Over the Rainbow with Skin Tears Mary Gloeckner MS,RN,CWON,APN
Disclosures: 1) Mary Gloeckner has no financial relationship with any commercial interest 2) Mary Gloeckner is a Board Member of ISTAP (International Skin Tear Advisory Panel)
Objectives: 1. Classify skin tears according to the ISTAP Classification System 2. Discuss the skin tear Toolkit components/interventions related to the prevention of skin tears 3. Discuss treatment options for skin tears
International Skin Tear Advisory Panel Unrestricted Educational Grant from Hollister Wound Care
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
What do Skin Tears Look Like?
Skin Tears are common in extremes of Age, and the Chronically and Critically ill population.
Prevalence of Skin Tears?
Prevalence of skin tears Reported rates of 5-44% True prevalence across healthcare settings not known!
Prevalence Of Skin Tears: Review of the Literature A 2011 study in a 114 bed Long Term Care Facility demonstrated a 22% prevalence of skin tears (LeBlanc & Christensen 2013) Carville et al (2007) asserted that skin tears are perceived to be common wounds and occur more frequently than pressure ulcers A 1994 study in a 347-bed facility in Western Australia demonstrated a 41.5% skin tear prevalence rate within its population (Everett, Powell 1994)
Most common LeBlanc, Christensen 2011
Consensus Report 2011
Consensus Report Sept. 2011
Introducing a Validated Skin Tear Classification System
ISTAP Skin Tear Classification Type 1: No Skin Loss Type 2:Partial Flap Loss Type 3: Total flap loss Linear or Flap Tear which can be repositioned to cover the wound bed Partial Flap loss which cannot be repositioned to cover the wound bed Total Flap loss exposing entire wound bed
TYPE 1 TYPE 2 TYPE 3
Skin Tears To manage and treat skin tears, nurses must understand: who is at risk for developing skin tears how to prevent these wounds from occurring how to manage these challenging wounds should they occur And YES we should be documenting them as wounds.
ISTAP Tool Kit
The Tool Kit was designed to include components that would serve as a basis for implementation guidance for Skin Tear 1)Prevention and 2)Treatment programs
ISTAP Skin Tear Tool Kit The Tool kit includes the following components: ISTAP Classification System Risk Assessment Pathway Quick Reference Guide for the ISTAP Risk Reduction Program and Rationale Skin Tear Decision Algorithm Pathway to Assessment / Treatment of Skin Tears Prevalence Study Data Collection Sheet Product Selection Guide Received a 98% consensus from international reviewers who agreed or somewhat agreed with content of the tool kit
ISTAP Risk Assessment & Risk Reduction Program
Look at Risk Factors & putting into place what the: - Individual needs - Healthcare Provider needs - Healthcare Setting needs
Quick Reference Guide: ISTAP RISK REDUCTION PROGRAM Risk Factor Individual Care giver / provider General Health Mobility Skin ISTAP Skin Tear Tool Kit Educate patient on skin tear prevention & promote active involvement in treatment decisions (if cognitive function not impaired) Optimize nutrition & hydration Encourage active involvement if physical function not impaired Appropriate selection & use of assistive devices Awareness of medication-induced skin fragility (steroids) Wear protective clothing (shin guards, long sleeves, etc. Moisturize skin (lubrication & hydration) Keep fingernails short Safe patient environment Educate client +/ circle of care / caregivers Protect from self harm Dietary consult if indicated Extra caution with extremes of BMI (<20 or >30) Review polypharmacy for medications reduction /optimization Daily skin assessment & monitor for skin tears Ensure safe patient handling techniques/ equipment & environment (trauma, Activities of Daily Living (ADLs), self injury) Proper transferring/ repositioning Initiate fall prevention program Remove clutter Ensure proper lighting Pad equipment/furniture (bedrails, wheel chair etc.) Avoid sharp finger nails/jewelry when having patient contact Individualize skin hygiene (warm, tepid, not hot, water; soapless or ph-neutral cleaners; moisturize skin) Avoid strong adhesives, dressings, tapes Implement comprehensive Skin Tear Reduction Program Include skin tears in audit programs Utilize validated classification system Develop consultative team (wound care/dietary specialists, rehab/pharmacists) Health Care setting
Risk factors for skin tears 1.Dependent patients who require total care for all activities of daily living most at risk Frequently acquired skin tears occur during routine activities of dressing, bathing, positioning, and transferring White et al, 1994
Risk factors for skin tears 2. Slightly impaired patients/residents Injury from hitting stationary equipment or furniture Used with permission sb/kb White et al, 1994
Risk factors: Critically ILL - Fluid Overload -Multi-system failure
4. Extremes of Ages: Neonates/Pediatrics -- Immature Skin(Premies) -- Medical adhesive injuries
Skin Tear Algorithm
Treatment: 1. Determine ISTAP classification 2. Cleanse the wound 3. Realign skin flap(do not remove the flap unless necrotic) 4. Cover with non-adherent dressing
Dressings: Soft silicone foam dressing Foam Hydrogels Tubular Net Bandage Products Not Recommended: Hydrocolloids Transparent films Closure strips
The key to any treatment program is an established Prevention program
Prevention Strategies Protect from trauma during routine care and from self-injury 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 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
ISTAP Increase awareness of Skin Tears worldwide Encourage Prevalence Studies Research
Data Collection Tool
Case Study by Mary Gloeckner RN,MS,CWON,APN (Member of ISTAP) Published in AJN: November 2016
Day #1: Wound Consult placed for WOC nurse to assess skin tear on Left shoulder
Patient Background 83 year old Male Resident of LTC Facility Admitted to hospital with Pneumonia & Aspiration
Two Type 3 skin tears: a) Left shoulder- 10.0 x 6.0 x 0.1cm b) Left upper back- 7.0 x 5.0 x 0.1cm
* Pt. fell 1 day prior to hospital admission * Anticoagulent therapy Profuse bleeding Hemoglobin 8 gm/dl
Treatment Goals: 1) Moist wound healing 2) Avoid trauma 3) Manage exudate(bleeding) 4) Prevent infection 5) Protect periwound skin
Daily Treatment: 1) Non-adherent topical antimicrobial 2) Cover with soft silicone foam dressing
Both skin tears became Complex wounds: As a result of profuse bleeding, this pt. required a blood transfusion
8 Days after treatment initiated
4 weeks after treatment initiated
After 4 weeks of treatment, skin tears completely healed
September 2016-WUWHS, Florence, Italy ISTAP was presented with: Most Progressive Society Award!!!
ISTAP Continues to grow President: President Elect: Treasurer: Secretary: Regional Directors: Africa: Australia/New Zealand: Europe: Latin America: North America: Kim LeBlanc(Canada) Karen Campbell(Canada) Ann Williams(USA) Diane Langemo(USA) Trish Idensohn(Capetown) Ann Marie Dunk(Australia) Dimitri Beeckman(Belgium) Samantha Holloway(Wales) Vera Santos(Brazil) Heidi Hevia(Chile) Kevin Woo(Canada) Mary Gloeckner(USA) Karen Edwards(USA)
EWMA 2017- Amsterdam, Netherlands
ISTAP goal: To have skin tears globally recognized as complex acute wounds
Thank You!! QUESTIONS??