Skin tears are a prevalent issue in the older population, whether in hospital or in the community. Older adults are more vulnerable not only to the risk of developing skin tears but also to having a slow healing time and complex problems following the incidence of the skin tear, which can lead to chronic, disabling or life-threatening consequences. Health professionals in the community specifically have a duty to recognise risk and take action to prevent skin tears from occurring in the first place. They can use their knowledge to take action, which can be life changing for patients in their care. This article focuses on the most recent guidance from 2018 from Wounds UK and Wounds International; the latter held a conference to determine the absolute best practice that should be adhered to when attempting to prevent these wounds from occurring in the clinical setting.
What is a skin tear?
First, it is important to clarify what a skin tear is, as there can be some confusion or misconception that it is a minor issue or something far less complex than one might think.
Campbell et al (2018) stated that many of the misunderstandings or misdiagnoses surrounding skin tears have resulted from a more specific terminology to classify them as wounds, causing confusion that results in skin tears often going unrecognised and without documentation. Therefore, an expert working group from Wounds International (2018) defined a skin tear as:
‘… a traumatic wound caused by mechanical forces, including removal of adhesives. Severity may vary by depth (not extending through the subcutaneous layer). Skin tears are traumatic wounds that may result from a variety of mechanical forces such as shearing or frictional forces, including blunt trauma, falls, poor handling, equipment injury or removal of adherent dressings.’
Campbell et al (2018) stated that these are painful wounds the affect quality of life and cause distress to the patient, increasing the likelihood of hospitalisation, while also prolonging hospitalisation time. The authors argued that skin tears are still an unrecognised and under-reported issue, and the new guidelines document produced by Wounds International (2018) was required in order to raise global awareness on the subject. There is a common misconception that skin tears are unavoidable and trivial, when, in fact, skin tears can develop into complex wounds that can become chronic and cause further complications. This, of course, then places a financial burden on health services' limited resources, as well as significantly affecting patients' quality of life.
The risk of skin tears in older people is higher, as they have much more fragile skin. This means less force is required to cause a traumatic injury, so the incidence of skin tears is often increased. Skin tears can occur on any part of the body but are more likely to occur on the extremities, such as the upper and lower limbs or the dorsal aspect of the hands (LeBlanc and Baranoski, 2011). Payne and Martin (1993) first identified skin tears, stating that they are traumatic injuries that can result in partial or full separation of the skin's outer layers, whereby there is a separation of the epidermis from the dermis (partial thickness wound) or both the epidermis and dermis from the underlying structures (full-thickness wound).
Risk factors
To recognise risks in the older people of the community population is paramount when assessing risk for skin tears. This is essential for prevention of not just the skin tear but the huge impact this would also have on patients and health services. There are both intrinsic and extrinsic risk factors for skin tears, as identified by Wounds International (2018):
Intrinsic risk factors
Changes in the skin that result from the normal ageing process make it more fragile and, therefore, far more vulnerable to become damaged. There is a reduced ability of the skin to regenerate and a less efficient protective immune system in older patients, because of which they are at an increased risk of skin breakdown from even minor force or trauma. Therefore, health professionals must prioritise skin care for older people as an essential part of their care of the patient.
The changes to the skin associated with ageing include:
- Thinning of the epidermis
- Flattening of the epidermal junction
- Loss of collagen, elastin and glycosaminoglycans
- Atrophy and contraction of the dermis (causing appearance of wrinkles and folds)
- Decreased activity of sweat glands and sebaceous glands, causing the skin to dry out
- Thinning of blood vessel walls
- Reduction of blood supply to the extremities
- An increased dermal low-echogenic pixels, leading to solar elastosis, which may also represent a risk factor for skin tears, thus indicating that skin tear risk factors might not only represent chronological ageing but also photo-ageing (Wounds International, 2018).
Extrinsic risk factors
Patients who require assistance with activities of daily living-such as mobility, washing and dressing-are at increased risk of skin tears due to handling and force or trauma (Wounds UK, 2015). These are known as extrinsic, or environmental, risk factors.
Of course, these may be found in combination with the intrinsic risks of aged skin also, presenting a complex mixture of risk factors. Therefore, Wound International (2018) concluded that, when caring for patients with vulnerable skin, it is possible to minimise extrinsic risk by taking certain measures. For example, a nurse or carer should keep their fingernails trimmed and not wear jewellery. The same would apply to the patient-if they need a specialist to cut their nails regularly, this should be organised. Padding and/or removing any potentially dangerous furniture or devices, such as bed rails and wheelchairs, is also important, and it is crucial to cover the skin with appropriate clothing, shin guards or retention bandages/stockinettes in vulnerable patients.
Another important consideration is skin care itself: a pH-balanced product is recommended (Carville et al, 2014; Wounds International, 2018), and preventative emollients are of equal importance.
Prevention
It is absolutely crucial that prevention should be the aim when assessing, planning and implementing care for skin tears, as, by controlling modifiable risk factors, skin health can be maintained and injury can be avoided. Wounds International (2018) identified that prevention is based around the same principles as risk factor identification, namely, general health, mobility and skin.
When taking on a new patient or re-assessing a patient who is due a skin health review or has a changed state of health, risk factors must be considered alongside other aspects of care, specifically, the individual patient's needs, the health professional's needs and education and the healthcare setting.
Emollient therapy is a very important component of skin care for older adults. Use of emollients promotes general skin health and twice-daily application has been proven to reduce the incidence of skin tears by 50% (Carville et al, 2014). Emollient products are available as moisturisers (creams, ointments and lotions), bath oils, gels and soap substitutes (National Institute for Health and Care Excellence (NICE), 2015).
Simple emollients function by ‘trapping’ moisture in the skin and reducing water loss by evaporation, whereas emollients that include additional substances known as humectants (e.g. urea) work in a different way by actively drawing water from the dermis to the epidermis and compensating for the reduced levels of natural moisturisers in the skin (Wounds UK, 2015; Wounds International, 2018). It is also important to consider patient choice as well as what is available and affordable, when considering emollient therapy and deciding on the products to use.
Ointments contain more oil than cream emollients, which can make them more effective, but they then tend to be greasier and, therefore, more difficult to remove, which could increase risk of tearing the skin if using some force when rubbing at the skin if someone is unaware of the risk this action would present. Emollients containing humectants produce similar rehydration effects but are less ‘heavy’ and more cosmetically acceptable for patients; therefore, these could improve quality of life alongside improving patient adherence (Wounds UK, 2015).
Many patients in the community may require help with bathing. Their bathing regimen should be considered, with emollient products used as soap substitutes and pH-balanced products used where required. If social care provides a carer for this, then they should be informed by the community nurses of the best products and regimen to use in order to prevent skin tears. Frequency of bathing should be minimised if this is possible in accordance with patient choice. The water temperature should not be too hot so as not to damage the outer skin layer through burns, and care should be taken to pat the patient's skin dry (not rub), with the use of soft cloths and towels that will not be abrasive on the skin.
The skin tear prevention regimen should also involve holistic elements that consider the patient's general health, such as optimising the patient's nutrition and hydration (Wounds International, 2018). Patients at extremes of weight (bariatric, cachectic or excessively thin) will require extra care to prevent skin tears. Polypharmacy should also be considered and appropriate extra care taken. Patients with dementia or mental health issues, such as where aggression is an issue, who also have fragile/aged skin and are at risk of skin tears will require extra measures to prevent skin tears where possible (Wounds International, 2018).
A fall prevention programme is important for at-risk patients. Self-care should be encouraged in suitable patients, to include emollient therapy, encouraging the patient to apply moisturisers themselves where possible, which can be incorporated into the patient's daily routine (Wounds International, 2018).
Counselling the patient on skin tears, preventative measures and general skin health can be beneficial, so the patient is able to monitor their own skin for changes. Patients can also be encouraged to be aware of potential risks and mindful of their environment, therefore avoiding self-injury to fragile skin. A self-care checklist could be given to patients who are able to comprehend and use it, so they are enabled to monitor their own skin health and wellbeing.
The risk of potential trauma among those at high risk of skin tears can be mitigated with a few considerations. This includes avoiding friction and shearing; good manual handling techniques should be ensured, and products such as hoists and glide sheets should be used where required. Padding for equipment and furniture can be used as per health protocol, and a generally safe environment should be ensured-for example, with adequate lighting and without any obstacles-particularly for patients who may have impaired vision or cognition issues. Falls risk assessment should be conducted, as well as confusion or delirium prevention screening.
Education
Education and awareness are vital for both the patient and the health professional to minimise risk of skin tears. Health professionals in all teams involved with the patient should be informed and made aware of risk factors and how these can be minimised. Nurses, healthcare assistants and members of the multidisciplinary care team (e.g. occupational therapists, physiotherapists and other specialists) are involved with patients' individualised care. A multidisciplinary approach to care is vital, where all practitioners are aware of practical risks, general skin health, intrinsic and extrinsic risk factors, in order to minimise risk wherever possible.
Conclusion
Skin tears can present a complex and chronic problem for an older person with fragile skin, and can be very disabling, reducing quality of life dramatically in some cases. The right care is essential from all members of the wider multidisciplinary team in the community for all older patients, in order to identify risk factors for skin tears, as well as for formulating a care plan of prevention that relates to these risk factors. Good skin care is essential, in addition to patient education and identifying ongoing issues with the patient's health that present a factor to consider when caring for them, such as mobility issues. Self-care should be encouraged where possible, and the correct use of and choice of emollients that are pH balanced is crucial. By preventing skin tears, the patient is afforded a better quality of life, and the need for NHS resources is limited.
KEY POINTS
- Skin tears are prevalent among older people as they have more fragile skin
- Skin tears can become a complex wound that remains chronic and disabling, reducing quality of life
- Intrinsic risk factors for skin tears include the aetiology of the patient's condition, while extrinsic factors include level of mobility, mental health and ability to self-care
- The multidisciplinary team involves not only nurses but the wider team of occupational therapists and physiotherapists who can be involved in skin tear prevention
- Emollients twice daily and good skin care is essential, and, when washing the skin, it should be patted dry and not rubbed
- Education of the team and the patient is paramount for skin tear prevention, in addition to regular skin care reviews
CPD REFLECTIVE QUESTIONS
- Discuss an older patient you have cared for in terms of the skin care they required and the condition they presented with: what were the risk factors with this patient and how could skin tears have been prevented? What individualised care plan for skin tear prevention would you formulate for this patient?
- Reflect on care that you have provided for someone with a skin tear – what was the outcome of the patient's condition and who was involved in the care? How was the wound cared for and what changes were made to the patient's general care?