3 Steps to Mastering Skin Tear Management

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Perspective of Nursing Care from Past to Future by Matron Marley

by Margaret Heale, RN, MSc, CWOCN

Hi blog buddies, Matron Marley here. I may be an ex-matron, but I may just have some gems for you. Today I would like to cast the threads (strings even) of time back to when I was a new nurse rather than a matron. The reason being the change happened then. I remembered it today when a rather frail lady caught her arm on a door mechanism. It tore such a huge triangle of her delicate skin, and my goodness did it bleed. I put on the gloves I keep in my pocket and pressed several napkins on it while the nurse went for supplies. She returned promptly with gloves, hand gel, gauze, skin prep, saline, cotton swabs, Xeroform, net and Steri-Strips™ (great invention, right up there with Velcro and cyanoacrylate).

This particular nurse is the skin tear queen. She expertly married up the skin edges with moist cotton swabs. Then she pressed firmly with dry gauze, as she rolled the gauze to lift it off, skin prep was applied, allowed to dry and the Steri-Strip put on. A single layer of Xeroform to allow the passage of fluid through to the gauze and everything secured with a piece of net. She then applied an ice pack and gave the lady a couple of pains pills. The nurse told me that they will fully do the dressing the next day and then every three days, but check it daily for pain, redness and swelling. The expectation is healing in 10-14 days.

The Three-Tiered Skin Tear Dressing Technique

There were a couple of things that impressed me in observing this nurse's approach to dressing the patient's skin tear. The first was that she was well organized, not just by bringing everything needed, but by separating the cleaning part of the dressing from the dressing part. She did not use the gloves that opened the packets of gauze to do the dressing either. This three-tier dressing technique is taught here.

Prep: This includes patient preparation, collecting supplies, checking the order and identifying the patient as well as pain management and positioning. It ends with opening the supplies needed for cleaning the wound, placing the chux and removing the old dressing.

Clean: The second step starts with hand decontamination and putting on fresh clean gloves. Mostly wounds are sprayed with a reusable wound cleanser and the skin cleaned with moist gauze and dried before application of skin prep. After this the chux is turned back for the final portion.

Dress: Fresh gloves are used to alcohol wipe tubes, open packs, etc., prior to donning clean gloves to apply the dressing.

The other thing that impressed me was the way she used the moist cotton swabs to approximate the edges of the flap. It is important to do this as soon as possible as the flap is more likely to remain viable.

Lessons from Years Past

"So what of the strings of time?," I hear you ask. Well, I was a very new nurse, I had only had my buckle a couple of weeks (another blog chapter). We had a male patient with the same injury and, as with all scrapes and grazes, we got out the iodine bottle. It came with a brush incorporated into the lid. After inexpertly trying to get the torn edges to fit together using metal forceps, I painted the whole thing with iodine and protected it with wadding (a firm tissue-paper and cotton wool sandwich). I then did a beautiful bandage from hand to elbow with a non-conforming cotton bandage (wrap). It looked perfect. I went on my days off.

When I returned three days later, we had a problem on our hands: three patients with cellulitis from scrapes and abrasions. The matron was furious that we were using the paint brush that came with the iodine solution. We were meant to apply the iodine with a fresh cotton wool ball, not the special incorporated brush. Did we not know of this important change in practice? Had we not read the monthly hospital update? NO MORE PAINTING FROM PATIENT TO PATIENT WITH THE BRUSH THAT COMES WITH THE IODINE. I cannot believe now that it didn’t occur to me that there was ‘a little infection control issue.’ How shocking is that!

Well, I learned my lesson and now when I see dressings done, I reflect on how things morph from unusual to common, from forward thinking to common sense and from common sense to bedside second nature. The man I did the beautiful bandage on, lost the flap of his skin tear and had to have a series of intra-muscular antibiotic injections for his cellulitis. We were not so fast to give IV drugs back then. The woman I watched our 'skin tear queen' take care of so expertly hardly noticed her injury. She only needed three or four dressing changes and just had a small scar.

The nurse went on to do a wonderful poster presentation called "No More TEARS" with the T of tears dripping like a tear. What a strange language that uses words in such ways! I do hope you only had to read that three times to get it! The pearls from her presentation were that staff need to: slow down, dry skin carefully, slow down, use a little powder (yes, it really can reduce skin tears), slow down, watch elbows shins and the leg rests of wheelchairs, but most of all, slow down. Good skin care with regular daily moisturizing helps the skin to stay supple and resilient. The use of arm sleeves is an awesome idea. We now have a local knitting group that knits us sleeves that are patient specific and go in the laundry. They look so much better than anything from our supply company. Her presentation significantly reduced the numbers of skin tears.

As for the best dressing for skin tears, I have seen so many over the years. The scariest of course is painting with iodine and applying wadding. I remember being really worried when the ER placed many Tegaderm™ dressings all over a woman’s skin-torn leg. Interestingly, it worked beautifully but I think she was lucky as I have also seen disasters from this approach. Using a so called non-stick dressing is almost as bad as using a paint brush (albeit, for a different reason). I really do like the Xeroform – it doesn't need to be dressed daily, supports the skin without any shear and doesn't cost too much. I am not keen on wraps or adhesives so the net is very useful. As always, the best treatment is not a treatment, but prevention.

Let me leave you today with a couple of links to the International Skin Tear Advisory Panel and this consensus document which has many references.

About The Author
Based on her extensive nursing experience Margaret Heale, Wound, Ostomy and Continence Nurse, takes us into the blog journal of a fictitious matron, "Perspective of Nursing Care from Past to Future by Matron Marley."

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.

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Prevention is indeed the key. I created an educational piece with references that includes prevention as well as treatment of skin tears. The research literature indicated that it is easy to cause a new skin tear when you remove the steri-strip or tegaderm, so why not use a gentler protocol?

Gently washing with saline, approximating the edges, using the most minimal steri-stripping necessary to keep the edges in place (which is sometimes none at all), and covering the skin tear with a continuously cleansing pain relieving dressing is the most evidence-based protocol out there. For really fragile skin, stretch netting can keep the dressing in place. This has been tested in hundreds of LTC facilities across the USA and well over 90% of them chose to adopt it. email me if you would like a copy of the fully referenced clinical education piece, policy and procedure.

Linda Benskin, PhD, RN, CWCN, CWS
Clinical Research & Education Liaison and Charity Liaison
Ferris Mfg. Corp.

I would like the skin tear protocol. I am also interested in a continuous pain relieving , anti microbial moist dressing

The Skin Tear Protocol is now available online! It can be downloaded from http://www.polymem.com/ed.html just click on the Skin Tear button to get to the area of the page with the Skin Tear Clinical Education. There is a 180+ center evaluation poster under the Cases tab, as well.

Linda Benskin, PhD,
Clinical Research & Education Liaison, and Charity Liaison
Ferris Mfg. Corp.

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