Risk Assessment and Prevention of Skin Tears:  Health Care Professionals Working Together

Risk Assessment and Prevention of Skin Tears: Health Care Professionals Working Together
Kimberly LeBlanc, MN RN CETN (C) PhD (student)
Co-Chair International Skin Tear Advisory Panel (ISTAP)
KDS Professional Consulting, Ottawa, ON, Canada.
kimleblanc@rogers.com
www.skintears.org
Conflicts of Interest
Speakers Bureau, Advisory Board, Unrestricted Education Grants
•
•
•
•
•
•
Hollister
3M
Molnlyke
Systagenics
Coloplast
Convatec
International Skin Tear Advisory Panel
Skintear.org
1
What do Skin Tears Look Like?
Skin Tears
Common in the extremes of age and the critically ill
Shearing, friction and/or trauma result in the separation of skin layers
Skin Tears are partial or full thickness depending upon the degree of tissue damage
LeBlanc et al, 2011
Skin Tear Definition:
A skin tear is a wound
caused by shear, friction,
and/or blunt force resulting
in separation of skin layers.
A skin tear can be partialthickness (separation of
the epidermis from the
dermis) or full-thickness
(separation of both the
epidermis and dermis from
underlying structures).
LeBlanc et al, 2011
2
ISTAP Skin Tear Classification
Type 1: No Skin Loss
Linear or Flap Tear
which can be
repositioned to cover
the wound bed
Type 2:
Partial Flap Loss
Partial Flap loss
which cannot be
repositioned to cover
the wound bed
Type 3:
Total flap loss
Total Flap loss
exposing entire
wound bed
LeBlanc, K., Baranoski et al, J Advances in Skin and Wound Care June 2013
Prevalence of Skin Tears
Prevalence Of Skin Tears: Review of the Literature
• Woo & LeBlanc (2014)
– Skin tears and pressure ulcers were detected in 14.7% and 15.8% respectively
– Correlation between PURS scores and skin tear development
• LeBlanc & Christensen (2013) found a 22% prevalence of skin tears in a 114 bed long‐term care facility
• Santos Amaral et al (2012) found the following prevalence rates:
– 3.3% skin tears; 3% pressure ulcers (Palliative Population)
– Correlation between Braden scores and skin tear development
• Kennedy & Kerse (2011) – Prevalence of pre‐tibial skin tears over a 2‐year period presenting to the ER
– Reported a prevalence of 2.1% in men and 4.6% in women 3
Prevalence Of Skin Tears: Review of the Literature
• 20% of known wounds in the veteran population (Carville, Smith 2004)
• Community settings: prevalence rates of 5.5% (Carville, Lewin,1998)
• 41.5% prevalence rate in the long‐term care population (Everett, Powell 1994)
• Malone et al (1991) estimated 1.5 million skin tears occur each year in institutionalized adults in the United States ISTAP Skin Tear Tool Kit for the Prevention and Treatment of Skin Tears
• The goal of the ISTAP Skin Tear Tool Kit is to provide a foundation to assist and guide individuals, their circle of care, and health care professionals in the risk assessment, prevention and treatment of skin tears. • The ISTAP Skin Tear Tool Kit is designed to allow the clinician to implement systematic approach to the prevention, management and treatment of skin tears. LeBlanc, K., Baranoski et al, J Advances in Skin and Wound Care Oct 2013
ISTAP Skin Tear Tool Kit
Methodology
• The ISTAP group developed the tool kit and subsequently subjected it to a global review and input from a wide group of 50 international reviewers. The purpose of this document is to disseminate the globally agreed ISTAP Skin Tear Tool Kit and to generate further research on this topic. • A three‐phase modified‐Delphi method was used to reach consensus on the components of the ISTAP Skin Tear Tool Kit. LeBlanc et al, 2013
4
ISTAP Skin Tear Tool Kit
LeBlanc et al, 2013
• General Health – Altered Sensory, Auditory, and Visual
status
– Cognitive Impairment
– Nutritional Concerns
– Polypharmacy
LeBlanc et al, 2013
• Mobility
– Mobility Related Issues
– Assistance with Activities of Daily Living
(ADLs)
– History or Risk of Falls
– Mechanical Trauma (Not related to mobility
aids
LeBlanc et al, 2013
5
• Skin
– Skin Changes related to Extremes of Age
and Critically Ill
LeBlanc et al, 2013
• Health Care Setting
– Recognize the need for and implement a comprehensive skin tear reduction program, – Support the use of atraumatic topical dressing options for the treatment of skin tears when they do occur to minimize the risk of further skin damage
– Include the prevalence and incidence of skin tears in current wound audit programs
LeBlanc et al, 2013
Intrinsic and extrinsic factors associated
with an increased risk of skin tears








Gender (male)
Race (Caucasian)
Immobility (chair or bed bound)
Inadequate nutritional intake
Long term corticosteroid use
History of previous skin tears
Altered sensory status
Cognitive impairment





Limb stiffness (joint
stiffness/contractures) and spasticity
Neuropathy
Having blood drawn
Poly-pharmacy
Very young (neonate) and very old
(>75 years of age)
LeBlanc et al, 2013
6
Intrinsic and extrinsic factors associated
with an increased risk of skin tears








Presence of ecchymosis
Dependence for activities of daily living
Using assistive devices
Applying and removing stockings
Removing tape or dressings
Vascular problems
Cardiac problems
Pulmonary problems






Visual impairment
Transfers and falls
Prosthetic devices
Continence/incontinence
Skin cleansers
Improper use of skin sealants
LeBlanc et al, 2013
Risk factors for skin tears
Dependent patients who require total care for all activities of daily living most at risk
Frequently acquired skin tears during routine activities of dressing, bathing, positioning, and transferring
LeBlanc & Baranoski et al 2011
Risk factors for skin tears
• Critically Ill
– Fluid overload
– Multi‐system failure
LeBlanc & Baranoski et al 2011
7
Risk Factors for skin tears
Independent ambulatory patients/residents
– Found on extremities
– Many had edema, purpura, or ecchymotic areas
LeBlanc & Baranoski et al 2011
Risk factors for skin tears
Slightly impaired patients/residents
– Injury from hitting stationary equipment or furniture or reasons as above for dependent and independent ambulatory patients
LeBlanc & Baranoski et al 2011
2011 survey results for top causes of
skin tears
LeBlanc et al, 2013
8
Location of skin tears
Most skin tears (80%) occur in upper extremities (Arms & hands)
LeBlanc et al, 2013, LeBlanc & Woo, 2014
Location – Skin Tears
Skin tears on back & buttocks often mistaken as stage II pressure ulcers
Almost half of skin tears are found without any apparent cause
LeBlanc et al, 2013, LeBlanc & Woo, 2014
Prevention Strategies
Determine and remove potential causes for trauma
Have individuals at risk:
– Wear long sleeves
– Long pants or knee high socks
– Providing shin guards for those who experience
repeat skin tears to shins
Determining and removing potential causes for
trauma
LeBlanc, Christensen, Orstead, Keast. 2008
9
Prevention Strategies
Ensuring a safe environment with adequate lighting
Minimizing objects that can be a source of blunt
trauma
Padding edges of furniture and equipment
Providing an uncluttered pathway
Avoiding scatter rugs
LeBlanc, Christensen, Orstead, Keast. 2008
Prevention Strategies
Applying hypoallergenic moisturizer at least two
times per day
Minimize bathing
Provide protection from trauma during routine care
Provide protection from self injury
Ensure proper transfer and lifting techniques to
avoid shearing and friction
LeBlanc, et al 2013, Carville et al, 2014
Prevention Strategies
Pad bed rails, or other objects that may lead to blunt
trauma
Promote adequate nutrition and hydration
Avoid adhesive products on frail skin
Keep nails short and filed to prevent self-inflicted
skin tears
LeBlanc, Christensen, Orstead, Keast. 2008
10
Prevention Strategies
Responsible Bathing
Should be based on individual need and preference
Should be performed with either soapless product or Ph‐
balanced soaps
Involves limiting baths; showering instead with warm, not hot, water
Includes the application of hypoallergenic moisturizers post showering while skin is still damp but not wet
LeBlanc, Christensen, Orstead, Keast. 2008
Prevention Strategies
Optimal nutritional intake will improve skin health, assist with the healing of the current skin tear and help with the prevention of future skin tears An interprofessional team—including a dietician—is crucial for patients with chronic wounds, including those at risk for skin tears
LeBlanc, Christensen, Orstead, Keast. 2008
DON’T FORGET THE TETANUS SHOT!
Tetanus is an acute, often fatal disease caused by wound contamination with Clostridium tetani
Human tetanus immunoglobulin (TIG) should be given to all individuals with interruption of the skin integrity by a non‐
surgical mechanism who have not received a tetanus toxoide
(Td) inoculation in the past 10 years
The TIG should be given before wound debridement because exotoxin may be released during wound manipulation **** This may not be the policy in all healthcare regions
Carden, DL. Tetanus. In: Tintinalli, JE. Kelen, GD. Stapczynski, JS. Emergency Medicine: A
comprehensive Study Guide, Sixth Edition. American College of Emergency Physicians. 2004.
11
ISTAP Skin Tear Tool Kit
LeBlanc et al, 2013
Pathway to Assessment / Treatment of Skin Tears
Person with a Skin Tear
Treat the Cause
GENERAL HEALTH cognitive, sensory, visual, auditory, nutrition chronic/critical disease, polypharmacy
AMBULATION history of falls, impaired mobility, activities to daily living (ADLs)
SKIN age, mechanical trauma, fragile skin, previous tears Debridement Non‐viable tissue only
Avoid sutures/staples
Local Wound Care
Atraumatic (dressing) removal, Cleanse, control bleeding, approximate wound edges, assess & classify according to ISTAP Classification system
Infection/Inflammation
Topical Antimicrobials for local infection
Systemic antibiotics for deep tissue infection
Consider Tetanus immunization
Patient‐centered Concerns
ADLs
Pain control
Educate client & circle of care
Moisture Balance
Peri‐ Wound Protection
(e.g., film forming liquid acrylate)
Wound: Non‐adherent or Low tack + Facilitate moisture balance
Non Advancing Edge
Re‐evaluate
Consider Active Therapy
Adapted from: Sibbald et al modified from. : LeBlanc, Christensen, Orstead, Keast.. 2008
Dressing Selection Specific to Skin Tears
When skin tears can occur it is paramount that wound care products are chosen that will optimize wound healing and not increase the risk of further skin damage. LeBlanc et al, 2013
12
Treating Skin Tears
Remember
– Do not add new risks for trauma
– Assess co‐morbidities (Venous disease, arterial disease, pressure)
– Choose a dressing that will:
Decrease trauma
Provide moist wound healing
Manage pain
LeBlanc et al, 2013
International Skin Tear Advisory Panel
Skintear.org
References
Carville K, Leslie G, Osseiran-Moisson R, Newall N, Lewin G. (2014).The effectiveness of a twice-daily skin-moisturising regimen for reducing the
incidence of skin tears. Int Wound J. 11:446–453
Carville, K., & Smith, J. (2004). Report on the effectiveness of comprehensive wound assessment and documentation in the community. Primary
Intention: The Australian Journal of Wound Management, 12, 41.
Carville, K., Lewin, G., Newall, N., Haslehurst, P., Michael, R., Santamaria, N., & Roberts, P. (2007). STAR: A consensus for skin tear classification.
Primary Intention: The Australian Journal of Wound Management, 15(1), 18.
Everett, J., S., & Powell, T. (1998). The underestimated wound. Primary Intention: The Australian Journal of Wound Management, 2, 8.
Hsu, M., & Chang, S. (2010). A study on skin tear prevalence and related risk factors among inpatients. Tzu Chi Nursing Journal, 9(4), 84-95.
Koyano Y, Nakagami G, Iizaka S, Minematsu T, Noguchi H, Tamai N, Mugita Y, Kitamura A, Tabata K, Abe M, Murayama R, Sugama J, Sanada H.
(2014) Exploring the prevalence of skin tears and skin properties related to skin tears in elderly patients at a long-term medical facility in Japan.
Int Wound J 2014; doi: 10.1111/iwj.12251
Krasner, D. L., Rodeheaver, G. T., Sibbald, R. G., & Woo, K. Y. (2012). International interprofessional wound caring. In Krasner, D.L., Rodeheaver,
G.T., Sibbald, R.G., & Woo, K.Y. (Ed.), Chronic wound care: A clinical source book for healthcare professionals (5th ed., pp. 3). Malvern, PA:
HMP Communications.
LeBlanc, K., Baranoski, B., Christensen, D., Langemo, D. K., Sammon, M., Edwards, K., Regan, M. (2013). International skin tear advisory panel:
Putting it all together, a tool kit to aid in the prevention, assessment and treatment of skin tears. Advances in Skin & Wound Care, 26(10), 451.
LeBlanc, K., Baranoski, B., Holloway, S., & Langemo, L. (2013). Validation of a new classification system for skin tears. ADVANCES IN SKIN &
WOUND CARE, 26(6), 264.
LeBlanc, K., Baranoski, S., Christensen, D., Langemo, D., Sammon, M., Edwards, K., Regan, M. (2011). State of the science: Consensus
statements for the prevention, prediction, assessment, and treatment of skin tears. Advances in Skin & Wound Care, 24(9), 2.
LeBlanc, K., Baranoski, S., Langemo, D., Holloway, S., & Regan, M. (2014). A descriptive cross-sectional international study to explore current
practices in the assessment, prevention and treatment of skin tears. International Wound Journal, doi:10.1111/iwj.12203
LeBlanc, K., Christensen, D., Cook, J., & Culhane, B. (2013). Prevalence of skin tears in a long term care facility. Journal of Wound, Ostomy &
Continence Nursing, 40(6), 580.
Malone, M., Rozario, N., Bavinski, M., & Goodwin, J. (1991). The epidemiology of skin tears in the institutionalized elderly. JAGS, 39, 591.
McErlean, B., Sandison, S., Muir, D., Hutchinson, B., & Humphreys, W. (2004). Skin tear prevalence and management at one hospital. Primary
Intention: The Australian Journal of Wound Management, 12(2), 83.
Santamaria, N. (2009). Wounds west: Identifying the prevalence of wounds within western Australia’s public health system. EWMA Journal, 9(3), 1318.
von Bertalaniffy, L. (1972). The history and status of general systems theory. Academy of Management Journal, 15(4), 407.
Woo, K., LeBlanc, K. (2014) Prevalence of skin tears among the elderly living in Canadian Long-term care facilities. Unpublished poster presentation,
Canadian Association of Wound Care Annual Conference, Toronto Ontario Oct 2014.
13