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. [email protected] 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
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