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

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1 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 i related to skin tear prevention and treatment Skin Tears traumatic acute wound resulting from separation of the epidermis i from the dermis 1

2 Prevalence of skin tears 1.5 million skin tears occur each year in institutionalized adults One of the largest problems in wound management with an increasing elderly population Risk factors for Skin Tears #1 Dependent patients who require total care for all activities of daily living most at risk Frequently acquired during routine activities of dressing, bathing, positioning (grabing arms, and transferring (friction), from assistive devices, removal of tape/dressings Risk Factors for skin tears #2 Independent ambulatory patients/residents Found on extremities Many have edema, purpura, or ecchymotic areas Many in wheelchairs, walkers Unsteady gait 2

3 Risk factors for skin tears #3 Slightly impaired patients/residents Injury from hitting stationary equipment or furniture or reasons as above for dependent and independent ambulatory patients Location of skin tears Most skin tears (80%) occur in upper extremities (arms & hands) Most common in people over 65 Yrs. old (Malone et al, 1991; McGough & Kopac, 1998; Payne & Martin, 1990) Location Skin Tears Skin tears on the back & buttocks often mistaken as stage II pressure ulcers Almost half of skin tears are found without any apparent cause Documentation is very important 3

4 When cause of skin tears is known ¼ from wheelchair injuries ¼ caused by accidentally bumping into objects Transfers (18%) Fall (12.4%) Classification System Payne Martin Classifications System STAR System Canadian Wound Care Association No universally accepted documentation system Payne, R.L., Martin, M.L. Defining & Classifying Skin Tears: Need a Common Language, OWM 39(5):16-26, June Payne Martin Classification System for skin tears Category I A linear type (Skin tear without tissue loss) Epidermis and dermis pulled apart as if an incision has been made (note areas of senile purpura) Payne, R.L., Martin, M.L. Defining & Classifying Skin Tears: Need a Common Language, OWM 39(5):16-26, June

5 Skin tears Category I B flap type Epidermal flap completely covers the dermis to within one millimeter of the wound margin Payne, R.L., Martin, M.L. Defining & Classifying Skin Tears: Need a Common Language, OWM 39(5):16-26, June Skin Tears Category II A Skin tears with partial tissue loss Scant tissue loss type <25% of the epidermal flap lost Payne, R.L., Martin, M.L. Defining & Classifying Skin Tears: Need a Common Language, OWM 39(5):16-26, June Category II B Skin Tear Moderate to large tissue type > 25% of the epidermal flap lost Payne, R.L., Martin, M.L. Defining & Classifying Skin Tears: Need a Common Language, OWM 39(5):16-26, June

6 Category III Skin Tear Skin tear with complete tissue loss Epidermal flap is absent Payne, R.L., Martin, M.L. Defining & Classifying Skin Tears: Need a Common Language, OWM 39(5):16-26, June Skin Integrity Risk Assessment Tool White, M., et al Geriatric Nursing 15(2):95 99, March 1994 Group I _History of skin tears within last 90 days _ Actual number of skin tears Group II _ Decision making skills impaired _ Slight impaired _ Extensive assistance/total dependence for ADL _ Wheelchair assistance needed _ Loss of balance _ Bed or chair confined _ unsteady gait _ Bruises Group III _ Physically abusive _ Resists ADL care _ Agitation _ Hearing impaired _ Decreased tactile stimulation _ Wheels self _ Manually/mechanically lifted _ Contracture of arms, legs, shoulders, hands _ Hemiplegia / hemiparesis _ Trunk partial or total inability to balance or turn body _ Pitting edema of legs _ Open lesions on extremities _ 3 4 senile purpura on extremities Implement a skin tear risk prevention plan of care for patients who meet Any of the criteria in group I 4 or more criteria in group II 5 or more criteria in group III A combination of 3 criteria in group II with 3 or more criteria in group III White, M., et al Geriatric Nursing 15(2):95-99, March

7 Prevention Strategies Ensure a safe environment Determine and remove potential causes for trauma Have individuals at risk: Wear long sleeves Protective arm, shin sleeves Long pants or knee high socks Providing shin guards for those who experience repeat skin tears to shins Ensuring a safe environment with adequate lighting Prevention Strategies Minimize objects that can be a source of blunt trauma ie: sharp corners on tables, counters; Padding edges of furniture and equipment Providing an uncluttered pathway; Avoiding scatter rugs Prevention Strategies Susceptibility to dryness and low relative humidity increases as skin ages Overheated homes in the winter months can lead to drying of the skin decrease temperature Hydration need to be distinguished from lubrication Lubrication is the result of coating the skin s surface with an oily covering that prevents water loss. Hypoallergenic moisturizers have a continuous water phase of suspended oil. When the water evaporates, oil is left behind thus hydrating the skin 7

8 Prevention Strategies Protect from trauma during routine care and from self injury Applying hypoallergenic moisturizer at least two times per day Provide protection from trauma during routine care; Keep nails short and filed to prevent self inflicted skin tears Provide protection from self injury Ensure proper transfer and lifting techniques to avoid shearing and friction, lift don t pull gentle care Pad bed rails, or other objects that may lead to blunt trauma Avoid adhesive products on frail skin Prevention Strategies Responsible Bathing Should be based on individual need and preference Should be performed with either soapless product or Ph balanced soaps; gel soap vs. bar soap Involves limiting baths; showering instead with warm, not hot, water Includes the application of hypoallergenic moisturizers post showering while skin is still damp but not wet Prevention Strategies Optimal nutritional intake will improve skin health, assist with the healing of the current skin tear and help with the prevention of future skintears An interprofessional team including a dietician is crucial for patients with chronic wounds, including those at risk for skin tears 8

9 Care & Treatment Clean skin tear with normal saline and control bleeding Document wound assessment: type of skin tear/category using Payne-Martin, flap or pedicle present, not present, surrounding skin appearance, dressing applied and when to change Approximate wound edges when applicable Apply non-adherent contact dressing; Can use calcium alginate if minor bleeding Care & Treatment Apply appropriate secondary dressing depending on wound exudate and location when required Change non-adherent contact layer, as needed or once per week, often depends on the amount of exudate/drainage Skin glue can be used on small or linear type of skin tears, where pedicle is present Initial & healed digital photo (written consent required) Care & Treatment Additional dressing choices Soft silicone based contact layers or mesh Absorbent clear acrylic dressings Calcium alginate dressings Foam dressings Hydrocolloid and or transparent films should be used with caution as they may tear the skin on removal. 9

10 Payne Martin Classification Category I A Linear type (Skin tear without tissue loss) Molnlycke Category I B Epidermal flap completely covers the dermis to within one millimeter of the wound margin Category II A Scant tissue loss type <25% of the epidermal flap lost Category II B Category III > 25% of the epidermal flap lost Epidermal flap is absent What type? Clinical decision Category II B >25% of flap missing Clinical decision Category II A <25% of flap missing Used with permission Molnlycke Healthcare 10

11 Category III Flap missing Clinical decision Category II B >25% flap missing Clinical decision Category II A <25% flap missing Category II A 11

12 Best practice recommandations The key to any treatment program is an established prevention program Education is a key component. It is important for registered and non registered staff and caregivers to be aware of proper techniques for providing care without causing skin tears Best practice recommandations Identify & Treat the Cause Obtain a complete patient history Identify persons at high risk for skin tears Supportpreventionofskin prevention of tears Address patient centered concerns Assess & assist with the development of a patientcentered plan of care Best practice recommandations Local wound care Classify & document according to the degree of trauma Provide an optimal wound healing environment Skin sutures and staples are not a viable option, other methods should be used. Non adherent contact layer, soft silicone, foams, etc. recommended 12

13 Best practice recommandations Provide organizational support Work with an inter professional team Documentation is essential this is an acute wound Educate patient, caregiver, and healthcare professionals Examine your Patients Skin Closely 13