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

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

2 Aims Review changes in skin associated with ageing Discuss best practice in relation to: Skin tears Haematoma

3 Compromised Barrier Function External protection becomes less and less effective with age Dry skin becomes more of a problem Skin becomes more sensitive to irritants

4 To Promote Skin Health Use emollient therapy Soap substitute Bath oil Topical moisturiser Gently dry skin after washing then apply moisturiser

5 Ageing skin

6 Skin ageing Atrophy of subcutaneous tissue Microcirculation vessel walls widen, atrophy and become disorganised Decrease in collagen amount and quality

7 Age related skin changes

8 Flattening of rete pegs Epidermis less proliferative Less resistant to shear forces

9 Dermis not fully developed until after birth At full term 60% of adult thickness Dermal epidermal junction reduced number of rete pegs More widely spaced Consequently less elasticity damage by shear Immature skin

10 Skin tears

11 Skin tears Traumatic wound, occurring principally on the extremities of older adults as a result of friction alone or shearing and friction forces (Payne & Martin 1993) Common problem in elderly people

12 Prevalence 16% of patients in 120 bed facilities in Australia 41.5% of known wounds found to be skin tears in elderly care residents (mean age 80 years 8-11% reported in all public hospitals in Western Australia Stephens-Hayes &Carville (2011)

13 Carville et al 2011 Skin tears and common wounds and occur more frequently than pressure ulcers

14 International survey skin tears 1127 health care professionals 16 countries 69.6% reported problems with current assessment and documentation in their practice setting 89.5% would value a simplified system 80.9% admitted they do not use an assessment or classification tool LeBlanc et al 2011

15 Who is at risk of skin tears Previous skin tears Advanced age Immature skin Poor nutrition Medication Impaired mobility Bruising Shearing, friction, pressure Prolonged use of corticosteroids Impaired sensory perception Disease processes e.g.renal failure, stroke, heart failure

16 Where do they occur Any anatomical location In the elderly upper and lower limbs Dorsal aspect of hand In neonates Associated with adhesives of device trauma Head face extremities

17 Prevention Provide a well lit environment Protect from self injury Encourage family members to use proper positioning, turning, lifting and transferring techniques (prevent friction ad shear) Provide padding to bed rails, wheelchair arms Clothes Limb protectors Use pillows and blankets to support limbs Nails short Jewellery Emollients Educate all staff and carers

18 Assessment Anatomical location Dimensions (length, width, depth) Percentage of viable /non viable tissue Type and amount of exudate Presence of bleeding or haematoma Degree of flap necrosis Integrity of surrounding skin Signs and symptoms of infection Associated pain

19 Assessment STAR Skin tear classification system Category 1a Edges can be realigned without undue stretching. Skin flap not pale dusky of darkened

20 STAR Skin tear classification system Category 1b Edges can be realigned colour is pale, dusky or darkened

21 STAR Skin tear classification system Category 2a Edges cannot be realigned, colour is not pale, dusky or darkened

22 STAR Skin tear classification system Category 2b Edges cannot be realigned skin is pale, darkened or dusky

23 STAR Skin tear classification system Category 3 Skin flap is completely absent

24 Treatment Control bleeding, apply pressure and elevate limb if appropriate Gently cleanse the wound with saline at body temperature Assess degree of loss of skin or flap colour (STAR) Assess surrounding skin for fragility, swelling, discolouration or bruising Unfold and smooth out flap completely If the flap is difficult to align, consider using a moistened non woven swab. Apply for 5-10 mins to rehydrate the flap

25 Treatment Place a dressing e.g. silicone coated, lipocolloid or soft adherent foam dressing over the wound, mark dressing with an arrow to indicate direction of removal Avoid tape closures Tubular bandage to limbs If skin tear is pale, darkened or dusky review at hours Leave dressing in place for a minimum of 5 days Use silicone based adhesive remover if necessary to minimise trauma on removal

26 On going treatment Extra layers of absorbent dressing can be applied if exudate levels are high A wound assessment tool should be utilised The wound should be monitored for any changes including signs of infection For skin tears on legs, consider leg ulcer guidelines

27 When to refer When the skin tear is extensive When injury is full thickness When there is significant bleeding When there is haematoma

28 Key principles for good management Assess and document Use recognised classification tool Skin tear first aid box

29 Meuleneire, F. Skin tears. A simple procedure to reach an efficient treatment. Poster presentation at the European Wound Management Association conference, Granada, Spain, 2002.

30 Case study 75 year old lady Stumbles and fell at home, right arm landed on cupboard 2 epidermal skin tears Daughter applied adsorbent dressing to bleeding wounds Arrived at A&E a few hours later Admitted with fractured hip

31 Forearm : skin tear at inclusion (measures 3x2cm)

32 Flap rinsed and folded back

33 Mepitel securing the flap, absorbent dressing and bandage

34 Day 6 : completely healed

35 Upper arm : skin tear (13 x 5 cm)

36 After replacing the epidermal flap 95% coverage

37 Fixation of the flap with Mepitel absorbent dressing changes day 1 and 3

38 Day 6 : almost complete healing 95% closure

39 Hutchcox and Williams 2011 Use of new URGOTUL in the local treatment of skin tears

40 Case study 3 86 year old man Sustained hand injury due to fall Epidermis destroyed Urgotul and absorbent dressing applied

41 3 weeks later

42 Case study 3 77 year old man Previously suffered from cancer Skin tear on elbow following fall 60% slough, 40% epithelialisation Fragile skin Urgotul and Allevyn Gentle applied

43 2 weeks later

44 Conclusion Identifying at risk patients and employ prevention techniques Every skin tear and haematoma should be assessed individually Assess carefully to decide whether to treat conservatively/actively/refer to plastic surgeons National guidance on prevention, assessment and management of skin tears would help healthcare workers to provide evidence based care

45 References Belton P (2011) Haematoma: Assessment, Treatment and Management. Wound Essentials 6; Carville K, Lewin G, Newall N et al (2007) STAR: a consensus for skin tear classification. Primary Intention 15;1:18-28 LeBlanc K, Baranoski S (2011) Skin Tears: State of Science: Consensus statement of the prevention, prediction, assessment and treatment of skin tears. Advances in Skin and Wound Care 24; 9: 2-15 LeBlanc K, Baranoski S, Regan M (2011) Skin Tear Survey (unpublished data) Payne RL, Martin MC (1993) Defining and classifying skin tears:need for a common language. Ostomy and Wound Management 39;5:16-26 Payne RL, Martin ML (1993) Defining and Classifying skin tears: need for a common language. Ostomy Wound Management 93:3; Stephens-Hayes J, Carville K (2011) Skin tears made easy. Wounds International 2;4

46 Thank you

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