Skin tears are common among the elderly population, both in hospital and in the community. Older adults are especially vulnerable since they experience a slower healing time and are at-risk of developing potentially complex and long-term problems. It is the duty of healthcare workers to recognise and prevent such risks.
What is a skin tear?
Campbell et al (2018) state that many of the misunderstandings or misdiagnoses surrounding skin tears have resulted from a more specific terminology, classifying them as wounds. Such misdiagnoses can lead to skin tears going unrecognised and without documentation. 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) define skin tears as painful wounds affecting quality of life and causing distress to the patient, leading to an increased likelihood of hospitalisation, while also prolonging their stay in hospitals. Skin tears are often an unrecognised and under-reported issue (Campbell et al, 2018), and Wounds International (2018) have subsequently issued guidelines 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 the NHS's limited resources, as well as significantly impacting upon the patient's quality of life.
The risk of tears in the skin of older people is increased due to their fragile skin, due to there being less force required to cause a traumatic injury, such as a puncture or cut. Tears are most likely to occur on the extremities, such as upper and lower limbs or the dorsal aspect of the hands (LeBlanc and Baranoski, 2011). Payne and Martin (1993) first identified skin tears, stating they are traumatic injuries that can result in partial or full separation of the skin's outer layers. In such injuries, 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
Wounds International (2018) have identifed both intrinsic and extrinsic risk factors to skin tears.
Intrinsic risk factors
As the skin ages, it becomes more fragile and therefore, far more vulnerable to damage. Older patients have a reduced ability to regenerate skin and a less efficient protective immune system, which means they are at an increased risk of skin breakdown from minor force or trauma. Therefore, healthcare professionals must make it a priority to ensure that the older person's skin is well-looked after. The changes to the skin associated with ageing include thinning of the epidermis and flattening of the epidermal junction, loss of collagen, elastin and glycosaminglycans, atrophy and contraction of the dermis (causing appearance of wrinkles and folds). They also include decreased activity of sweat glands and sebaceous glands that cause the skin to dry out, thinning of blood vessel walls and a reduction of blood supply to the extremities, and an increased dermal low-echogenic pixels (LEP), including solar elastosis, which may also represent a risk factor for skin tears. This indicates that skin tear risk factors might not only represent chronological ageing, but also photoageing.
Extrinsic risk factors
Patients who require assistance with activities of daily living such as mobility, washing, 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. They, of course, may be combined with the intrinsic risks of aged skin, thus presenting a complex mixture of risk factors. Wounds International (2018) therefore conclude that when caring for patients with vulnerable skin, it is possible to minimise extrinsic risks by taking various measures. For example, a nurse or carer should keep their fingernails trimmed and not wear jewelry, and the same care would apply to the patient-if they need a specialist to cut their nails regularly, this should be organised promptly. Padding and/or removing any potentially dangerous furniture or devices such as bed rails and wheelchairs is also of importance, and it is crucial to cover the skin with appropriate clothing, shin guards or retention bandages/stockinette, in vulnerable patients. Another factor is skincare itself: a pH balanced product, is recommended (Carville et al, 2014; Wounds International 2018), and preventative emollients are of equal importance.
Prevention
It is 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. Prevention should be based around the same principles as risk-factor identification: general health, mobility and skin (Wounds International, 2018).
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, such as the individual patient's needs, the healthcare professional's (HCP) needs and education, and the healthcare setting.
Emollient therapy is an important component of skincare in older adults. This promotes general dermatological health and application twice a day has been found to reduce 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).
Wounds International (2018) state that simple emollients function by ‘trapping’ moisture into the skin and reducing water loss by evaporation. Other 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).
Ointments contain more oil than cream emollients, which can make them more effective, but they then tend to be greasier and hence, more difficult to remove. This could increase the chances of the skin tearing if force is applied when rubbing it, especially if someone is unaware of the risks this action could present. Emollients containing humectants produce similar rehydration effects but are less ‘heavy’ and more cosmetically acceptable for patients, and therefore, could increase quality of life alongside improving patient adherence (Wounds UK, 2015). Wounds International (2018) have stated that 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.
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. The carer should be informed by the community nurses, general practitioners or practice nurses, of the best products and regimen to use to prevent skin tears. Frequency of bathing should be minimised in accordance with patient choice. The water temperature should not be too hot so as to prevent burns and care should be taken to pat the patient's skin dry with soft cloths and towels rather than rubbing it (which is too abrasive and could tear the skin).
It is also important to include holistic care in the skin tear prevention regimen, such as by 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 assessed for and reviewed. Extra measures should be taken to prevent skin tears in older individuals with fragile/aged skin, who also have dementia or other mental health issues, especially those individuals demonstrating aggressive behaviour (Wounds International, 2018).
A fall prevention programme for at-risk patients is also important and should be implemented. Counselling the patient on general skin health and prevention of tears can be beneficial, enabling the person to monitor their own skin. Patients can be encouraged to be aware of potential risks and be 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 can monitor their own skin health and wellbeing.
Consideration should be given to at-risk patients, with a care regimen that incorporates the prevention of friction and shearing, ensuring the use of good manual handling techniques and products. These include provisioning the patient with hoists and glide sheets where required, padding for equipment and furniture, or as per health protocol. It should be ensured that the patient lives in a safe environment, by checking that there is adequate lighting, and removeing any obstacles-particularly in patients who may have impaired vision or cognition issues, conducting falls risk assessments, conducting confusion or delirium prevention screening and encouraging use of protective clothing/devices where required.
Education
Education and awareness is vital for both, the patient and the healthcare professional, to minimise risk of skin tears. HCPs in the team and in other teams who are involved with the patient should be informed and made aware of risk-factors and how these can be minimised. It is always important to remember that nurses, healthcare assistants and all members of the multidisciplinary care team (e.g occupational therapists, physiotherapists, other specialists) are involved with the patient's individualised care. A multidisciplinary approach to care is of paramount importance, involving all practitioners being aware of general skin health and practical risks, both intrinsically and extrinsically, especially in older patients with fragile skin, in order to minimise risk wherever possible. Education is also key in risk reduction throughout the care of the older person.
Key points
- Skin tears are prevalent among older people as they have more fragile skin
- Intrinsic risk factors involve the aetiology of the patient's condition
- Extrinsic risk factors involve level of mobility, confusion, and ability to care for self
- The multidisciplinary team involves not only nurses but the wider team of occupational therapists and physiotherapists that can be involved in skin tear prevention
- Skin tears can become a complex wound that remains chronic and disabling, reducing quality of life
- 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 of paramount importance, as well as regular skin care reviews.