Skin Tears: Prevention and Management
by Laurie Swezey RN, BSN, CWOCN, CWS, FACCWS
Skin tears are a common problem among the elderly due to increased skin fragility associated with aging. Due to the increasing prevalence of this problem, and the potential for poor and/or delayed wound healing in the elderly population, nurses should be aware of prevention strategies for skin tears, as well as management of skin tears once they have occurred.
Prevention of Skin Tears
Prevention of skin tears begins with identifying individuals who are at high risk for skin tears. Individuals at high risk are those who have suffered skin tears before, individuals with chronically dry skin, individuals with little or no subcutaneous fat and those who are also at high risk for falls. As you may have noticed, this describes almost the entire elderly population.
Prevention strategies should include:
- assessment of the skin on admission and routinely throughout the patient's stay
- optimization of nutrition status (which may require dietary/nutrition support)
- increasing moisture content of the skin with regular use of emollients/moisturizers
- protection of the skin using clothing (i.e., long sleeves, knee-high socks and pants) or commercial products (i.e. shin guards, padded sleeves)
- education regarding safe patient handling techniques for caregivers, including family members
- safeguarding the patient's environment (i.e., padding corners of furniture, adequate lighting, removal of rugs or other tripping hazards, use of appropriate aids to move patients)
Management of Skin Tears
Despite our best efforts at prevention, skin tears still occur. Should your patient experience a skin tear, management should involve the following:
- control bleeding- apply light pressure until bleeding has subsided
- classify the skin tear based on an approved classification system (i.e., Star, Payne & Martin, ISTAP)
- cleanse the wound using water or normal saline
- realign the wound edges using a moistened q-tip or your gloved finger to gently line up the edges of the flap with the surrounding tissue
- apply an appropriate dressing (i.e., colloid or silicone-based mesh and foam dressing, calcium alginate, and select securement products that provide prolonged dressing wear-time and gentle removal. If the wound is bleeding; do not use adhesive strips)
Avoid removing the dressing for several days if possible. Mark the preferred direction of removal on the outside of the dressing so that the person removing the dressing does not inadvertently reopen the skin tear. Use a stocking-type dressing or tubular bandage to secure the dressing in place. When it is time to perform a dressing change, take care to remove the dressing in the direction indicated by the arrow, so as not to disturb the wound flap. Observe the wound for signs of infection and note the color of the flap tissue- if it is dusky or dark in color, this may indicate that the flap is non-viable.
Skin tears made easy. Wounds International 2(4) November. http://www.woundsinternational.com/made-easys/skin-tears-made-easy/page-2
Bianchi J (2012) Preventing, assessing and managing skin tears. Nursing Times; 108: 13, 12-16. http://www.nursingtimes.net/nursing-practice/clinical-zones/wound-care/p...
About The Author
Laurie Swezey RN, BSN, CWOCN, CWS, FACCWS is a Certified Wound Therapist and enterostomal therapist, founder and president of WoundEducators.com, and advocate of incorporating digital and computer technology into the field of wound care.
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.