Skin tears are a big issue in the elderly population, whether in hospital or in the community, although epidemiological studies on skin tears are limited and the actual prevalence of skin tears is not truly understood. Older adults are more vulnerable to becoming not only exposed to the risk of developing skin tears but also in having a slow healing time (Gerstein et al, 1993) and complex problems following the incidence of the skin tear, that can lead to chronic, disabling or life-threatening consequences. As health professionals in general practice, we have a duty to recognise risk and take action to prevent skin tears from occurring in the first place. We can use our knowledge to take action, and this can be life changing for the patient in our care. This article will focus on the most recent guidance from 2018 from Wounds UK and Wounds International (LeBlanc et al, 2018).
Firstly, it is important to clarify what a skin tear is, as there can be some confusion or misconception that it is a minor issue or something far less complex than one might think. Campbell et al (2018) state that many of the misunderstandings or misdiagnoses surrounding skin tears have resulted from a more specific terminology to classify them as wounds, causing confusion that results in skin tears often going unrecognised and without documentation. An expert working group from Wounds International (LeBlanc et al, 2018) defined a skin tear, therefore, as:
‘A traumatic wound caused by mechanical forces, including removal of adhesives. Severity may vary by depth (not extending through the subcutaneous layer). Skin tears are traumatic wounds that may result from a variety of mechanical forces such as shearing or frictional forces, including blunt trauma, falls, poor handling, equipment injury or removal of adherent dressings.’
Campbell et al (2018) state that these are painful wounds the affect quality of life and cause distress to the patient, increasing the likelihood of hospitalisation, while also prolonging hospitalisation time. Campbell et al (2018) explain that skin tears are still an unrecognised and under-reported issue, and the guidelines document produced by Wounds International (LeBlanc et al, 2018) has been required in order to raise global awareness on the subject. There is a common misconception that skin tears are unavoidable and trivial: ‘it's just a skin tear’; when in fact skin tears can develop into complex wounds that can become chronic and cause further complications. This places a financial burden on limited NHS resources as well as significantly impacting on the patient's quality of life (Rayner et al, 2015; LeBlanc et al, 2018).
The risk in older people is higher as they have much more fragile skin (Farage et al, 2008). This means less force is required to cause a traumatic injury, so the incidence of skin tears is often increased (LeBlanc et al, 2018). Skin tears can occur on any part of the body but are more likely to occur on the extremities, such as upper and lower limbs or the dorsal aspect of the hands (LeBlanc and Baranoski, 2011) – with LeBlanc et al (2018) reporting that up to 70-80% of skin tears occur on the hands and arms. Payne and Martin (1993) first identified skin tears, stating they are traumatic injuries that can result in partial or full separation of the skin's outer layers, whereby there is a separation of the epidermis from the dermis (partial thickness wound), or both the epidermis and dermis from the underlying structures (full thickness wound).
Risk factors
Recognising risks in older people in general practice is paramount. This is essential for prevention of not just the skin tear but also the huge impact on the patient and health service this would have. There are both intrinsic and extrinsic risk factors for skin tears, as identified by LeBlanc et al (2018).
Intrinsic risk factors
Changes in the skin that result from the normal ageing process mean it is more fragile and therefore far more vulnerable to becoming damaged (LeBlanc et al, 2018). There is a reduced ability of the skin to regenerate and a less efficient protective immune system in older patients, which means they are at an increased risk of skin breakdown from even minor force or trauma. In our work as health professionals we must therefore make it an essential part of our care of the patient that the care of the older person's skin is seen as a priority.
The changes to the skin associated with ageing include (Moncrieff et al, 2015):
- Thinning of the epidermis and flattening of the epidermal junction
- Loss of collagen, elastin and glycosaminglycans
- Atrophy and contraction of the dermis (causing appearance of wrinkles and folds)
- Decreased activity of sweat glands and sebaceous glands – causing the skin to dry out
- Thinning of blood vessel walls and a reduction of blood supply to the extremities
- An increased dermal low-echogenic pixels (LEP), including solar elastosis, may also represent a risk factor for skin tears.
Extrinsic risk factors
Patients who require assistance with activities of daily living – such as mobility, washing, dressing – are at increased risk of skin tears due to handling and force or trauma (Wounds UK, 2015). These are known as extrinsic – or environmental – risk factors. They may be combined with the intrinsic risks of aged skin, presenting a complex mixture of risk factors. LeBlanc et al (2018) therefore conclude that when caring for patients with vulnerable skin, it is possible to minimise extrinsic risk by taking various measures.
For example, a practice nurse or carer should keep their fingernails trimmed and not wear jewellery, and the same care would apply to the patient – if they need a specialist to cut their nails regularly, this should be organised promptly. Padding and/or removing any potentially dangerous furniture or devices such as bed rails and wheelchairs is also of importance, and it is crucial to cover the skin with appropriate clothing, shin guards or retention bandages/stockinettes in vulnerable patients.
Another factor is skin care itself: a pH balanced product is recommended (LeBlanc et al, 2018; Carville et al, 2014), and preventative emollients are of equal importance.
Table 1 shows some common causes of skin tears, but it should be noted that almost half of skin tears are found without any apparent documented cause (LeBlanc et al, 2018).
Table 1. Range of causes of skin tears
| Blunt trauma |
| Falls |
| While performing activities of daily living |
| Dressing/treatment related |
| During patient transfer |
| Equipment injury (eg wheelchairs, bed rails etc) |
Prevention
It is crucial that prevention should be the aim when assessing, planning and implementing care for skin tears, as by controlling modifiable risk factors, skin health can be maintained and preventable injury can be avoided. LeBlanc et al (2018) identify that prevention is based around the same principles as risk factor identification:
- Skin
- General health
- Mobility.
When taking on a new patient or re-assessing a patient who is due a skin health review or has a changed state of health, risk factors must be considered alongside other aspects of care: the individual patient's needs; the health professionals needs and education; and the healthcare setting.
Skin
Emollient therapy is a very important component of skincare for older adults' skin. Use of emollients promotes general skin health and twice-daily application has been proven to reduce incidence of skin tears by 50% (Carville et al, 2014). Emollient products are available as moisturisers (creams, ointments and lotions), bath oils, gels and soap substitutes (National Institute for Health and Care Excellence (NICE), 2015).
LeBlanc et al (2018) state that simple emollients function by ‘trapping’ moisture into the skin and reducing water loss by evaporation, whereas emollients that include additional substances known as humectants (eg urea), work in a different way by actively drawing water from the dermis to the epidermis and compensating for the reduced levels of natural moisturisers in the skin (Wounds UK, 2015). It is also important to consider patient choice as well as what is available and affordable, when considering emollient therapy and deciding on the products to use.
Ointments contain more oil than cream emollients, which can make them more effective, but they then tend to be greasier and more difficult to remove, which could increase risk of tearing the skin if using some force when rubbing at the skin if someone is unaware of the risk this action would present. Emollients containing humectants produce similar rehydration effects but are less ‘heavy’ and more cosmetically acceptable for patients, and therefore could mitigate this and increase quality of life alongside improving patient adherence (Wounds UK, 2015).
A lot of patients in the community may require help with bathing. Their bathing regimen can be discussed with themselves and their carer, recommending emollient products such as soap substitutes and pH-balanced products to use as required. Frequency of bathing should be recommended to be minimised if this is possible in accordance with patient choice. It is best to counsel the patient and their carer regarding various factors, for example the water temperature when washing should not be too hot, so as not to damage the outer skin layer through burns, and care should be taken to pat the patient's skin dry (not rub), with soft cloths and towels to be used that will not be abrasive on the skin.
Practice nurses should also ensure they prevent skin trauma from adhesives, dressings and tapes, and consider medications that may directly affect skin (for example topical and systemic steroids) (LeBlanc et al, 2018).
General health
LeBlanc et al (2018) also place importance on the skin tear prevention regimen involving holistic elements, that consider the patient's general health, such as optimising the patient's nutrition and hydration. This is where the practice nurse could liaise with the patient's case manager if they have a complex array of needs, and if they do not have a case manager but there is an identified number of needs, making a referral may be necessary.
Patients at extremes of weight (bariatric, cachectic or excessively thin) may require extra care to prevent skin tears and may need support via a dietician.
Polypharmacy should also be considered and appropriate extra care taken in combination with their pharmacist and GP. Patients with dementia or mental health issues where aggression is an issue who also have fragile/aged skin and are at risk of skin tears, will also require extra measures to prevent skin tears where possible (LeBlanc et al, 2018).
It may be necessary to refer to an appropriate specialist if impaired sensory perception is a problem, for example in those living with diabetes (LeBlanc et al, 2018).
Counselling the patient on skin tears and preventative measures, and general skin health can be beneficial, so the patient is able to monitor their own skin for changes. Patients can also be encouraged to be aware of potential risks and be mindful of their environment, therefore avoiding self-injury to fragile skin. A self-care checklist could be given to patients who are able to comprehend and use it, so they are enabled to monitor their own skin health and wellbeing.
Mobility
Mobility is also often an issue for many older patients, and the more immobile someone becomes, the frailer they become, with muscle wastage, and the more at risk they are of pressure ulcers. Active movement should therefore be encouraged and appropriate equipment considered for suitability and assessing associated risk factors (LeBlanc et al, 2018). Therefore, a referral may be required for an assessment by occupational therapist practitioners for the appropriate equipment.
A falls prevention programme is important and key to implement in at-risk patients. Wounds International (LeBlanc et al, 2018) have stated that self-care should be encouraged in suitable patients, to include emollient therapy, encouraging the patient to apply moisturisers themselves where possible, which can be incorporated into the patient's daily routine. It is the responsibility of all involved in the care of the patient to ensure all factors relating to falls risk are considered and that a falls risk prevention tool is completed.
Nurses should also encourage patients to apply clothing and compression garments carefully to avoid damage to skin (LeBlanc et al, 2018).
Education
Education and awareness is vital for both the patient and the health professional to minimise risk of skin tears. Health professionals in the team, and in other teams involved with the patient, should be informed and made aware of risk factors and how these can be minimised. It is always important to remember nurses, healthcare assistants, and also all members of the multidisciplinary care team (eg occupational therapists, physiotherapists, other specialists) are involved with the patient's individualised care.
Conclusion
A multidisciplinary approach to care is of paramount importance, involving all practitioners being aware of practical risks, general skin health, and risk factors both intrinsically and extrinsically in older patients with fragile skin. Education is also key in risk reduction throughout the care of the older person.
KEY POINTS:
- Skin tears are prevalent among older people as they have more fragile skin
- Intrinsic risk factors involve the aetiology of the patient's condition. Extrinsic risk factors involve level of mobility, confusion, and ability to care for self
- The multidisciplinary team involves not only nurses but the wider team of occupational therapists and physiotherapists that can be involved in skin tear prevention
- Skin tears can become a complex wound that remain chronic and disabling, reducing quality of life
- Emollients twice daily and good skin care is essential, and when washing the skin it should be patted dry and not rubbed
- Education of the team and the patient is of paramount importance, as well as regular skin care reviews
CPD reflective practice:
- Discuss an older patient you have cared for in terms of the skin care they required and the condition they presented with – what were the risk factors with this patient and how could skin tears have been prevented? What individualised care plan for skin tear prevention would you formulate for this patient?
- Reflect on care that you have provided for someone with a skin tear – what was the outcome of the patient's condition and who was involved in the care? How was the wound cared for and what changes were made to the patient's general care?