Preventing Skin Tears in Nursing Home Patients

Skin Tear Care



Evelyn Smith

M. S. in Library Science, University of North Texas (2012)

Any family member who has received a phone call at the end of a nurse's shift about a loved one's recently discovered skin tear will welcome this bibliography of articles on the causes and prevention of skin tears. Nurses and attendants will also benefit from these references.

Personal experiences, however, occasion the research that resulted in this Web page.  Although my STEM class that inspired one of the primary topics of this blog,  Mild Cognitive Impairment, ended in May 2011, Mother is now in her third year of living on a hospice ward of a nursing home that specializes in the care of dementia patients since she needs help with all her activities of daily living.  Her skin  is paper thin not only because she is now 87, but also because even though she is given a liquid  multiple vitamin daily, and  the staff dietician and the ward’s charge nurse routinely monitor her food and water intake, she  rarely goes outside the building, so her skin lacks the vitamin D nutrients that it otherwise would have.

However, providing a diet rich in vitamins  C, D, and E and when weather permits making sure that she receives a sunbath in warm weather of about ten minutes daily, using a PH-neutral cleanser and moisturizing her skin in the morning and at night, and dressing her in long sleeves, cotton gardener gloves, and pants might help prevent some future skin tears.  Nevertheless, since the cause of some skin tears must remain a mystery, the careful covering of her skin tears with dressings and adhesives that will not further damage the skin is also necessary. 

Bank, D. (2006, August 31).  Preventing skin tears in a nursing and rehabilitation center: An interdisciplinary effort. OWN: Ostomy Wound Management.  Retrieved from
http://www.ncbi.nlm.nih.gov/pubmed/16980728

A connection exists between dry skin and skin tears because dry skin makes aging skin more susceptible to trauma. Trauma, in turn, makes for more skin tears.  These injuries result when the outer skin level, or epidermis, separates from the dermis, the skin layer immediately underneath it.  As the rete ridge that joins these two layers flattens with age, institutionalized patient more likely to suffer from skin tears. Using harsh soap with a high PH value further dries the skin and lessens its water-holding ability, but applying an emollient or moisturizer twice daily to the arms and legs lessens the chance of skin tears.

Fleck, C. A. (2007). FAQs: Preventing and treating skin tears.  Advances in skin and wound care.  Journal for Prevention and Healing. 20(6), 315-321.  Retrieved from
http://www.nursingcenter.com/lnc/static?pageid=727851

The ridge separating the epidermis and dermis begins to flatten as early as the sixth decade of life; however, patients totally dependent on others for their Activities of Daily Living (ADLs) are particularly at risk for skin tears most often on their forearms and arms.  Skin tears not only result in bruised skin, but they also result in fluid loss, and edema. Furthermore, skin tears and bruising (a.k.a. Senile Purpura of the skin) decrease pain perception.

Older skin heals more slowly than younger skin because of a reduced inflammatory response, a delayed formation of new blood vessels, the dwindling function of sebaceous (sweat), glands, a decrease in  collagen, and changes in aging skin that result in skin discoloration.  All of which causes a slower formation of the healing tissue that grows over a wound.

If a skin-tear occurs, both health-care professionals and a patient’s relatives should be familiar with the Payne-Martin skin-tear classification system that covers three levels of skin tears from best case to worst case scenario:

Category 1: Skin tear without tissue loss;

Category 2: Partial tissue loss;

Category 3: Complete tissue loss.

Since skin tears can influence the patient’s general well-being, prevention of skin tears should be the goal of all caregivers.  Accordingly, Fleck suggests the following preventive internal and external measures:

• Keep the patient well-hydrated by monitoring fluid in-take;

• Moisturize the skin since mature skin has a decreased percentage of sweat glands a lessened ability to retain moisture and dermal proteins;

• Dress  the patient in long-sleeves and slacks or else wrap his or her legs in gauze;

• Put gloves on the patient [instead of socks or mittens], which he or she can easily remove.

Older skin is ordinarily drier than younger skin,

so it needs moisturizing.

Jennigan, K. (2010, April 21).   What are the cause of thin skin in the elderly?  Livestrong.com. Retrieved from http://www.livestrong.com/article/109989-causes-thin-skin-elderly/

Changes in connective tissue and collagen result not only in sagging skin, but an increasingly dry skin is more likely to suffer water loss, skin tears, bruising, or the formation of small hemorrhages , or Senile Purpura, and possible infection.  Additionally, the elderly slowly loss fat or else it moves to the abdomen.  This causes an additional thinning of fat cells in the arms and legs. Because both sweat production declines and oil-decreasing glands lessen their effectiveness, it’s harder for the skin to retain moisture, so moisturizers need to be applied.

Hamilton, E, (2013).  How to protect the skin from skin tears. Aged Carer.  Retrieved from
http://www.agedcarer.com.au/topic/aged-care-tips/ageing-skin-care/how-prevent-and-care-skin-tears

The elderly are at risk for skin care because of their dry and fragile skin, the use of multiple medications, poor nutrition and hydration, immobility and the harm that results from their inability to move themselves, and [all too often] chronic diseases, such as diabetes.  Since incontinent nursing home patients often have to have their clothes changed several times daily, Hamilton recommends that the patient’s family buys fabrics that easily stretch and/or a size too large.  The use of padded sheepskin booties, bed-cover pads, elbow protectors, and seat covers for wheelchairs, as well as air mattresses and long-sleeved shirts and blouses can protect against possible skin tears. Once a skin tear occurs, the use of silicon-based adhesives, tubular and roller bandages may prevent further skin damage.

Malone, M. L., Rozario, N. Gavinski, M., and Goodwin, J. (1991, June).  The epidemiology of skin tears in the institutionalized elderly (Abstract only).  Journal of the American Geriatric Society. 39(6), 591-595. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/2037750

Incidence of skin tears for females increases with age.  Eighty percent of all skin tears occur in the arms and forearms, and over half of these result from unknown causes.

Miner, K. Katz, M, & Razor, B. (2009, November 1).  Skin tear and management.  Nevada RNformation.  Free Library. Retrieved from
http://www.thefreelibrary.com/Skin+tear+prevention+and+management.-a0214204947

Miner, Katz, and Razor offers a long-list of strategies to prevent skin tears:

• Training staff in positioning, turning, lifting, and transferring methods;

• Dressing patients in long sleeves, pants, and gloves or else placing tubular dressings on the arms as an added layer of protection;

• Padding wheelchair arms, bed rails, and sharp furniture edges;

• Avoiding harsh soaps, scrubbing while bathing;

• Gently patting patients dry;

• Applying moisturizers without alcohol;

• Maintaining hydration levels;

• Using mild PH balanced skin cleansers.

Once a skin tear occurs, they recommend

• Using hydrogel sheets, silicon-faced foam, and bio-cellulose dressings that can remain in place for three, five, and seven days respectively or else using tubular-support bandages;

• Using adhesive closure strips if the skin tear has a flap.

Skin tears: The clinical challenge. (2006, September 3).  Pennsylvania Patient Safety Advisor. 3(3), 5-10. Retrieved from
http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2006/Sep3(3)/Pages/01b.aspx

Statistics occasioned by skin tears in Pennsylvania hospitals and nursing homes may prove useful when predicting patients particularly susceptible to skin tears:

• "Skin integrity events" cause 62 percent of all skin tears while 32 percent of skin tears result from falls;

• Patients age 75 to 84 have 41 percent of all skin tears;

• Males have slightly more skin tears (52 percent) than females (48 percent);

• Skin tears most frequently take place on the forearms and arms, followed by the hands and legs;

• Catching the skin on unpadded furniture and safety guards often causes skin tears; 

• At particular risk are patients over the are of 70, those with hearing and/or vision loss, compromised nutrition, a history of skin tears, dementia, and dependence on others to take care of their ADLs. 

The Pennsylvania Safety Advisor recommends the following preventive measures:

• Modifying the patient’s environment; 

• Providing adequate nutrition and hydration;

• Avoiding activities that cause friction and shearing;

• Taking special caution when removing tape. 

Stephen-Haynes, J. & Corville, K. (2011).  Skin tears made easy.  Wounds International. 2(4).  Retrieved from http://www.woundsinternational.com/made-easys/skin-tears-made-easy/page-4

Stephen-Haynes and Corville both identify risk factors for developing skin tears as well as offer suggestions to reduce their possibility:

Risk factors include

• Age and gender;

• History of previous skin tears;

• Dry fragile skin;

• Steroids;

• Bruising;

• Impaired mobility and/or vision;

• Poor nutrition and hydration;

• Cognitive impairment;

• Compromised vascularity;

• Chronic heart disease, renal failure, or cerebral disease;

• Dependence upon others for dressing, bathing, or transferring.

Preventive measures include

• Trimmed finger nails;

• No jewelry;

• Padding of wheelchairs, bed rails, and furniture with sharp corners;

• Care in transfer;

• Adequate lighting at night for still mobile patients;

• Use of lifting devices and slide sheets;

• Use of Ph-neutral cleansers instead of soap;

• Moisturizers applied regularly;

• Changing adult diapers regularly for incontinent patients;

• Gently removing peripheral devices;

• Use of barrier film or cream instead of taped bandages;

• Use of tubular and roller bandages;

• Dressing the patient in long-sleeved clothing and pants.

Conclusion

A review of these articles underlines the idea that skin tear prevention should be a joint venture that involves both the nursing home staff and a concerned and regularly involved family member.  This is particularly true in the case of dementia patients since they might  scratch themselves without realizing that this results in a skin tear. 

That might also mean that the patient's family may need to buy larger clothing sizes and regularly drop in at the nursing home to see that the patient is actually wearing large-sleeved shirts and pants, being bathed with PH-neutral skin cleansers instead of soaps, and having attendants regularly apply moisturizer without alcohol.  The last is harder than it sounds, although the nursing home administrator where Mother lives recommends using olive oil.  If a family member regularly visits the patient, this will also let the nursing staff know that someone truly cares about his or her welfare.  Even so, when a nurse calls late at night reporting a skin tear, this worries loved ones. 

The medical links furnished on this Web page represent the opinions of their authors, so they complement—not substitute—for a physician's advice.