BACKGROUND AND STATEMENT OF THE PROBLEM

A.  Traumatic wounds from mechanical injury of skin

B.  Need to clearly differentiate etiology of skin tears from PU

C.  Common in the older adult, especially over the areas of age-related purpura

PARAMETERS OF ASSESSMENT

A.  Use either the three-group risk-assessment tool (White et al., 1994) or the ISTAP (LeBlanc, Baranoski, Christensen et al., 2013; LeBlanc et al., 2018) recommendations to assess for skin tear risk.

B.  Use ISTAP-validated simplified classification system to classify skin tears (LeBlanc, Baranoski, Christensen et al., 2013; LeBlanc et al., 2018).

1. Type 1: a skin tear with no skin loss
2. Type 2: a skin tear with partial flap loss
3. Type 3: a skin tear with total flap loss

IV. NURSING CARE STRATEGIES AND INTERVENTIONS

A.  Preventing skin tears (Baranoski, 2000; Baranoski & Ayello, 2012; LeBlanc, Baranoski, Christensen et al., 2013, 2016; LeBlanc et al., 2018)

1. Provide a safe environment:
   • Do a risk assessment of older adult patients on admission.
   • Implement prevention protocol for patients identified as at risk for skin tears.
   • Have patients wear long sleeves or pants to protect their extremities (Bank, 2005).
   • Have adequate light to reduce the risk of bumping into furniture or equipment.
   • Provide a safe area for wandering.
2. Educate staff or family caregivers in the correct way to handle patients to prevent skin tears. Maintain nutrition and hydration:
   • Offer fluids between meals.
   • Use lotion, especially on dry skin on arms and legs, twice daily (Hanson et al., 1991).
   • Obtain a dietary consultation.
3. Protect from self-injury or injury during routine care:
   • Use a lift sheet to move and turn patients.
   • Use transfer techniques that prevent friction or shear.
   • Pad bed rails, wheelchair arms, and leg supports (Bank, 2005).
   • Support dangling arms and legs with pillows or blankets.
   • Use nonadherent dressings on frail skin.
     • Apply skin-protective products (creams, ointments, liquid sealants, and so forth) or a nonadherent wound dressing, such as hydrogel dressing with gauze, as a secondary dressing, silicone, or Telfa-type dressings.
   • Use gauze wraps, stockinettes, flexible netting, or other wraps to secure dressings rather than tape.
   • Use no-rinse, soapless bathing products (Birch & Coggins, 2003; Mason, 1997).
   • Keep skin from becoming dry; apply moisturizer (Bank, 2005; Hanson et al., 1991).

B.  Treating skin tears (Baranoski & Ayello, 2012; LeBlanc, Baranoski, Christensen et al., 2013, 2016; LeBlanc et al., 2018)

1. Gently clean the skin tear with normal saline.
2. Let the area air dry or pat dry carefully.
3. Approximate the skin tear flap.
4. Use caution when removing dressings as skin damage can occur when removing dressings (LeBlanc, Baranoski, Christensen et al., 2016).
5. Consider adding an arrow on the dressing to indicate the direction of the skin tear to minimize any further skin injury during dressing removal.
   1. Skin sealants, petroleum-based products, and other water-resistant products, such as protective barrier ointments or liquid barriers, may be used to protect the surrounding skin from wound drainage or dressing, or tape-removal trauma.
   2. Always assess the size of the skin tear; consider doing a wound tracing.
   3. Document assessment and treatment findings.

EVALUATION AND EXPECTED OUTCOMES

A.  No skin tears will occur in at-risk patients.

B.  Skin tears that do occur will heal.

FOLLOW-UP MONITORING OF CONDITION

A.  Continue to reassess for any new skin tears in older adults.

ABBREVIATIONS

CMS            Centers for Medicare & Medicaid Services

EPUAP       European Pressure Ulcer Advisory Panel

ISTAP         International Skin Tear Advisory Panel

NMF            Natural moisturizing factor

NPUAP       National Pressure Ulcer Advisory Panel

PI                 Pressure injuries

PPPIA         Pan Pacific Pressure Injury Alliance

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Updated: November 2020

Boltz PhD, RN, GNP-BC, FGSA, FAAN, M., Capezuti PhD, RN, FAAN, E., Zwicker DrNP, APRN, BC, D., & Fulmer PhD, RN, FAAN, T. T. (2020). Evidence-Based Geriatric Nursing Protocols for Best Practice (6th ed.). Springer Publishing. Retrieved November 4, 2020, from https://www.springerpub.com/evidence-based-geriatric-nursing-protocols-for-best-practice-9780826188144.html#description

Chapter 28: Persaud-Jaimangal, R., Ayello, E., & Sibbald, G. (2021) Preventing Pressure Injuries and Skin Tears.  In M. Boltz, E. Capezuti, D. Zwicker & T. Fulmer (eds.).  Evidence-Based Geriatric Nursing Protocols for Best Practice (6th ed. pp 501-525).   New York: Springer.