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Clinical FocusStrazzieri-Pulido et al, 2015), and 30% in palliative caresettings (Maida et al, 2012). In the paediatric acute caresetting, one study reported a skin tear prevalence of17% (McLane et al, 2004). A recent audit of in-patientsin acute hospitals across Wales identified a prevalenceof 2.57% (Clark et al, 2017).Predisposing risk factorsSkin tears are more prevalent with, but not limitedto, the extremes of age, for example the physiologicalcharacteristics of neonatal/infant skin may affect theskin’s ability to resist shear, friction and/or blunt force(LeBlanc et al, 2011). Infant skin is not fully maturedand remains at high risk of skin tears until 3 years ofage. Furthermore, skin changes related to extremesof age and those who are critically or chronically illput these patients at higher risk (LeBlanc et al, 2011).Dry skin (xerosis) in combination with advancing ageTable 1. Modifiable and non-modifiablerisk factors for skin tearsModifiable risk factorsNon-modifiable riskfactorsXerosisPruritusTypes of medical adhesives usedCare during activities of daily livingFalls riskMedicationsNutritional statusTraumaHealth professionals’ approachto managing individuals withaggressive behaviour/cognitiveimpairmentPhoto-ageingSkin changes with ageingincluding dermatoporosisCritical and chronic illnessDementia/cognitive ive behaviourRequiring assistance withactivities of daily livingFrom: LeBlanc et al (2013b)Table 2. ISTAP guide for the prevention of skin tears 2018 MA Healthcare LtdRisk factorIndividualCaregiver/providerGeneral health Self-management approach(if cognitive function not impaired) Educate patient on skintear prevention and promoteactive involvement in treatmentdecisions (if cognitive functionis not impaired) Optimise nutrition and hydration Educate patients on medicineinduced skin fragility (e.g. topicaland system steroids) Safe patient environment Educate client and/or circle of caregivers Protect from self-harm Dietary consult if indicated Extra caution with extremes of body mass index ( 20 or 30kg/m2) Review polypharmacy for medication reduction/optimisation Medical review of comorbidities for improved management Educate caregivers on gentle patient handling Educate caregivers on skin fragility with extremes of age Educate caregivers on medicine-induced skin fragility (e.g. topicaland system steroids)Mobility Encourage active involvementif physical function not impaired Appropriate selection and useof assistive devices Daily skin assessment and monitor for skin tears Ensure safe patient handling techniques/equipment and environment(trauma, activities of daily living, self-injury) Physical therapy consult to assess and improve mobility and assistwith safe transfers Proper transferring/ repositioning Initiate fall assessment and prevention program Remove clutter Eliminate scatter rugs Ensure proper lighting Pad equipment/furniture (bed rails, wheel chair, etc.) Assess footwear Educate caregivers to lift rather than pull Use protective clothing/devices, e.g. stockinette, long sleeves,shin guardsSkin Awareness of medicationinduced skin fragility (e.g. topicaland system steroids) Wear protective clothing (shinguards, long sleeves, etc) Moisturise skin (lubrication andhydration) twice a day Keep fingernails short Individualise skin hygiene (warm, tepid, not hot, water; soapless orpH-neutral cleansers; moisturise skin twice a day) Avoid strong adhesives, dressings, tapes Avoid sharp fingernails/jewelry with patient contact Use room humidifier if air dry Maintain a room temperature that is not too hot Control oedemaFrom: LeBlanc et al (2013b)Nurse Prescribing 2018 Vol 16 No 12 601Downloaded from magonlinelibrary.com by 068.231.162.179 on November 5, 2019.

Clinical FocusGeneral health Chronic/critical disease, polypharmacy,impaired: congnitive, sensory, visual,auditory, nutritionMobility History of falls, impaired mobility,dependant for activities of daily living(ADL), mechanical traumaSkin Extremes of age, fragile skin, previousskin tearsNo riskReassess with changeof statusAt risk: 1 or more of the riskfactors listed aboveHigh risk: visualimpairment, impairedmobility, dependent ADL,extremes of age, fragile skinand previous skin tearsImplement Skin TearReduction ProgramSee ISTAP Quick ReferenceGuide and/or ISTAP RiskReduction ProgrammeFigure 1. ISTAP Skin Tear Risk Assessment Pathway(LeBlanc et al, 2013b)results in pruritus (Carville et al, 2014), which leadsto itching due a decrease in skin moisture. This typeof mechanical trauma can predispose the patient toskin tears (White et al, 1994). Changes with ageingcan also decrease sensation and lead to increasedrisk of mechanical trauma, this in combinationwith associated comorbidities may result in delayedwound healing (McGough-Csarny and Kopac,1998). Dermatoporosis is a term that has beendeveloped to group the common skin changes thatoccur with advanced ageing (Kaya and Saurat, 2007;2013). These include ecchymosis, senile purpura,haematoma and stellate pseudoscars. In clinicalpractice it can be difficult to differentiate betweenthese skin changes.LeBlanc et al (2013b) have identified modifiableand non-modifiable risk factors that can helpto prevent the risk of skin tears (Table 1). These602 risk factors need to be addressed in any plan forpreventing skin tears (All Wales Tissue ViabilityForum, 2015).Skin tear preventionPrevention and/or reduction of the incidence of skintears is possible, but it requires the involvement ofboth the individual patient and caregivers to increasethe likelihood of success. ISTAP has developed a tableas a quick reference guide for reducing the risk andpreventing skin tears (Table 2). While a number ofintrinsic factors contribute to an increased risk of skintears (e.g. dry, thin, inelastic tissue; impairedcognition; agitation; impaired nutrition), there arealso extrinsic factors (Table 3) that can be managedto reduce the risk and prevent skin tears (StephenHaynes and Carville, 2011). ISTAP has also developeda ISTAP Skin Tear Risk Assessment Pathway, whichidentifies those at risk and link the patients at risk toa prevention programme (Figure 1.) Education of thepatient and caregivers is important as is managementof the environment to enhance patient safety(Stephen-Haynes and Carville, 2011).Skin tear assessmentReliable and accurate wound descriptions anddocumentation are essential components of any woundassessment (Stephen-Haynes and Carville, 2011). Aspart of the daily assessment of an individual, nursesshould look for the presence of any lesions includingskin tears. One resource that nurses can use is the DataCollection Tool developed by ISTAP, which is part ofthe Tool Kit (LeBlanc et al, 2013b). This tool has sevencomponents that need to be assessed for each skin tear.In addition, the measurement of each skin tear,drainage amount and colour should be documented(Stephen-Haynes, 2013). Each healthcare setting andagency needs to develop a protocol that all healthprofessionals follow to ensure consistency in theassessment of skin tears. Assessment data can providethe healthcare provider a mechanism to communicate,improve continuity among disciplines and establishappropriate treatment modalities.Skin tear managementSkins tears should be managed with the same principlesas other wounds (Baranoski et al, 2016), using asystematic and holistic approach (Clothier, 2014). Thekey areas include: Primary prevention is considered the key tomanagement of skin tears. Introduce and documenta prevention plan to prevent further trauma. Educatethe patient and circle of care in prevention andmanagement of skin tears Identify and treat the cause. Remove or minimise thecause of the skin tear (Le Blanc et al, 2011; Baranoskiet al, 2011). For example, if the cause is secondaryNurse Prescribing 2018 Vol 16 No 12Downloaded from magonlinelibrary.com by 068.231.162.179 on November 5, 2019. 2018 MA Healthcare LtdISTAP Skin Tear Risk Assessment Pathway

Clinical Focusto falls, a falls prevention programme needs to beimplemented Address patient and family centred concerns.Control pain by offering analgesia (Beldon, 2008).Acknowledge and address the patient and familybeliefs, cultural and psychological variables whileformulating a management plan (Le Blanc et al,2011). Minimise the negative influence of theskin tear on the individual and their care givers toimprove activities of daily living and quality of life Determine the healing potential of the skin tear.When the skin tear occurs on the lower limb, it isessential to take a comprehensive clinical historyand vascular assessment, such as using a Dopplerultrasound to obtain the ankle brachial pressureindex, or viewing the wave form to rule out anysignificant peripheral vascular disease; beforeapplying compression therapy to manage anyperipheral oedema in either arms or legs (ErwinToth and Stenger, 2007) Local wound care. Remove any existing dressingwithout damaging the peri-wound and interruptingthe healing process. Control bleeding by applyingpressure and elevating the limb if applicable. Aninitial dressing selection may be one that promotesclotting, such as a calcium alginate. Cleanse thewound with a non-cytotoxic solution, e.g. normalsaline or potable water, irrigating the wound at apressure less than 8psi to remove blood clots anddebris from the skin flap (LeBlanc et al, 2008).ISTAP also suggest that the principles of WoundBed Preparation and TIME be used to guide woundassessment (Sibbald et al, 2011; Schultz et al, 2003).These principles include:Tissue/debridementDebride non-viable skin flaps. Realign the viable skinflap (the pedicle), approximating the wound edges, tothe extent possible. Figures 2–7 show the procedurefor cleansing the wound and re-approximating the flapedges using a moistened swab.Skin tears are considered to be acute wounds that havethe potential to be closed by primary intention (LeBlancet al, 2016). Sutures and staples are not recommendeddue to the fragility of elderly skin (Le Blanc et al, 2011).Traditional adhesive strips are no longer advised dueto their adhesive nature increasing risk of skin injury(LeBlanc et al, 2016; Stephen-Haynes and Callaghan,2017). Therefore, other methods of wound closuremay need to be considered such as topical skin glue i.e.cyanoacrylates (Le Blanc et al, 2016). 2018 MA Healthcare LtdInfectionSkin tears do not generally need to be debrided.However, the wound bed needs to be thoroughly cleaned.Covert and overt infection should be managed witha topical antimicrobial and spreading and systemicNurse Prescribing 2018 Vol 16 No 12 Table 3. Skin tear bdomenButtocksOtherType (using the ISTAPClassification System)Type 1 – no skin lossType 2 – partial flap lossType 3 – total flap lossCauseDuring activities of daily livingBlunt force traumaFrom a fallAdhesive/tape injuryResisting care/agitationUnknownWhere did the skintear occur?Critical careAcute careLong-term careHome careRehabPalliative careOtherFacility acquiredYesNoIntrinsic factorsSenile purpuraEcchymosisHaematomaPresence of oedemaInability to reposition independentlyTopical steroid useSystemic or long-term steroid useAnticoagulantsChemotherapy agentsCo-existing pressure ulcerFecal or urinary incontinenceExtrinsic factorsRemoval of tape or stockingsInadequate nutritionPolypharmacyUsing assistive devicesBlood drawsTransfers and/or fallsProsthetic devicesSkin cleansersFrom: LeBlanc et al (2013b)infection with systemic and topical antimicrobials(International Wound Infection Institute, 2016). Tetanusimmunoglobulin should be administered if the patienthas not been vaccinated with tetanus toxoid in the past10 years, before debridement to prevent the potentialrelease of exotoxin (Carden and Tintinalli, 2004).603Downloaded from magonlinelibrary.com by 068.231.162.179 on November 5, 2019.

Clinical FocusMoistureIt is important to promote moist wound healing,ensuring moisture balance and preventing peri-woundskin maceration. The peri-wound should be protectedwith a skin barrier product.Epidermal marginsSkin tears should typically follow acute wound healingtrajectory of 7–14 days (Le Blanc et al, 2008). Ifhealing takes longer, re-evaluate. Refer to a woundcare specialist when the skin tear is infected orextensive (Le Blanc et al, 2016).Dressing selectionFollowing a systematic review by ISTAP and a widerconsultation of an international group of healthprofessionals, recommendations were suggested forthe selection of dressings (Appendix 1) (Le Blanc etal, 2016). From the consensus process dressings suchas films and hydrocolloids were not included in therecommendations due to their adhesive properties.Iodine dressings were also omitted due to their dryingnature. Furthermore, honey dressings were left outdue to the high risk of peri-wound maceration,although more recent evidence has suggested thatleptospermum honey-based dressings have beenreported to be effective without causing maceration(Johnston and Katzman, 2015).Reassessment of the skin tear should takeplace approximately every 3-7 days and carefulconsideration given to whether the dressing needschanging. If a patient has very fragile skin it ispreferable to leave the dressing in place for up to5 days to avoid further trauma to the skin flap(Stephen-Haynes, 2013). Where a change of dressingis required, and to promote flap viability, the dressingshould be removed in the direction of the pedicle,rather than against it.Specifying the skin tear classification (Figure 8), sizeand shape and the direction for dressing removal onthe dressing can be a useful visual means of conveyingthis information (Holloway and Le Blanc, 2017).Figure 2. Cleanse the woundFigure 3. Use two moistened cotton tipped swabs tobegin to re-approximate the edgesFigure 4. Slowly re-approximate the edgesSkin tears are largely unrecognised acute wounds,that can become chronic and complex if not assessedand treated. ISTAP recommend the use of guidingprinciples such as WBP and TIME to guide assessmentand management. This article reviewed the prediction,prevention, assessment and management of skin tears.There are still gaps in the evidence with regards to theprevalence, incidence, population specific risk factorsand prevention strategies for skin tears. Currently,treatment recommendations are largely based onexpert opinion; therefore, more research is needed toidentify how treatment options impact on the healingof skin tears.604 Figure 5. Slowly re-approximate the edgesNurse Prescribing 2018 Vol 16 No 12Downloaded from magonlinelibrary.com by 068.231.162.179 on November 5, 2019. 2018 MA Healthcare LtdConclusion

Clinical FocusKey Points Skin tears are a common, but largely unrecognised acutewound that if left untreated can become chronic and complex Healthcare facilities should implement a skin tear preventionprogramme Educate both healthcare providers and patients/families on theprevention and treatment of skin tears Use the ISTAP website for the most up-to-date information onskin tears skintears.orgFigure 6. Once the edges are re-approximated pat theskin flap on the wound bed to ensure adhesionCPD reflective questions What is the prevalence of skin tears in the palliative caresetting? Identify five modifiable risk factors for skin tears? Define what a type 2 skin tear is? How would you deal with thisin practice?All Wales Tissue Viability Nurse Forum. Prevention and managementof skin tears. London:Wounds UK; 2015Amaral AF, Pulido KC, Santos VL. Prevalence of skin tears amonghospitalized patients with cancer.[Article in Portuguese]. Rev EscEnferm USP. 2012;46 Spec No:44-50Figure 7. Final outcome of the process ofre-approximating the edgesBaranoski S, LeBlanc K, Gloeckner M. CE: Preventing, Assessing,and Managing Skin Tears: A Clinical Review. Am J Nurs.2016;116(11):24–30Baranoski S, Ayello EA, Langemo D. Wound assessment. In:Baranoski S, Ayello EA, eds. Wound Care Essentials: PracticePrinciples. 3rd ed. Ambler, PA: Lippincott Williams & Wilkins.101– 125; 2011Beldon P. Management options for patients with pretibial lacerations.Nurs Stand. 2008;22(32):53–54, 56, 58 passimISTAP skin tear classificationCarden DL, Tintinalli JE. Tintinalli Emergency medicine: acomprehensive study guide. 6th ed. Irving: TX American Collegeof Emergency Physicians; 2004Carville K, Smith J. Report on the effectiveness of comprehensivewound assessment and documentation in the community. PrimaryIntention: The Australian Journal of Wound Management.2004;12(1):41Carville K, Leslie G, Osseiran-Moisson R, Newall N, Lewin G. Theeffectiveness of a twice-daily skin-moisturising regimen forreducing the incidence of skin tears. Int Wound J. 2014;11(4):446–453 2018 MA Healthcare LtdType 1: noskin lossType 2:partial flaplossType 3: totalflap lossLinear or flaptear which canbe repositionedto cover thewound bedPartial flap loss Total flap losswhich cannot be exposing entirerepositioned to wound bedcover the woundbedFigure 8. ISTAP skin tear classification(LeBlanc et al, 2011) (Used with permission)Nurse Prescribing 2018 Vol 16 No 12 Clark, M, Semple MJ, Ivins N et al. National audit of pressure ulcersand incontinence-associated dermatitis in hospitals across Wales:a cross-sectional study. BMJ Open. 2017;7(8):e015616. r A. Assessing and managing skin tears in older people.Independent Nurse. 2014; 8(5):23–26Everett S, Powell T. Skin tears - the underestimated wound. PrimaryIntention 1994; 2(1):28–30Erwin-Toth P, Stenger B. Teaching wound care to patients, familiesand healthcare providers. In: Krasner D, Rodeheaver G, Sibbald G,eds. Chronic Wound Care: A Clinical Source Book for HealthcareProfessionals. 4th ed. Wayne, PA: HMP Communications; 2007Holloway S, LeBlanc K. Dealing with Skin Tears. J Nurse Pract. 2017;22:64–66International Wound Infection Institute. Wound Infection in ClinicalPractice. Wounds International; 2016605Downloaded from magonlinelibrary.com by 068.231.162.179 on November 5, 2019.

Clinical FocusJohnston C, Katzman M. A Clinical Minute: Managing Skin Tearswith Medihoney. Ostomy Wound Manage. 2015;61(6)McLane KM, Bookout K, McCord S, McCain J, Jefferson LS. The 2003national pediatric pressure ulcer and skin breakdown prevalencesurvey: a multisite study. J Wound Ostomy Continence Nurs.2004;31(4):168–178Kaya G, Saurat JH. Dermatoporosis: a chronic cutaneousinsufficiency/fragility syndrome. Clinicopathological features,mechanisms, prevention and potential treatments. Dermatology.2007;215(4):284–294McErlean B, Sandison S, Muir D, Hutchinson B, Humphreys W.Skin tear prevalence and management at one hospital. PrimaryIntention: The Australian Journal of Wound Management.2004;12(2):83Kaya G, Saurat J. Dermatoporosis: A new concept in skin aging. EurGeriatr Med. 2013;166(1):440LeBlanc K, Christensen D, Orsted H, Keast D. Best practicerecommendations for the prevention and treatment of skin tears.Wound Care Canada. 2008;6(1):14–30McGough-Csarny J, Kopac CA. Skin tears in institutionalized elderly:an epidemiological study. Ostomy Wound Manage. 1998;44(3A)Suppl:14S–24S, discussion 25SLeBlanc K, Baranoski S, Christensen D et al; Skin Tear ConsensusPanel Members. Skin tears: state of the science: consensusstatements for the prevention, prediction, assessment, andtreatment of skin tears . Adv Skin Wound Care. 2011;24(9)Suppl:2–15Schultz GS, Sibbald RG, Falanga V et al. Wound bed preparation:a systematic approach to wound management. Wound RepairRegen. 2003;11 Suppl 1:S1–S28Sibbald RG, Goodman L, Woo KY et al. Special considerations inwound bed preparation 2011: an update . Adv Skin Wound Care.2011;24(9):415–436, quiz 437–438LeBlanc K, Christensen D, Cook J, Culhane B, Gutierrez O.Prevalence of skin tears in a long-term care facility. J WoundOstomy Continence Nurs. 2013a;40(6):580–584Strazzieri-Pulido KC

Nov 05, 2019 · In the paediatric acute care setting, one study reported a skin tear prevalence of 17% (McLane et al, 2004). A recent audit of in-patients in acute hospitals across Wales identified a prevalence of 2.57% (Clark et al, 2017). Predisposing risk factors Ski