SKIN TEARS. Esther White SKINtelligence project lead nurse

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Melanie Karin Porter
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1 SKIN TEARS Esther White SKINtelligence project lead nurse

2 Skin tears Common in the older age Can be a full tear removal of skin Can be a split or flap which can be replaced

3 Acute or Chronic? Many patients with skin tears will see these acute episodes become chronic, especially on their legs. They can become hard to treat, difficult to heal and cause extreme pain and distress

4 Can we prevent them? Well known risk factors, put the older generation at high risk: Older age fragile skin Certain medications Reduced mobility Reduced sensory awareness And lots more!

5 SKIN TEAR ASSESSMENT Completing a simple skin tear risk assessment on a patient will only take a minute or two Putting a prevention plan into place may take longer but is it more efficient than dealing with a skin tear which becomes a chronic wound? Is there a balance?

6 Skin Tear Risk Assessment 1. Complete the assessment form 2. Count up the ticks 3. Patient at risk? Yes then start prevention plan No then reassess at a later point It is essential that you START the patient on the prevention plan as soon as they are recognised as at risk Ensure all staff are aware

7 Skin tear risk assessment Group one (1 or more) Tick if appropriate Skin tear in the last 90 days A current skin tear Total ticks

8 Tick if appropriate Decision-making skills impaired Extensive assistance/total dependence for ADL s Wheelchair user Wheelchair assistance required Unsteady gait/ Loss of balance Confined to bed or chair Bruises Physically abusive/ agitated Resists ADL care Hearing/visual impairment Decreased tactile stimulation Manually/mechanically lifted Paralysis anywhere on the body Trunk total or partial inability to balance to turn body Pitting oedema of legs Open lesions of extremities Dry/scaly skin Total ticks 3 or more ticks in this plan indicate risk, so start a prevention plan

9 Prevention If indicated start a prevention plan Let everyone know! If measuring improvement with safety cross make sure someone is responsible for this

10 Soap substitutes ONLY Soap affects the skin s natural ph Need to return it back using soap substitutes Hydromol ointment currently on formula Can mix with water prior to use to soften CAUTION in bath or shower

Daily moisturising Apply emollient (check up to date formula) currently Balneum DAILY suggest at night Particularly to hands, arms and legs Helps the skin to

11 Daily moisturising Apply emollient (check up to date formula) currently Balneum DAILY suggest at night Particularly to hands, arms and legs Helps the skin to be strong and less fragile GP s should prescribe as is on current formula Go DOWNWARDS (or in the direction of hair growth) with the cream to avoid folliculitis

12 Protect limbs Protect arms and legs Long sleeves and trousers preferable Use Tubifast on formulary (can cut a hole for thumb)

13 Everyone s responsibility Domestics, kitchen staff, carers, nurses etc Cautious of the risks they pose Look out for swinging wheelchair parts! Family can help too moisturising or giving hand and arm massage

14 Good hydration and nutrition Internal hydration = external hydration Good nutrition = optimum body weight and skin condition Extra protein if wound present

15 Other areas to consider Medical devices that may need adhering Adhesive dressings Derma-S barrier film Allevyn LIFE Tissue Viability for advice Manage moisture Wet skin is particularly vulnerable Check pad absorbency Check frequency of change Sweat? consider natural fibres or a cooler setting

16 Final thoughts Ensure correct use of correct slings, use extra caution on removal Check hands on staff for appropriate jewellery and nail length and sharpness Promote a safe environment Clear, bright plenty of space to move No sharp edges on furniture

17 If you do get a skin tear after trying everything Gently cleanse with warm tap water Replace flap (if there is one) Cover with non stick dressing (Atrauman or Adaptic Touch) Cover with small pad Apply blue or yellow line Pilot care plan hopefully on its way!

18 Look at the Skin Tear Risk Assessment Still a draft copy work still to be done Choose 5 patients who you think are at risk and complete assessment Start prevention plan when indicated Use safety cross to record any skin tears Measure at the end of 2 3 month Improvement? Then roll out to more patients Follow PDSA cycle and report back to SKINtelligence!

Skin Tears. An Under Appreciated Wound. Objectives 9/24/2010. Sharon Baranoski MSN, RN, CWCN, APN, DAPWCA, FAAN

Skin Tears. An Under Appreciated Wound. Objectives 9/24/2010. Sharon Baranoski MSN, RN, CWCN, APN, DAPWCA, FAAN Skin Tears: An Under Appreciated Wound Sharon Baranoski MSN, RN, CWCN, APN, DAPWCA, FAAN Objectives Identify patients who are at risk for skin tear insult Use the Payne Martin Classification Discuss interventions