Prevention, treatment and management of skin tears in clinical practice Clinical Specialist

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1 Prevention, treatment and management of skin tears in clinical practice Clinical Specialist

2 Agenda The skin What is a skin tear? Risk factors for skin tear development Skin tear assessment and classification Management and treatment of skin tears Prevention of skin tears

3 Skin What would you do without it?

4 The Skin Man Copyright: Gunther von Hagens' BODY WORLDS, Institute for Plastination, Heidelberg, Germany,

5 We love to decorate it!

6 Deeply rooted in cultural history

7 The skin we live in is more than a simple wrapping! Important component of an individuals appearance Defines us as individuals Innate to our smell, our touch, to ourselves

8 Structure of the skin The skin can be divided into three main layers: Epidermis Dermis Subcutaneous layer

9 Structure of the skin: Epidermis The epidermis varies in thickness from 0.05 mm on the eyelids to stratum mm basale on the soles of the feet and palms of the hand. stratum spinosum Moving stratum from granulosum the lower layers upwards to the surface, the four layers of the epidermis are: stratum corneum

10 Structure of the skin: Dermis The dermis varies in thickness, ranging from 0.6mm on the eyelids to 3mm on the back, palms and soles. It is found below the epidermis and is composed of a tough, supportive cell matrix. Two layers comprise the dermis: a thin papillary layer a thicker reticular layer

Structure of the skin: Dermis With increasing age, individuals experience dermal and subcutaneous tissue loss, epidermal thinning, and serum composition changes, all of which cause decreased skin

11 Structure of the skin: Dermis With increasing age, individuals experience dermal and subcutaneous tissue loss, epidermal thinning, and serum composition changes, all of which cause decreased skin surface moisture. In turn, the skin s elasticity and tensile strength decrease. These factors are common in the elderly in all care settings and combine to increase the skin s vulnerability to trauma.

12 Ageing skin

13 Ageing skin It is known that ageing skin is a chronic condition, and current evidence supports that it also results in an increased risk of Skin Tear development.

14 Ageing skin With the ageing process, skin becomes more susceptible to dryness. Xerosis cutis, or dry skin, is extremely common in the elderly and occurs as the result of diminished or loss of sebaceous and sweat gland activity. It is seen most often on the lower legs but also occurs on the hands and trunk.

15 Skin Tears How BIG is the problem?

16 Reported prevalence and incidence rates of skin tears Stephen Haynes J, Carville K. Skin tears Made Easy. Wounds International 2011; 2(4): Available from

17 What is a skin tear? The International Skin Tear Advisory Panel defines a Skin Tear as: a wound caused by shear, friction; and/or blunt force resulting in separation of skin layers LeBlanc et al. (2016). The Art of Dressing Selection: A Consensus Statement on Skin Tears and Best Practice, ADVANCES IN SKIN & WOUND CARE VOL. 29 NO. 1 page 34

18 What is a skin tear? Skin tears are preventable acute wounds with a high propensity to develop into chronic wounds and impose health burdens on individuals and care agencies. Although Skin Tears are often precipitated by trauma, they are often slow to heal and may become chronic wounds because of coexisting conditions.

19 Who is at risk of skin tears? Healthcare professionals must be able to identify individuals at risk for skin tears and aid in the prevention of these wounds and in their treatment when they occur.

20 Who is at risk of skin tears? Individuals suffering from skin tears often suffer from a long history of skin tears. As with any wound, once closed the area of injury will have reduced tensile strength, and with each subsequent skin tear, the individual will be at greater risk for skin tears

21 Who is at risk of skin tears? extremes of age the critically ill medically compromised individuals requiring assistance with personal care

22 Intrinsic and extrinsic risk factors

23 What causes skin tears? Equipment injuries (wheelchair/bed rails) Blunt trauma Patient transfers Falls Dressing/tape removal Activities of Daily Living (ADL s)

24 Location on the body Skin tears can occur on any anatomical location. In the elderly they are often sustained on the extremities such as the upper and lower limb and on the dorsal aspect of the hands. Skin tears in neonates with immature skin tend to be associated with the use of adhesives or device trauma and often occur on the head, face and extremities.

25 Location on the body What are the most common sites to see skin tears?

26 Assessment of skin tears Wound assessment is a cumulative process of observation data collection and evaluation Before initiating any treatment, the first step in a Skin Tear assessment is to understand the patients wound aetiology or cause of the wound In relation to Skin Tears, this can be challenging as there are a multitude of factors contributing to Skin Tear development and at times is unknown

27 Assessment Prior to initial assessment of Skin Tears, the wound should be cleansed, removing all residual hematoma or debris, and the flap reapproximated. If the flap is difficult to align, consider applying a moistened non woven gauze compress to the area for 5 to 10 minutes to rehydrate the flap before repositioning.

28 Assessment T of T.I.M.E If the skin flap is present but not viable, it may need to be debrided. Care should be taken during debridement to ensure that viable skin flaps are left intact and fragile skin is protected. An assessment of the skin viability is of crucial importance. Schultz GS, Sibbald RG, Falanga V et al., Wound Rep Reg (2003);11:1 28. Wound Bed Preparation and TIME are clinical concepts supported by Smith & Nephew.

29 Assessment I of T.I.M.E It is important to note that Skin Tears are acute wounds. Initially, these wounds may display increased inflammation to the injured area as the result of the trauma. Prior to treating for infection, it is critical that healthcare professionals distinguish between inflammation from trauma and that of wound infection. Ensure that all topical dressings selected for the management of infection are compatible with fragile skin, preventing further trauma. Courtesy of International Advisory Board on Wound Bed Preparation The above is adapted from table 6, International Advisory Board on Wound Bed Preparation Schultz GS, Sibbald RG, Falanga V et al., Wound Rep Reg (2003);11:1 28. Wound Bed Preparation and TIME are clinical concepts supported by Smith & Nephew

30 Assessment M of T.I.M.E. Traditionally, Skin Tears are not heavily exudating wounds; however, depending on the location and comorbidities, such as peripheral oedema, Skin Tears may be heavily exudating. Absorbent dressings such as foams, gelling fibres, or alginates may be required to manage exudate. Schultz GS, Sibbald RG, Falanga V et al., Wound Rep Reg (2003);11:1 28. Wound Bed Preparation and TIME are clinical concepts supported by Smith & Nephew

31 Assessment E of T.I.M.E. Skin tears are acute wounds that typically should proceed to wound closure in a timely fashion and follow an acute wound closure trajectory of 7 to 14 days. When this fails to happen, given the complex comorbidities often found in those at risk of Skin Tears, a wound care specialist should be consulted to ensure that all potential factors that could delay wound healing have been addressed. Schultz GS, Sibbald RG, Falanga V et al., Wound Rep Reg (2003);11:1 28. Wound Bed Preparation and TIME are clinical concepts supported by Smith & Nephew

32 Skin tears presentation

33 Classification of skin tears Payne and Martin brought Skin Tears to the attention of the wound care community in 1990, reporting an incidence rate of 2.23% in individuals older than 55 years living in long term care facilities. Despite the reported prevalence rates, Skin Tears continue to be underappreciated both in the literature and in practice. Payne RL, Martin M. Skin tears Ithe epidemiology and management of skin tears in older adults. Ostomy Wound Manage 1990;26(1):26 37.

34 Classification of skin tears (1990) Payne RL, Martin M. Skin tears Ithe epidemiology and management of skin tears in adults. Ostomy Wound Manage 1990;26(1):26 37.

Classification of skin tears In response to the need for a universally accepted validated skin tear classification system, Carville et al established and

35 Classification of skin tears In response to the need for a universally accepted validated skin tear classification system, Carville et al established and validated the STAR Classification System in Carville K, Lewin G, Newall N, et al. STAR: a consensus for skin tear classification. Primary Intent 2007;15(1):18 28.

36 STAR classification system (2007) Carville K, Lewin G, Newall N, et al. STAR: a consensus for skin tear classification. Primary Intent 2007;15(1):18 28.

STAR classification tool 1,2,3 1. Adapted from: Carville K., Lewin G., Newall N., et al (2007). STAR: a consensus for skin tear classification. Primary intention:15 (1);18 28

37 STAR classification tool 1,2,3 1. Adapted from: Carville K., Lewin G., Newall N., et al (2007). STAR: a consensus for skin tear classification. Primary intention:15 (1); Skin tears made easy, Stephen Haynes, Caville K., Wounds International, Vol. 2, Issue 4, November Allevyn Star Chart Skin Tears, Smith & Nephew Wound images courtesy of Silver Chain

38 ISTAP classification tool LeBlanc K, Baranoski B, Christensen D, et al. International Skin Tear Advisory Panel: a tool kit to aid in the prevention, assessment, and treatment of skin tears using a simplified classification system. Adv Skin Wound Care 2013;26:

39 ISTAP Classification/Pathway The ISTAP pathway is composed of 3 categories: (1) general health (chronic and critical disease, polypharmacy, impaired cognition, sensory, visual, auditory, and nutrition); (2) mobility (history of falls, impaired mobility, dependent activities of daily living, and mechanical trauma) (3) skin (extremes of age, fragile skin, and previous Skin Tears) LeBlanc K, Baranoski B, Christensen D, et al. International Skin Tear Advisory Panel: a tool kit to aid in the prevention, assessment, and treatment of skin tears using a simplified classification system. Adv Skin Wound Care 2013;26:

40 Management Patient Healthcare Professional Patient Family Caregiver

41 Documentation of skin tears To accurately document and treat skin tears, it is important that a common language be used to describe them. Proper documentation is vital to understanding the extent of the problem. As with other wound types, skin tear documentation requires a systematic framework for: Assessment Treatment Evaluation of outcomes

42 Treatment of skin tears Due to the thin nature of the skin, skin tears tend to involve some damage to the epidermis and the dermis, and may take some time to heal. Therefore, to optimise healing, management of these wounds is best carried out at the time of injury.

43 Treatment of skin tears Clean the wound Reposition the skin flap as accurately as possible Select an appropriate wound dressing A silicone faced foam dressing that does not require secondary retention allows for healing to commence without trauma on removal (Fleck, 2007). LeBlanc et al. (2016). The Art of Dressing Selection: A Consensus Statement on Skin Tears and Best Practice, ADVANCES IN SKIN & WOUND CARE VOL. 29 NO. 1 page 33

44 Treatment of skin tears A major component of wound bed preparation relates to ensuring that the proper product is applied to the wound, which will: protect the peri wound skin control or manage exudate control or manage infection allow for moist wound healing respect the local conditions of the wound bed and; optimise caregiver time

45 Wound cleansing Skin tears should be cleansed following assessment. Bacteria, debris, and/or necrotic tissue must be removed. Optimal wound healing cannot occur unless surface slough, biofilms, and foreign debris have been removed, thus lowering the bioburden.

46 Treatment of skin tears 1a linear tear Realign the skin flap without undue tension Apply an easy to remove dressing such as ALLEVYN Gentle Border dressing 1 or ALLEVYN LIFE dressing 2 and leave intact 1. Hurd, T., Gregory, L., Jones, A. and Brown, S., A multi centre in market evaluation of ALLEVYN Gentle Border, Wounds UK, 2009, vol 5, no Stephen Haynes, J. et al (2013) The clinical performance of a silicone foam in an NHS community trust. JCN. 27(5): 50 59

Apply an easy to remove dressing such as ALLEVYN Gentle Border dressing 1 or ALLEVYN LIFE dressing 2 and leave intact 1. Hurd, T., Gregory, L.

47 Treatment of skin tears 1b epidermal flap, 2a and 2b epidermal/dermal skin flaps Using a moistened gloved finger gently roll out flap of skin. Do NOT attempt to appose the edges of the flap to wound edge. Apply an easy to remove dressing such as ALLEVYN Gentle Border dressing 1 or ALLEVYN LIFE dressing 2 and leave intact 1. Hurd, T., Gregory, L., Jones, A. and Brown, S., A multi centre in market evaluation of ALLEVYN Gentle Border, Wounds UK, 2009, vol 5, no Stephen Haynes, J. et al (2013) The clinical performance of a silicone foam in an NHS community trust. JCN. 27(5): 50 59

graft Option 2: Treat conservatively ALLEVYN Gentle

48 Treatment of skin tears Class 3 Option 1: Refer to surgical team for possible Debridement and/or skin graft Option 2: Treat conservatively ALLEVYN Gentle Border/ ALLEVYN LIFE Hydrogel sheet ACTICOAT Dressing

49 Ideal wound dressing Care should be taken to chose a topical dressing that will: Decrease trauma to the wound and periwound skin, Provide moist wound healing, Manage exudate, Decrease pain, and Be cost effective.

50 Ideal wound dressing If possible, leave the dressing in place for several days to avoid disturbing the flap The flap should not be disturbed for at least 5 days to allow for adherence to the cellular structures below.

51 Dressing selection The research supporting the use of adhesive strips is outdated, and while more research is needed, case studies and expert opinion suggest that adhesive strips are not the current treatment option of choice for skin tears. Expert opinion suggests that the use of adhesive strips may increase the risk of further skin injury as they do not protect the fragile periwound skin and wound bed associated with Skin Tears.

52 Removal of dressing

53 Removal of dressing Drawing an arrow on the top of the ALLEVYN dressing can help prevent removing the dressing against the skin tear. Always remove the dressing in the direction of arrow.

54 Removal of dressing Drawing an arrow on the top of the ALLEVYN dressing can help prevent removing the dressing against the skin tear. Always remove the dressing in the direction of arrow.

55 Removal of dressing

56 Lets get practical with ALLEVYN Gentle Border

57 Prevention of skin tears What measures do you adopt in your local areas to help prevent skin tears from occurring?

58 Prevention of skin tears Assess for risk upon admission to healthcare service and whenever the individual s condition changes. Implement a systematic prevention protocol. Have individuals at risk wear long sleeves, long pants/trousers, or knee high socks. Provide shin guards for those individuals who experience repeat skin tears to shins. Ensure safe patient handling techniques and equipment/environment.

59 Prevention of skin tears Involve individuals and families in preventive strategies. Educate registered and non registered staff and caregivers to ensure proper techniques for providing care without causing skin tears. Consult dietitian to ensure adequate nutrition and hydration. Keep skin well lubricated by applying hypoallergenic moisturiser at least twice per day. Protect individuals at high risk from trauma during routine care and from self injury.

60 Skin tears boxes

61 Summary Skin tears should be treated in a systematic way to include: Cleansing with normal saline, Control of bleeding, Removing clots and debris, Approximating wound edges, Choosing an appropriate dressing to address wound bed characteristics. Best practice supports that a skin flap (the pedicle) should be approximated to the extent possible, and an appropriate dressing should be applied depending on wound characteristics

62 Case studies

63 Using ALLEVYN Gentle Border on a Lower Leg Skin Tear on a Frail Elderly Lady Jola Merrick, Clinical Manager, Herons Park NH, Kidderminster, 2011

64 Background 86 year old female, lived at Nursing Home home for 2 years PMH Osteoarthritis Pulmonary Embolism on Warfarin Prone to cellulitis of legs Antibiotics On admission Category 4 PU on bunion area of Left foot due to legs being very contracted Good positioning now stops reoccurrence Incontinent of urine and faeces Advanced Dementia Good appetite is fed pureed diet drinks normal fluids Skin prone to dryness moisturised every day arms and legs

65 Clinical challenge Despite all efforts the patient does get skin tears Skin tear developed short toe nail caught on opposite leg whilst being hoisted into bath Surrounding skin fragile and sensitive Needed a dressing that the adhesive wouldn t damage or traumatise the surrounding skin ALLEVYN Gentle Border dressing of choice STAR Classification 2A 1.5cms x 1.5cms

66 ALLEVYN Gentle Border Dressing foot STAR Classification 2A Dressing to be removed in direction of arrow to prevent damage to skin flap

67 Results ALLEVYN Gentle Border caused no trauma to the wound or the surrounding skin and the dressing removal did not cause the patient to become anxious Skin integrity intact Healed in 3 weeks

68 Healed 3 weeks

69 Using Allevyn Ag Gentle to manage a skin tear on an elderly patients arm Judith White, Team Leader DN, Camphill Clinic, Nuneaton 2009

70 Background 86 Year old Male Alcoholic Skin fragile, thin and bruised from ageing and previous falls Fell over 15/1/09 Skin tear to right arm Unkempt Scratches arm pulls off dressing and retention bandages Nails not clean Undernourished

71 Clinical challenge Infection Protection of surrounding skin and bony prominences Bandage concordance ALLEVYN Ag Gentle chosen Manage infection Active Fluid Management Gentle on peri wound skin Haematoma present ideal environment for bacterial proliferation Very bright red granulation tissue Very painful Surrounding skin very sore and sensitive

72 Results Reduction in slough and infection Comfort Faster Healing Rates Reduction in dressing changes Continue with ALLEVYN Gentle Ag Dressing 30/1/09 Signs of Infection greatly reduced mainly Healthy red Granulation tissue Epithelisation

73 Wound outcome Complete healing 11/2/09

74 Wound timeline 15/01/09 19/01/09 30/01/09 11/02/09 Patient developed a skin tear to his right arm. Primary dressing applied Area develops signs of infection, ALLEVYN Ag Dressing applied Infection greatly reduced, mainly epithelisation Area appears healed

Case report Mr S. knocked leg with supermarket trolley. Sustained class 2a injury Skin flap rolled carefully out using moistened gloved finger.

75 Case report Mr S. knocked leg with supermarket trolley. Sustained class 2a injury Skin flap rolled carefully out using moistened gloved finger. Non adherent dressing applied, padding and retention bandage & left intact. Doppler Ultrasound determined good vascular supply moderate compression bandage applied. Discharged to care of Practice Nurse.

Patient has all clips removed and a simple non adherent silicone

76 Case Report Class 3 injury, necrotic tissue and haematoma have been debrided and a meshed skin graft applied. Patient has all clips removed and a simple non adherent silicone dressing applied, padding and supportive bandaging and discharged. From injury to discharge 4 days.

77 Traumatic skin tear to lower leg Wound care team, Doncaster and Bassetlaw Hospitals NHS Trust

78 Presentation Right leg skin tear from safety sides/bed rail? Large haematoma bleeding/pretibial Plastic surgeon stated wound would take years to heal patient was not fit for surgery Stated conservative management only

79 Objectives High risk patient Debridement needed Reduce oedema Reduce potential for infection Conservative management only

80 Management Irrigated 2 litres saline with consultant. ACTICOAT Absorbent used to protect from HCAI. VISCOPASTE, Softban TM & K Lite TM to reduce swelling x2 weekly.

81 Management ACTICOAT Absorbent was used for 6 weeks Reviewed on a weekly basis All dressings changed twice weekly Stepped down to VISCOPASTE after 6 weeks

82 Outcome Dead tissue removed with dressings Patient felt no pain and very happy with the treatment plan as she did not want to go to theatre

83 Time scale Discharged from the acute Trust after 7 weeks Treated by District Nurses at home From initial presentation to full healing 4 months

84 Thank you Any questions?

85 References Stephen Haynes J, Carville K. (2011). Skin tears Made Easy. Wounds International; 2(4) LeBlanc et al. (2016). The Art of Dressing Selection: A Consensus Statement on Skin Tears and Best Practice, ADVANCES IN SKIN & WOUND CARE VOL. 29 NO. 1 page 34 Carville K, Lewin G, Newall N, et al. (2007). STAR: a consensus for skin tear classification. Primary Intent;15(1): LeBlanc K, Baranoski B, Christensen D, et al. (2013). International Skin Tear Advisory Panel: a tool kit to aid in the prevention, assessment, and treatment of skin tears using a simplified classification system. Advances in Skin & Wound Care;26: Fleck, C. (2007) Preventing and treating skin tears. Advances in Skin and Wound Care; 20: 6,

86 What is a skin tear? 00 1 A wound caused by pressure on the underlying structures 2 A wound caused by venous insufficiency 3 A wound caused by shear, friction; and/or blunt force resulting in separation of skin layers 4 A wound caused by infection

87 What is a skin tear? 1 A wound caused by pressure on the underlying structures 2 A wound caused by venous insufficiency 3 A wound caused by shear, friction; and/or blunt force resulting in separation of skin layers 4 A wound caused by infection 0% 0% 0% 0%

88 What is the purpose for drawing an arrow on the dressing covering a skin tear? 00 1 To indicate which way to remove the dressing to avoid pulling against the skin flap 2 To indicate when the dressing needs to be removed 3 To indicate which corner to remove the dressing from 4 To indicate how long to leave the dressing on for

89 What is the purpose for drawing an arrow on the dressing covering a skin tear? 1 To indicate which way to remove the dressing to avoid pulling against the skin flap 0% 2 To indicate when the dressing needs to be removed 0% 3 To indicate which corner to remove the dressing from 0% 4 To indicate how long to leave the dressing on for 0%

90 What is the ideal dressing for skin tears? 00 1 Adhesive strips 2 Silicone faced foam dressing 3 Film dressing 4 Super absorber

91 What is the ideal dressing for skin tears? 1 Adhesive strips 0% 2 Silicone faced foam dressing 0% 3 Film dressing 0% 4 Super absorber 0%

92 How many days is it recommended that a skin flap be left undisturbed for? 00 1 One day 2 Two days 3 Three days 4 At least five days

93 How many days is it recommended that a skin flap be left undisturbed for? 1 One day 0% 2 Two days 0% 3 Three days 0% 4 At least five days 0%

Skin tears and haematoma. Janice Bianchi MSc, BSc, RGN, RMN, Pg Cert Ed

Skin tears and haematoma. Janice Bianchi MSc, BSc, RGN, RMN, Pg Cert Ed Skin tears and haematoma Janice Bianchi MSc, BSc, RGN, RMN, Pg Cert Ed Aims Review changes in skin associated with ageing Discuss best practice in relation to: Skin tears Haematoma Compromised Barrier