THE FIRST PART of this series, which appeared in the December issue of Nursing2010, focused on skin tear types and risk factors for these traumatic wounds. This article focuses on managing and preventing skin tears.
Your interventions for a patient with a skin tear are similar to those you'd use to manage other wounds.1,2
* Address factors that affect wound healing. Many factors can hinder the wound healing process, including medications such as immunosuppressants, anti-inflammatory agents, and anticoagulants; smoking; underlying disease states; and local wound conditions (high bacterial burden, necrotic tissue in the wound bed, and excessive moisture).2 Work closely with the healthcare team to manage and control these issues. Follow best practice guidelines for wound bed preparation and dressing selection.
* Provide nutritional support. An interdisciplinary team approach is crucial for patients with wounds, so involve the nutritionist in the patient's care.3,4
* Control pain. Uncontrolled pain can undermine the patient's quality of life and well-being. Administer analgesics, as appropriate, to manage skin tear-associated pain.5-7 Work with the healthcare team to determine the best strategies for managing the patient's pain. Remember that skin tears frequently occur on the arms, are visible, and can cause psychological pain and stress that can increase physical pain.6,8 An appropriate dressing can help pain management by protecting the site from further trauma and promoting moist wound healing.9 (More on dressings shortly.)
Closing and dressing the tear
Unlike chronic wounds, skin tears are acute wounds that may be closed by primary intention. Although sutures or staples typically are used to close wounds by primary intention, this often isn't a viable option given the fragility of older adults' skin.5,6 A feasible option is to approximate the edges of the skin tear or flap tissue as close as possible and secure them in place with skin closure strips or a 2-octyl cyanoacrylate topical bandage.6,8
When approximation isn't an option and the wound shows no evidence of infection, follow the general principles of dressing selection, being sure to choose a product that won't further damage periwound skin.6,10,11 Choices may include silicone-based mesh or foam products, absorbent transparent dressings, calcium alginate dressings, or foam dressings.12,13 Use hydrocolloids or traditional film dressings cautiously, as they may cause skin stripping if not removed properly. Putting an arrow on the dressing to indicate the direction of the skin tear can help minimize further skin injury during dressing removal.14
Because these are tetanus-prone wounds, they may require immunization if the patient hasn't had a tetanus vaccine in the last 5 years. If the skin tear is infected or extensive, the wound should be assessed by the healthcare provider, wound ostomy continence nurse, or another wound-care specialist to determine the best treatment options.
Preventing skin tears
Skin tears can be relatively simple to prevent if healthcare providers take time to identify patients at high risk and implement a prevention protocol. Although validated risk assessment tools are available for predicting pressure ulcer risk, the same isn't true for skin tears.5,6 Assess patients for risk factors on admission and whenever their condition changes, and follow a systematic prevention protocol.
Some prevention strategies include:
* having at-risk patients wear long sleeves, long pants, or knee-high socks
* providing shin guards for patients who repeatedly experience skin tears to the shins
* ensuring a safe environment with adequate lighting. Minimize the risk from objects or equipment that could cause blunt trauma; for example, by padding wheelchair arms and leg supports.5,6,11,15
Involve patients and their family members in skin tear prevention.5 All caregivers need to know how to provide care without causing skin tears. Take these steps:
* moisturize the patient's skin by applying lotion at least two times per day
* minimize bathing and use an emollient antibacterial soap
* use proper transfer and lifting techniques to avoid shearing and friction when transferring or moving patients
* pad bed rails, wheelchair legs, and other objects that may lead to blunt trauma
* promote adequate nutrition and hydration
* avoid adhesive products on frail skin. If dressings or tapes are required, use paper tapes or silicone dressings to avoid skin stripping when adhesives are removed. You also can tape onto hydrocolloid strips applied around the wound.5,6,11
Keeping it together
Skin tears are a common problem for older adults. By taking steps to prevent injuries, you can help patients avoid these painful wounds.
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13. LeBlanc K, Christensen D, Cuillier B. Managing skin tears in long-term care. Poster presentation at the Canadian Association of Wound Care annual conference, Montreal, Quebec. 2005. [Context Link]
14. Ayello EA, Sibbald RG. Preventing pressure ulcers and skin tears. In: Capezuti E, Zwicker D, Mezey M, Fulmer T, eds. Evidence-based Geriatric Nursing Protocols for Best Practice. 3rd ed. New York, NY: Springer; 2008. [Context Link]
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