evidence & practice / outer tissue

WOUNDS

Prevention and management

of skin tears in older people
McInulty L (2017) Prevention and management of skin tears in older people. Emergency Nurse. 25, 3, 32-39.
Date of submission: 1 January 2017; date of acceptance: 21 February 2017. doi: 10.7748/en.2017.e1687

Lorna McInulty Abstract

Senior lecturer in emergency
and unscheduled care,
University of Central
Lancashire School of Health
Sciences, Preston, England
Skin tears are frequently encountered in emergency and unscheduled care, and are prevalent
in older people. Patients may present soon after an acute skin tear, or at a later stage when the
wound presentation is different and there are complications. This article describes evidence-based
recommendations and strategies for the prevention, assessment and management of skin tears,
discusses risk factors and explains when to refer patients for specialist management.

Correspondence Keywords
l.mcinulty@btopenworld.com; emergency nurse, pretibial lacerations, skin tears, wounds, wound dressings
lemcinulty@uclan.ac.uk

Conflict of interest
None declared
Peer review
This article has been subject
to external double-blind
peer review and checked
for plagiarism using
automated software
Aims and intended learning outcomes
The aim of this article is to describe the
nature and management of skin tears, and
outline best practice. After reading the article,
and completing the time outs, you should
be able to:
»» Describe the predisposing factors for skin tears.
»» Summarise prevention strategies.
»» Describe the anatomy, physiology and
functions of the skin.
»» Summarise the process of wound healing.
»» Understand potential complications
associated with skin tears.
»» Explain which dressings are appropriate for
managing skin tears.
Prevalence of skin tears
A skin tear is defined as ‘a wound caused by
shear, friction and/or blunt forces, resulting
in separation of skin layers’ (LeBlanc and
Baranoski 2011). In emergency and urgent
care settings, skin tears are usually associated
with older people, but they are not uncommon
in neonates and infants who have immature
skin, and when the epidermis and dermis are
not fully cohesive (Bianchi 2012).
Premature babies, neonates and infants
who require hospital care are particularly at
risk of skin trauma caused by invasive devices
and the dressings and tapes used to secure
them. These devices are generally placed
in and around the head and face, or in the
extremities. Therefore, these are the areas
where skin tears are seen in this age group.
Paediatric risk factors differ from those
associated with older people, who are at
risk of these injuries because of general
frailty, difficulty mobilising and falls. Skin
tears in older people occur in the lower
limbs, particularly in the pretibial region,
the forearms and hands (Battersby 2009,
Clothier 2014). Other groups at risk of skin
tears include people who are critically ill or
clinically compromised (NHS Education for
Scotland (NES) 2015). These patients might
also be older as increases in co-morbidities
and complex health problems are common
in this population.
A range of co-morbidities increases the risk
of skin tears, including chronic cardiovascular
and renal disease (Stephen-Haynes and Carville
2011), and poor nutrition and hydration
(Clothier 2014), while chronic pulmonary
disorders (LeBlanc et al 2008) and suppressed
immunity (NES 2015) are risk factors in all
patient groups.
Accurate figures for prevalence of skin
tears in the UK are not readily available, but
some researchers claim that many skin tears
go unreported (Clothier 2014, All Wales
Tissue Viability Forum 2015, Stephen-Haynes
and Deeth 2016). It is reasonable to assume
that prevalence in the UK is comparable to
similarly developed nations with growing
populations of older people, such as Australia
and the US. One Australian study found a skin
tear prevalence of 8% to 11% in patients in
public hospitals (Mulligan et al 2009), while
US figures, although more than ten years old
(Baranoski 2005), suggest that 1.5 million
older people a year sustain skin tears in care
facilities for older people.

32 / June 2017 / volume 25 number 3 emergencynurse.co.uk

Downloaded from RCNi.com by ${individualUser.displayName} on Jul 20, 2017. For personal use only. No other uses without permission.
Copyright © 2017 RCN Publishing Company Ltd

A follow-up to the Australian study
(Mulligan et al 2011) suggested an overall
4.3% increase in skin tears from the 2009
figures. There are more recent figures
from small-scale US studies (LeBlanc and
Baranoski 2011) and UK-based clinical audits
(Stephen‑Haynes et al 2011), but these are
confined to care homes, and do not therefore
illustrate the true extent of the problem.
Skin tears are not uncommon across all age
groups, but development of chronic wounds
is strongly related to increasing age (Morgan
2015). Chronic wounds in this context are
loosely defined as acute wounds that fail to
heal within an expected timeframe. However,
many skin tear wounds can, with appropriate
management, be prevented or resolved. The
rest of this article focuses on these aspects of
care in relation to older people.
TIME OUT 1
Risk factors and causes of skin tears
Thinking about older people, write a list of what you consider
to be the risk factors and causes of skin tears.
Risk factors and causes of skin tears
Readily identifiable causes of skin tears
include traumatic removal of dressings or
surgical tape and blunt force trauma related
to falls or wheelchair injuries (Hebert 2016).
Clinicians should be aware of the need to
adhere to uniform policy, as long fingernails
and inappropriate jewellery can also cause skin
tears (Stephen-Haynes and Carville 2011, All
Wales Tissue Viability Forum 2015). Not all
causes are obvious. Putting on or removing
tights and stockings can put vulnerable skin
at risk (Hebert 2016), and when activities
like these are undertaken by clinicians or
other carers, the risk is magnified. Prevention
strategies, therefore, are important and
preferable to cure.
Additional risk factors include being over 75,
being female, a history of previous skin tears,
cognitive or sensory impairment including
from diabetes and dementia, visual impairment
(Clothier 2014), agitation, incontinence and
polypharmacy (Herbert 2016).
TIME OUT 2
Prevention
What can be done to prevent skin tears in community and
hospital settings?
Prevention
Community and hospital healthcare
professionals can reduce the risk of skin tears
by taking the preventive actions listed in Box 1
(LeBlanc and Baranoski 2011).
emergencynurse.co.uk
Downloaded from RCNi.com by ${individualUser.displayName} on Jul 20, 2017. For personal use only. No other uses without permission.
Copyright © 2017 RCN Publishing Company Ltd
Revalidation
Find out more at:
rcni.com/revalidation
Prevention should start with early Online archive
identification of those at risk (Bianchi 2012). For related information,
visit emergencynurse.
Many prevention strategies are simple and co.uk and search using
easily implemented but might be neglected the keywords
by older people. Therefore clinicians should
advise them about potential hazards, including
trip hazards such as loose footwear, uneven
carpets and scatter rugs.
Areas of the home in which people
frequently move around should be clutter
free, for example the route from the living
room to the kitchen and the bedroom to the
bathroom, and sharp-edged furniture should
be padded. Clinicians must use moving and
handling equipment properly to further
protect patients.
Charities such as Age UK can visit people
at home to offer advice about practical falls
prevention, and some emergency departments
(EDs) have close links and easy referral systems
to such organisations. Referral for people
at risk can also be made to community falls
teams, which usually include an occupational
therapist and social worker who can
provide grab rails, properly fitting footwear
and other aids.
There is increasing momentum in the
UK ambulance service to promote fall
prevention by encouraging paramedics to
refer patients to falls teams to try to reduce
injury and subsequent transfer to hospital
(Snooks et al 2014).
Paramedics, like district nurses, are well
placed to risk assess patients’ homes, and in
some areas paramedics are formally included
in falls teams. Such falls prevention schemes
help preserve patients’ independence and
dignity (Pyer et al 2015).
Anatomy and physiology
Despite prevention strategies, skin tears still
occur, and when assessing or managing these
injuries it is important to understand the
anatomy and physiology of the skin.
BOX 1. Skin tear prevention
»» Assess for risk on admission to healthcare services and whenever the patient’s condition changes.
»» Implement a systematic prevention protocol.
»» Ensure those at risk wear long sleeves, long trousers or knee-high socks.
»» Provide shin guards/leg protectors for those who experience repeat skin tears on shins.
»» Ensure safe patient handling techniques and equipment/environment.
»» Involve patents and families in prevention strategies.
»» Educate nursing staff and caregivers to ensure proper techniques for providing care without causing
skin tears.
»» Consult a dietician to ensure adequate nutrition and hydration.
»» Keep skin well lubricated by applying hypoallergenic moisturiser at least twice a day.
»» Protect people at high risk of trauma from self-injury during routine care.
(LeBlanc and Baranoski 2011)
volume 25 number 3 / June 2017 / 33
evidence & practice /outer tissue

TIME OUT 3 to shearing forces and friction. The epidermis

Skin anatomy and physiology has no blood supply, so receives oxygen and
Look at Figure 1 and try to label the layers and structures nutrients through diffusion from the capillaries
of the skin. The answers are shown opposite. in the dermis (Hogan-Quigley et al 2012).
The layers of epidermis closest to the
The skin consists of three layers, the epidermis, dermis receive most nutrition and the amount
the dermis and the subcutaneous layer, or they receive reduces the nearer the layers
hypodermis. The epidermis is roughly one are to the skin surface. The outermost layer
tenth of a millimetre thick, but consists of of the epidermis is the stratum corneum,
five individual layers. The innermost layer which is made up of dead cells. These cells
is the stratum basale and is attached to the are continuously shed in a process called
dermis by a basement membrane. In youth, desquamation, and new skin cells develop
this membrane is plump and healthy, but with from the dermis and push the epidermal layers
age it becomes flattened and has less resistance upwards. This is an ongoing process with skin
turnover taking approximately four weeks
(Colbert et al 2009), although this may be
Figure 1. Skin anatomy and physiology longer as people age (Hebert 2016).
The dermis is a form of connective tissue
17 Epidermal layers that contains important structures, including
nerve endings, blood and lymphatic vessels,
hair follicles and sweat glands. It is separated
5
from the epidermis by the basement membrane
4 whose composition decreases with age
16 3 (Hebert 2016). Collagen and elastin, which
provide the skin’s strength and elasticity,
19 2 also reduce with ageing (Stephen-Haynes
and Deeth 2016). There may be diminished
7 capillary blood flow and less oil produced by
1
the sebaceous glands, resulting in drier skin
(Stephen-Haynes and Carville 2011), and
falling oestrogen levels in older women also
18
15 affect skin integrity (Farage et al 2013). A
combination of these factors make the skin
11
6 vulnerable to friction and shearing.
13 14 The subcutaneous layers of skin consist
of fat and connective tissues. As the ageing
9 dermis loses its healthy properties, so too
8 does the subcutaneous layer, which becomes
12
10
thinner and less resistant to trauma. The
looser connection between the dermis and
subcutaneous layer means that bleeding
Figure 2. Comparison of older and younger skin is more difficult to control, therefore
large haematomas can develop (Figure 2).
Ultimately, the level of trauma necessary to
injure the skin is far less than that necessary
to injure younger, healthier skin.
Epidermis
TIME OUT 4
Haematoma
Areas of skin tears
Try to recall patients you have seen with skin tears. On what
area of the body did the patients sustain the injuries?
Haematoma Dermis
The dorsal aspects of the hands age more
rapidly, partly due to greater exposure to the
Subcutaneous damaging effects of the sun, and are more
Young skin fat layer
susceptible to loss of the fatty layers, so are
vulnerable to skin tears, alongside the forearms
Older skin and pretibial areas. Hebert (2016) suggests that
70% to 80% of skin tears occur on the hands

34 / June 2017 / volume 25 number 3 emergencynurse.co.uk

Downloaded from RCNi.com by ${individualUser.displayName} on Jul 20, 2017. For personal use only. No other uses without permission.
Copyright © 2017 RCN Publishing Company Ltd
and arms, and that most are sustained between Assessment of skin tears Answers to time out 3
6am and 11am, or 3pm and 9pm, when people Wound inspection and documentation should 1. Stratum basale
generally undertake more physical activity. include the following: 2. Stratum spinosum
»» Description of the anatomical site of 3. Stratum granulosum
TIME OUT 5 the wound. 4. Stratum lucidum
»» History of the mechanism of injury and time 5. Stratum corneum
Skin functions
6. Eccrine sweat gland
List the functions of the skin and explain why it is important the injury was sustained.
7. Sebaceous gland
for the skin to remain intact. »» Wound dimensions.
8. Hair follicle
»» The degree of viable compared to non-viable
9. Cutaneous vascular plexus
Functions of the skin tissue, including flap necrosis. 10. Adipose tissue (fat)
The skin has many important functions, »» Evidence and type of exudate, for example 11. Hair follicle receptor
including protection and sensation, immunity, haemoserous fluid or blood. 12. Pacinian corpuscle
vitamin D synthesis, temperature regulation, »» Presence of haematoma. 13. Sensory nerve fibre
excretion of water and urea, and supporting »» Condition of the surrounding skin, for 14. Hypodermis (subcutaneous
movement and growth through its elastic example swelling, maceration, induration layer)
properties. Therefore, it is important that or infection. 15. Reticular layer
it remains intact and, in cases of trauma, is »» Possibility of wound edge approximation. 16. Papillary layer
appropriately managed to encourage rapid Clinicians should take a holistic approach 17. Hair shaft
healing and recovery. (Clothier 2014), so should also undertake a 18. Arrector pili muscle
pain assessment using an appropriate scale 19. Meissner’s corpuscle
Appearance of skin tears (Stephen-Haynes and Deeth 2016), and the
Skin tears have characteristic appearances result should be recorded and acted on before
(Figure 3), and patients often present with working on the wound itself. Benbow (2016)
some skin loss, an obvious skin flap, or both. recommends wound photography as ‘an adjunct
There are two grades of skin tear, partial to documentation of assessment’, and states
thickness and full thickness (Stephen-Haynes that other factors, such as smoking, ageing,
and Deeth 2016), and the former results in nutrition, mobility and stress must also be taken
separation of the epidermis from the dermis, into account during assessment. The All Wales
while the latter results in separation of the Tissue Viability Forum (2015) considers an
epidermis and dermis from the underlying assessment incomplete if attention is not given
structures, such as tendon or bone. Visual to underlying disease processes, such as diabetes
inspection helps to determine this. and peripheral vascular disease, which may have
If patients present with a dressing in contributed to the injury, and which can affect
place, it is important to try to establish the the healing process.
direction of the flap so the dressing can be There are various skin tear classification
removed in the least traumatic way. Clinicians systems and it is good practice to use one.
should either document this information, or The most well-known validated systems are the
draw an arrow on the dressing to indicate Payne-Martin Classification (Payne and Martin
the direction of the flap, and the best way 1993) and the Skin Tear Classification System
to remove the dressing. (STAR) (Carville et al 2007).

Figure 3. Skin tear audit research (STAR) classification

Category 1a Category 1b Category 2a Category 2b Category 3

A skin tear where the edges can be
realigned to the normal anatomical
position without undue stretching
and the skin or flap colour is not
pale, dusky or darkened.
A skin tear where the edges can be
realigned to the normal anatomical
position without undue stretching
and the skin or flap colour is pale,
dusky or darkened.
A skin tear where the edges
cannot be realigned to the normal
anatomical position and the skin
or flap colour is not pale, dusky
or darkened.
A skin tear where the edges A skin tear where the skin flap
cannot be realigned to the normal is completely absent.
anatomical position and the
skin or flap colour is pale, dusky
or darkened.

(Silver Chain Nursing Association and School of Nursing and Midwifery, Curtin University of Technology 2010)

emergencynurse.co.uk volume 25 number 3 / June 2017 / 35

Downloaded from RCNi.com by ${individualUser.displayName} on Jul 20, 2017. For personal use only. No other uses without permission.
Copyright © 2017 RCN Publishing Company Ltd
evidence & practice /outer tissue
The Payne-Martin system (Table 1)
describes three categories of skin tear based
on no tissue loss (category I), partial tissue
loss (category II), or complete tissue loss
(category III), and categories I and II are
subdivided.
The STAR classification (Figure 3) has five
categories based on appearance. The main
factors in assessment include the presence or
absence of a flap, also known as a pedicle,
colour of the skin and flap itself, and whether
or not the edges of the tear can be realigned.
The images in the STAR tool make this a more
practical and useful option, particularly for less
experienced practitioners, and it alludes to the
desired outcomes for skin tears by including
the possibility of anatomical realignment.
A more recent classification, produced
and validated by the International Skin
Tear Advisory Panel (ISTAP) (LeBlanc et al
2013a), appears to be a combination of the
main elements of the Payne-Martin and
STAR systems, although it does not refer to
the colour of the skin flap. The tool aims to
‘establish a simple and common language
for describing and documenting (skin tears)’
(LeBlanc et al 2016). Developed by experts
and researchers, this tool could, and perhaps
should, supersede the older ones.
Initial wound management
The general principles of wound management
are the same as for other wounds, and include
haemorrhage control, cleansing, gentle removal
of haematoma and tetanus prophylaxis if
required (Table 2).
TIME OUT 6
Tetanus
Which patients do you think would require tetanus
vaccination and why?
It is important to approximate a skin tear and
return it as closely as possible to its normal
anatomical position. This can be achieved
using a gloved finger, or a non-traumatic tool
such as a cotton bud dampened in water or
saline to prevent fragments of cotton adhering
to the wound.
TABLE 1. Payne-Martin skin tear classification system
Category I: No tissue loss
Category II: Partial tissue loss
Category III: Skin tear with complete tissue loss
36 / June 2017 / volume 25 number 3
Downloaded from RCNi.com by ${individualUser.displayName} on Jul 20, 2017. For personal use only. No other uses without permission.
Copyright © 2017 RCN Publishing Company Ltd
If this proves difficult, clinicians should
attempt to rehydrate the skin, which makes the
flap more pliable. This can be done by placing
a moist, non-woven swab over the area for up
to ten minutes (LeBlanc et al 2016).
Patients with wounds assessed as full-
thickness should be referred to a specialist
according to local policy, and practitioners
should also consider referring patients with
significant bleeding or haematoma (Stephen-
Haynes and Carville 2011).
TIME OUT 7
Assessment tools
Recall a patient with a skin tear who you have cared for.
What, if any, assessment tool did you use and what were your
specific treatment goals?
The main aims of treatment are to preserve
the skin flap and protect the surrounding
skin, promote healing and prevent infection.
Wound healing by primary intention
progresses through four stages – haemostasis,
inflammation, proliferation and maturation –
which are not necessarily sequential, but often
overlap (Rogers and Jones 2016). This process
occurs in simple wounds that do not involve
tissue loss, but the process is different in
wounds with tissue loss, which heal by
secondary intention (Brown 2015). This article
does not expand further on wound healing.
Wound management and
dressing choice
Wound dressings should be appropriate for
wound environments, and should promote the
healing process. Due to the fragility of the skin
in this injury, sutures or surgical staples are
generally precluded (LeBlanc and Baranoski
2011). Instead, an atraumatic wound dressing
should be applied and left undisturbed for as
long as is practicable or desirable, based on the
wound assessment and presence of exudate.
Dressings should be chosen for their ability
to maintain a moist environment and to
protect the surrounding skin (LeBlanc and
Baranoski 2016), but patient preference,
comfort and ease of removal are also
important factors (Morgan 2015).
Ia) Linear type
Ib) Flap type
IIa) Scant tissue loss less than 25%
IIb) Moderate to large tissue loss over 25%
emergencynurse.co.uk
 Exudate can be heavier if the limb is
already oedematous, for example in patients
with chronic heart failure, and a holistic
assessment should determine whether
underlying disease processes are sufficiently
well controlled. Dusky or darkened skin
flaps suggest possible vascular compromise,
therefore a dressing change and reassessment
should take place within 24 to 48 hours
(Wounds UK 2012).
In terms of treatment options, an
international consensus statement, presented
by LeBlanc and Baranoski (2011) on behalf of
the ISTAP, suggests that research on adhesive
strips, such as Steristrips, is outdated and is no
longer the treatment of choice.
The panel suggests using surgical glue for
some minor skin tears, but emphasises that
all dressing choices are based on a thorough
wound assessment, and state that ‘best practice
supports… the use of hydrogel, alginate,
lipido-colloid-based mesh and foam dressings,
soft silicone, foam, or non-adherent dressings,
applied depending on wound characteristics’.
This is repeated in the most recent consensus
work (LeBlanc et al 2016).
Other recent literature (Hebert 2016)
agrees with the range of dressings described
above, but continues to advocate adhesive
strips, petroleum-based ointments and gauze
as treatment options. While Hebert (2016)
provides a rationale for using most of the
dressings she describes, there is no rationale
for the latter treatment options, which perhaps
supports the consensus statement that they are
not best practice.
Another recent UK report by experts
supports the international consensus statement
(Stephen-Haynes and Deeth 2016).
TABLE 2. Criteria for tetanus prophylaxis
Immunisation status Clean wound
Fully immunised, ie has received a total
of five doses of vaccine at appropriate
intervals
Primary immunisation complete,
boosters incomplete but up to date
Primary immunisation incomplete or A reinforcing dose of vaccine and further doses as required to complete the
boosters not up to date
Not immunised or immunisation status An immediate dose of vaccine followed, if records confirm the need, by completion
not known or uncertain
(Public Health England 2013)
emergencynurse.co.uk
Downloaded from RCNi.com by ${individualUser.displayName} on Jul 20, 2017. For personal use only. No other uses without permission.
TIME OUT 8 FURTHER RESOURCES
Choosing appropriate dressings Edwards et al’s (2013)
Wound Dressing Guide
Think about the range of dressings available in your can be accessed at
workplace. Do you know their properties and how to select cms.qut.edu.
an appropriate dressing? If possible, go online and consult au/__data/assets/
Edwards et al’s (2013) comprehensive Wound Dressing pdf_file/0003/451767/
Guide to extend your knowledge. Much of the information Book2-wound-dressing-
about dressings described in this article is derived guide.pdf
from this useful guide.
Alginate
Alginate dressings, such as Kaltostat, are
manufactured from seaweed and contain
properties that absorb significant amounts
of fluid through hydrophilic gel formation.
They are dry when applied to a wound and
expand, becoming more gel-like as they draw
fluids in. This helps to clear out wounds,
maintain a moist environment and, to an
extent, protect them from bacteria, reducing
the risk of infection (Edwards et al 2013).
These dressings are useful for exuding
wounds, but not for dry or necrotic wounds.
In addition, alginates usually possess
haemostatic properties, because of the
calcium contained in the dressing, which
helps blood coagulation (Joint Formulary
Committee 2017).
Edwards et al (2013) recommend using
alginates in infected wounds when antibiotic
cover is in place. However, a secondary
dressing might be required to hold the alginate
in place and to absorb excess exudate. Foam
dressings, for example Lyofoam, are often
used in combination with alginates because
of their ability to absorb excess exudate,
provide additional protection to the injured
area and conform to uneven body surfaces
(Edwards et al 2013).
Tetanus-prone wound
Vaccine Human tetanus immunoglobulin
None required Only if high risk
None required unless next dose due soon and convenient to give now Only if high risk
Yes: one dose of human tetanus
recommended schedule to ensure future immunity immunoglobulin in a different site
Yes: one dose of human tetanus
of a full five-dose course to ensure future immunity immunoglobulin in a different site
volume 25 number 3 / June 2017 / 37
Copyright © 2017 RCN Publishing Company Ltd
evidence & practice /outer tissue
Hydrogel
Hydrogel dressings, such as Derma-gel, are
designed to moisturise wounds and promote
autolytic debridement, that is to help the
wound separate naturally and shed devitalised
tissue from healthy tissue (Edwards et al 2015).
The dressing encourages the body’s enzymes to
carry out this process. There are different types
of hydrogels, including tubes of gel, gel sheets
and gel-impregnated dressings. Gel sheets are
suitable for flat wounds, such as skin tears.
They should not be combined with foam
dressings, however, as the foam will absorb the
gel (Edwards et al 2015), so are more suitable
for drier rather than heavily exuding wounds
(LeBlanc et al 2016). They will still often
require a secondary dressing to secure them,
and can cause maceration of the surrounding
healthy skin, but this can be minimised by
using barrier cream on the surrounding area
(Stephen-Haynes and Deeth 2016).
Silicone
Silicone dressings like Mepitel are suitable
for skin tears as they provide a wound
contact layer, but are atraumatic on removal
(Meuleneire and Rücknagel 2013). However,
clinicians must be aware that some dressings
only have a silicone border, which supports
adhesion to the skin, so the central portion of
the dressing could adhere to the wound itself,
leading to traumatic removal.
Silicone dressings can be used on infected
wounds, although appropriate antibiotic cover
must be in place, and there is a variety of
presentations including foams, sheets and semi-
transparent films.
Sheet-type dressings do not have to be
trimmed to wound size and can lie safely on
healthy skin, which makes removal easier
(Edwards et al 2013). These dressings are
reputedly cost-prohibitive, but if used correctly
they can be cost-effective (Anuerin Bevan
University Health Board 2014), specifically
in terms of reduced dressing change times,
number of dressings and pain management
costs (Meuleneire and Rücknagel 2013).
Lipido-colloid
Lipido-colloid dressings are newer to the
market, and combine lipido-colloid particles,
either in a non-occlusive fine mesh or within
a foam dressing, and promote healing in a
moist environnent by encouraging fibroblast
proliferation and collagen production (Urgo
Medical 2015). This type of product is
supported by the National Institute for Health
and Care Excellence (2016) for chronic wound
management and non-healing acute wounds.
38 / June 2017 / volume 25 number 3
Downloaded from RCNi.com by ${individualUser.displayName} on Jul 20, 2017. For personal use only. No other uses without permission.
Copyright © 2017 RCN Publishing Company Ltd
In a clinical review of these dressings,
White et al (2011) explained their
physiological effects on wound healing, and
supported the notion of atraumatic removal.
Hydrocolloids
Finally, hydrocolloids such as Duoderm or
Granuflex are no longer recommended because
their adhesive can compromise fragile skin on
removal (LeBlanc et al 2016). All dressings
should promote moist wound healing as
this provides favourable conditions for the
pathophysiological processes of wound
healing, and reduces pain by keeping nerve
endings moist.
Patients can present to an ED soon after
sustaining an acute skin tear, or at a later
stage when presentation might be different,
and complications, such as infection, might
be present, so practitioners must understand
the rationale for the various treatment
options. It is also extremely important,
when referring patients for continuing care,
to specify the treatment used, the rationale
and recommended follow up, as not all
clinicians are aware of best practice.
TIME OUT 9
Best practice
Think about the management of skin tears in your clinical
environment. Does it reflect best evidence and, if not, how
could you influence this?
Complications
Infection is a potential complication of skin
tears, and having the least chance of infection
is an important outcome for clinicians and
patients (Keeton et al 2015). If there is
an infection, careful consideration should
be given to whether topical or systemic
antibiotics are required, bearing in mind
that indiscriminate use of antibiotics is not
recommended. However, infection is likely
to delay healing time and could progress to
cellulitis or sepsis. Other complications include
delayed healing if patients have oedema or
peripheral vascular disease.
Patient education is vital to help prevent
complications, and should include advice
about rest and exercise, limb elevation,
analgesia, nutrition and smoking cessation.
Patients with skin tears are likely to
experience pain and poor mobility, which
can compromise their quality of life and
potentially lead to physical and mental distress
(LeBlanc et al 2016).
The management and experience of skin tears
is under appreciated both in the literature and
in clinical practice, according to LeBlanc et al
emergencynurse.co.uk
(2016), so to address these issues they, as of the risk factors, and should use patient Write for us
part of the ISTAP, developed a tool kit for the education and appropriate referral systems For information about
writing for RCNi
prevention, assessment and management of to reduce the prevalence, enhance the healing journals, contact
skin tears (LeBlanc et al 2013b). process and prevent complications. writeforus@rcni.com
It is vitally important that clinicians
Conclusion understand the nature and rationale for For author guidelines,
Skin tears are prevalent in older people dressings used in skin tear management, go to rcni.com/
writeforus
and management can be adversely affected and keep up to date with best evidence from
by co‑existing medical conditions, such as experts in the field.
diabetes, infection and peripheral vascular
disease. It is better to try to prevent, rather TIME OUT 10
than cure, skin tears, because of the potential Reflection
pain and distress they can cause patients. Now that you have completed the article, you might like
All healthcare professionals should be aware to write a reflective account as part of your revalidation.

References

All Wales Tissue Viability Forum (2015)
Prevention and Management of Skin Tears. www.
welshwoundnetwork.org/files/8314/4403/4358/
content_11623.pdf (Last accessed: 3 January 2017.)
Anuerin Bevan University Health Board
(2014) Wound Healing Products: Formulary
and Guidelines. www.wales.nhs.uk/sites3/
docopen.cfm?orgid=814&id=122268
(Last accessed: 5 February 2017.)
Baranoski S (2005) Meeting the challenge of skin
tears. Advanced Skin Wound Care. 18, 2, 74-75.
Battersby L (2009) Exploring best practice in the
management of skin tears in older people. Nursing
Times. 105, 16, 22-26.
Benbow M (2016) Best practice in wound
assessment. Nursing Standard. 30, 27, 40-47.
Bianchi J (2012) Preventing, assessing and
managing skin tears. Nursing Times. 108, 13, 12-16.
Brown A (2015) Phases of the wound healing
process. Nursing Times. 111, 46, 12-13.
Carville K, Lewin G, Newall N et al (2007) STAR:
A Consensus for Skin Tear Classification. www.
woundsaustralia.com.au/journal/1501_03.pdf
(Last accessed: 3 January 2017.)
Clothier A (2014) Assessing and Managing Skin
Tears in Older People. www.independentnurse.
co.uk/clinical-article/assessing-and-managing-
skin-tears-in-older-people/63411 (Last accessed:
3 January 2017.)
Colbert B, Ankney J, Lee K et al (2009) Anatomy and
Physiology for Nursing and Health Professionals.
Pearson Education, Harlow, England.
Edwards H, Gibb M, Finlayson K et al (2013) Wound
Dressing Guide. cms.qut.edu.au/__data/assets/
pdf_file/0003/451767/Book2-wound-dressing-
guide.pdf (Last accessed: 3 January 2017.)
Farage M, Miller K, Elsner P et al (2013)
Characteristics of ageing skin. Advances in Wound
Care. 2, 1, 5-10.
Hebert G (2016) No more skin tears. Wound Care
Advisor. 5, 5, 28-32.
Hogan-Quigley B, Palm M, Bickley L (2012) Bates
Nursing Guide to Physical Examination and History
Taking. Wolters Kluwer Lippincott Williams and
Williams, Philadelphia PA.
Joint Formulary Committee (2017) Alginate
Dressings. www.evidence.nhs.uk/formulary/
bnf/current/a5-wound-management-products-
and-elasticated-garments/a52-advanced-
wound-dressings/a526-alginate-dressings
(Last accessed: 8 February 2017.)
Keeton H, Crouch R, Lowe K (2015) What is
important to patients in wound management?
Emergency Medicine. 32, 153-154.
LeBlanc K, Christensen D, Orsted H et al (2008)
Best practice recommendations for the prevention
and treatment of skin tears. Wound Care Canada.
6, 1, 14-30.
LeBlanc K, Baranoski S (2011) Skin Tears: State
of the Science: Consensus Statements for the
Prevention, Prediction, Assessment, and Treatment
of Skin Tears. www.skintears.org/Consensus-
Statements/Statement9.aspx (Last accessed: 3
January 2017.)
LeBlanc K, Baranoski S, Holloway S et al (2013a)
Validation of a new classification system
for skin tears. Advances in Skin and Wound
Care. 26, 6, 263-265.
LeBlanc K, Baranoski S, Christensen D et al (2013b)
International Skin Tear Advisory Panel: a tool kit to
aid in the prevention, assessment, and treatment
of skin tears using a simplified classification
system. Advances in Skin and Wound Care.
26, 10, 459-476.
LeBlanc K, Baranoski S, Christensen D et al
(2016) The art of dressing selection: a consensus
statement on skin tears and best practice.
Advances in Skin and Wound Care. 29, 1, 32-46.
Meuleneire F, Rücknagel H (2013) Soft Silicone
Dressings Made Easy. www.woundsinternational.
com/media/issues/674/files/content_10804.pdf
(Last accessed: 5 February 2017.)
Morgan T (2015) Are your wound management
choices costing you money? Journal of
Community Nursing. 29, 4, 17-20.
Mulligan S, Scott L, Prentice J et al (2009)
WoundsWest Wound Prevalence Survey 2009:
State Report. www.whia.com.au/whwp/wp-
content/uploads/2015/05/WWWPS09-State-
Report-Final.pdf (Last accessed: 3 January 2017.)
Mulligan S, Prentice J, Scott L (2011) WoundsWest
Wound Prevalence Survey 2001: State
Overview Report. www.whia.com.au/whwp/
wp-content/uploads/2015/05/WWWPS2011-
State-wide-Report Overview-Final.pdf
(Last accessed: 3 January 2017.)
National Institute for Health and Care Excellence
(2016) UrgoStart for Chronic Wounds. www.nice.
org.uk/advice/MIB82/chapter/Summary (Last
accessed: 5 February 2017.)
NHS Education for Scotland (2015) Skin Tears:
Prevention, Assessment and Management.
www.nes.scot.nhs.uk/education-and-training/
by-theme-initiative/healthcare-associated-
infections/training-resources/skin-tears-
prevention,-assessment-and-management.aspx
(Last accessed: 5 February 2017.)
Payne R, Martin M (1993) Defining and classifying
skin tears: need for a common language. Ostomy
Wound Management. 39, 5, 16-26.
Public Health England (2013) Tetanus: The Green
Book Chapter 30. www.gov.uk/government/
publications/tetanus-the-green-book-chapter-30
(Last accessed: 8 February 2017.)
Pyer M, Campbell C, Ward A et al (2015) Falls
assessment and prevention in older people: an
evaluation of the crisis response service. Journal
of Paramedic Practice. 7, 2, 68-72.
Rogers T, Jones K (2016) Minor injury and
management. In Curtis K, Ramsden C (Eds)
Emergency and Trauma Care for Nurses
and Paramedics. Second edition. Elsevier,
Chatswood NSW.
Snooks H, Carter B, Dale J et al (2014) Support
and Assessment for Fall Emergency Referrals
(SAFER 1): Cluster Randomised Controlled Trial
of Computerised Clinical Decision Support
for Paramedics. journals.plos.org/plosone/
article?id=10.1371/journal.pone.0106436
(Last accessed: 5 February 2017.)
Stephen-Haynes J, Callaghan R, Bethell E et al
(2011) The assessment and management of skin
tears in care homes. British Journal of Nursing.
20, 11, 10-23.
Stephen-Haynes J, Carville K (2011) Skin Tears
Made Easy. www.woundsinternational.com/
media/issues/515/files/content_10142.pdf
(Last accessed: 3 January 2017.)
Stephen-Haynes J, Deeth M (2016) The prevention,
assessment and management of skin tears.
Practice Nurse. 46, 6, 32-37.
Urgo Medical (2015) Presentation of TLC:
An Exclusive Wound Management Solution.
www.urgo.co.uk/205-tlc-technology
(Last accessed: 3 January 2017.)
White R, Cowan T, Glover D (2011) Supporting
Evidence-Based Practice: A Clinical Review of TLC
Technology. www.urgomedical.com/wp-content/
uploads/TLC%20evidence%20review.pdf (Last
accessed: 3 January 2017.)
Wounds UK (2012) Best Practice Statement.
Care of the Older Person’s Skin. Second
edition. www.woundsinternational.com/
media/issues/622/files/content_10608.pdf
(Last accessed: 3 January 2017.)

emergencynurse.co.uk volume 25 number 3 / June 2017 / 39

Downloaded from RCNi.com by ${individualUser.displayName} on Jul 20, 2017. For personal use only. No other uses without permission.
Copyright © 2017 RCN Publishing Company Ltd