Empowering and Engaging Nurses Through a Nurse-Driven Skin Tear Protocol

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Skin Tear Protocol


Payne and Martin brought skin tears to the attention of wound and skin specialists and to the wound care community when they reported an incidence rate of 2.23% in individuals aged 55 years and older, living in a long-term care facility. A skin tear is "a wound caused by shear, friction, and/or blunt force resulting in a separation of skin layers."1 Skin tears may be partial- or full-thickness wounds, develop into chronic wounds without proper treatment and follow-up, and, most importantly, are preventable.

Primary Prevention is the Best Skin Tear Management Strategy

Skin tears are often observed in older adults as a result of modifiable and non-modifiable risk factors:

  • Decrease in collagen or elasticity of the skin
  • Dry skin
  • Medications (anticoagulants, steroids, etc.)
  • Trauma (associated with falls)
  • Sun exposure throughout life
  • Genetics

Skin tears are highly prevalent in the older adult population and are often underreported in literature. Skin tears may cause pain, poor mobility, and a decrease in quality of life.1 Skin tears start as acute wounds with the ability to close by primary intention. We hope for healing in 7 to 14 days; however, most residents have multiple comorbidities that prevent or slow healing. The expected rate of healing for a skin tear is 20% to 40% wound reduction in two to four weeks.1


  • Perform risk assessment (a validated risk assessment tool for skin tears does not exist – one of my future goals).
  • Moisturize.
  • Protect.
  • As with all wounds, treat the cause.


  • Systematic approach with non-adherent contact layer and silicone or foam bordered dressing, changing two to three times per week, depending on drainage.

Advances in Skin and Wound Care also discusses the International Skin Tear Advisory Panel (ISTAP) recommendations, specifically:1

  • Treat the cause (dry skin, falls, medications, etc.).
  • Take a systematic approach that is appropriate for partial- and full-thickness skin tears.
  • Address resident-centered goals.
  • Provide appropriate local wound care.

Best practices

  • Provide moist wound healing.
  • Protect fragile skin (periwound and wound bed).
  • Decrease trauma and pain with dressing removal.

Other considerations

  • Tetanus vaccination (depending on the cause of the skin tear)
  • Antimicrobial properties (if infection is suspected)
  • Debridement (depending on assessment findings)
  • Consultation with wound specialist

Nurse-Driven Protocol: Clinical and Professional Results

Skin tears often pose a problem in the long-term care setting, as observed and discussed in the literature. Refer to my previous blog, "Prevention and Treatment of Skin Tears in the Elderly Population," for more about this topic. Additionally, evidence has shown us that a delay in treating a wound with the appropriate treatment may lead to a delay in wound healing. Therefore, a skin tear protocol for prevention and management of skin tears in a long-term care setting is beneficial.

Results and data collection are currently in process, but the trend seems to be faster healing times and increases in nurse satisfaction post implementation of the protocol. Giving nurses autonomy and empowering them to promote positive patient outcomes results in an increased level of nurse satisfaction. Nurses are able to apply an evidence-based protocol that facilitates positive patient outcomes. Additionally, nurses often use this as an opportunity to come up with an individualized plan of care for their patients. For example, the primary nurses are looking at the causes of the skin tears and putting individualized interventions into place (padding wheelchairs, lotion for dry skin, wearing long sleeves, sun protection, discussing medications with the provider, etc.). Empowering our bedside nurses and promoting a culture of evidence-based practice and nurse engagement facilitates improved patient outcomes and increased nurse satisfaction!

1. LeBlanc K, Baranoski S, Christensen D, et al. The art of dressing selection: a consensus statement on skin tears and best practice. Adv Skin Wound Care. 2016;29(1):32–46.

About the Author
Holly is a board certified gerontological nurse and advanced practice wound, ostomy, and continence nurse coordinator at The Department of Veterans Affairs Medical Center in Cleveland, Ohio. She has a passion for education, teaching, and our veterans. Holly has been practicing in WOC nursing for approximately six years. She has much experience with the long-term care population and chronic wounds as well as pressure injuries, diabetic ulcers, venous and arterial wounds, surgical wounds, radiation dermatitis, and wounds requiring advanced wound therapy for healing. Holly enjoys teaching new nurses about wound care and, most importantly, pressure injury prevention. She enjoys working with each patient to come up with an individualized plan of care based on their needs and overall medical situation. She values the importance of taking an interprofessional approach with wound care and prevention overall, and involves each member of the health care team as much as possible. She also values the significance of the support of leadership within her facility and the overall impact of great teamwork for positive outcomes.

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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