent further skin breakdown Health records have evidence that assessment has been carried out to determine the cause of the skin tear, and that this has been removed

Best Practice Statement 2006 StatementReason How to demonstrate statement is being achieved The skin tear should be classified according to the degree of tissue damage Classification of the damage enables correct and suitable treatment and intervention to be initiated and maintained Health records show that individuals with a skin tear have had a full assessment and that a plan of management has been developed, which incorporates review of the wound and continuity of care between different care settings

Best Practice Statement 2006 StatementReason How to demonstrate statement is being achieved Management of skin tears should consider: Stopping bleeding if it is persistent Preventing infectionPreventing infection Minimising pain and discomfortMinimising pain and discomfort Recovering skin integrityRecovering skin integrity Wounds which are managed following the principles of moist wound healing, result in enhanced healing rates and reduced infection rates Evidence of initial and ongoing management to prevent further tissue damage should be recorded within the individual’s health records

Best Practice Statement 2006 StatementReason How to demonstrate statement is being achieved Management of wounds involves maintaining skin integrity: If the skin tear has dried out, it should be removed using a sterile technique Wounds which are managed following the principles of moist wound healing, result in enhanced healing rates and reduced infection rates Treatment interventions and a plan of care should be evident within the individual’s health records

Best Practice Statement 2006 StatementReason How to demonstrate statement is being achieved If the skin flap is still viable, cleanse with warm, saline or tap water, and roll the flap back into place to obtain optimum skin cover Wounds which are managed following the principles of moist wound healing, result in enhanced healing rates and reduced infection rates Treatment interventions and a plan of care should be evident within the individual’s health records

Best Practice Statement 2006 StatementReason How to demonstrate statement is being achieved If the skin tear is viable, secure using one of the suggested methods: Adhesive wound closure stripsAdhesive wound closure strips Skin glueSkin glue Silicone non-adhesive dressingsSilicone non-adhesive dressings Wounds which are managed following the principles of moist wound healing, result in enhanced healing rates and reduced infection rates Treatment interventions and a plan of care should be evident within the individual’s health records

Best Practice Statement 2006 StatementReason How to demonstrate statement is being achieved The method of skin application will still require the application of an appropriate secondary dressing to provide further protection Wounds which are managed following the principles of moist wound healing, result in enhanced healing rates and reduced infection rates Treatment interventions and a plan of care should be evident within the individual’s health records

Treatment Issues Lower limb - Localised oedema - compression therapy, consider ABPI, pulse oximetryLower limb - Localised oedema - compression therapy, consider ABPI, pulse oximetry Arrow on outer dressing to orientate flap positionArrow on outer dressing to orientate flap position AnalgesiaAnalgesia Use of adhesive and fixation productsUse of adhesive and fixation products

Preventative options Protective gloves, short nails, no jewellery (carer & client)Protective gloves, short nails, no jewellery (carer & client) Padding to wheelchair arm and foot restsPadding to wheelchair arm and foot rests Correct manual handling and transfer techniquesCorrect manual handling and transfer techniques Long sleeve clothes and trousers, padded garmentsLong sleeve clothes and trousers, padded garments Keep the individual and thus their skin well nourished and hydratedKeep the individual and thus their skin well nourished and hydrated Frequent application of emollientsFrequent application of emollients Adhesive removersAdhesive removers Moving and handling techniquesMoving and handling techniques Barrier preparations/ skin protectants – IV fixationBarrier preparations/ skin protectants – IV fixation Environmental awarenessEnvironmental awareness