Preventing Pressure Ulcers and Skin Tears

Afza.Malik GDA

 Geriatric Nursing and Pressure Ulcer

Preventing Pressure Ulcers and Skin Tears
Pressure Ulcer In Old Age,Pressure Ulcers,Ulcer Risk Factors,Assessment,Pressure,Interventions And Care Strategies,Skin Tears,Assessment of Skin Tears,Interventions for Skin Tears.

Pressure Ulcer In Old Age

    The skin is the largest external organ, so preserving its integrity is an important aspect of nursing care. Performing a risk assessment and implementing a consistent prevention protocol may avoid some losses of skin integrity including pressure ulcers or skin tears. 

    Although pressure ulcers and skin tears may look similar, they are different types of skin injury; skin tears are acute traumatic wounds, whereas pressure ulcers are chronic wounds. 

    It is important, therefore, to assess the wound and to determine the correct etiology so that the proper individualized treatment plan can be implemented.

Pressure Ulcers

    Pressure ulcers are a significant health care problem worldwide (Bolton, 2010). They have a significant impact on health-related quality of life (HRQL: Gorecki et al., 2009). 

    In February 2009, the National Pressure Ulcer Advisory Panel (NPUAP: European Pressure Ulcer Advisory Panel [EPUAP] & NPUAP. 2009), in conjunction with the EPUAP, revised the classic 1989 pressure ulcer definition (”Pressure ulcers prevalence,” 1989) to eliminate the word friction in the definition. 

    Pressure ulcers For description of Evidence Levels cited in this chapter: A Systematic Approach, page 7. 2982009 International NPUAP-EPUAP Pressure Ulcer Definition and Classification System

Pressure Ulcer Definition

    A pressure ulcer is localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure, or pressure in combination with shear. 

    A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated.

    NPUAP/EPUAP pressure ulcer classification system Category/Stage 1: Non-blanchable redness of intact skin Intact skin with non-blanchable erythema of a localized area, usually over a bony prominence. 

    Discoloration of the skin, warmth, edema, hardness, or pain may also be present. Darkly pigmented skin may not have visible bleaching.

Further Description

    The area may be more painful, firmer or softer, or warmer or cooler than adjacent tissue. 

    Category 1 may be difficult to detect in individuals with dark skin tones. This may indicate an “at-risk” individual.

    Category/Stage 2: Partial thickness skin loss or blister Partial thickness, loss of dermis presenting as a shallow, open ulcer with a red or pink wound bed, without slough. It may also present as an intact or open or ruptured serum-filled blister. 

    Further description Presents as a shiny or dry shallow ulcer without slough or bruising. This category should not be used to describe skin tears, tape burns, incontinence-associated dermatitis, maceration, or excoriation.

    Category/Stage 3: Full thickness skin loss (visible fat) Full thickness tissue loss, subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. Some slough may be present. It may include undermining and tunneling.

    The depth of a Category 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput, and malleolus do not have (adipose) subcutaneous tissue and Category 3 ulcers can be shallow. 

    In contrast, areas of significant adiposity can develop extremely deep Category 3 pressure ulcers. Bone or tendon is not visible or directly palpable.

    Category/Stage 4: Full thickness tissue loss (muscle and bone are visible) Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present. It often includes undermining and tunneling.

    The depth of a Category 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput, and malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow. 

    Category 4 ulcers can extend into muscle and/or supporting structures (eg, fascia, tendon, or joint capsule) making osteomyelitis or osteitis likely to occur. Exposed bone or muscle is visible or directly palpable.

Additional Categories for the United States

    Unstageable/Unclassified: Full thickness skin or tissue loss depth unknown Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed.

    Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined, but it will be either a Category 3 or 4. Stable (dry, adherent, intact, without erythema, or fluctuance) eschar on the heels serves as “the body's natural (biological) cover” and should not be removed.

    Suspected deep tissue injury-depth unknown Purple or maroon localized area of discolored, intact skin or blood-filled blister caused by damage of underlying soft tissue from pressure and/or shear are believed to develop as a result of the tissues' internal response to external mechanical loading (EPUAP & NPUAP, 2009).

    The exact combination of pressure, ischemia, muscle deformation, and reperfusion injury that leads to a pressure ulcer remains unclear (EPUAP & NPUAP, 2009). 

    Most pressure ulcers on adults are found on the sacrum, with heels being the second most common site (VanGilder, Amlung, Harrison, & Meyer, 2009). 

    Data in 2009 from 92,408 US facilities reported an overall prevalence rate of 12.3%, with facility acquired rate of 5.0% and 3.2% when Stage 1 ulcers are excluded (VanGilder, Amlung, Harrison, & Meyer, 2009). 

    This same study of 86,932 US acute care facilities reported an overall prevalence rate of 11.9%, with facility acquired rate of 5.0% and 3.1% when Stage 1 ulcers were excluded (VanGilder et al., 2009).

    Summarizes the number of pressure ulcers by stages from this study (VanGilder et al., 2009). 

    The distribution of pressure ulcers has changed over the past years, with the number of Stage 1 ulcers decreasing and the number of unstageable pressure ulcers increasing to 15% as well as suspected deep tissue injury (sDTI) to 9% (VanGilder, MacFarlane, Harrison , Lachenbruch, & Meyer, 2010). 

    Device-related pressure ulcers account for 9.1% of ulcers, with ears being the most common location. In hospice patients, besides sacrum and heels, elbows were a common site for ulcers with most ulcers occurring within 2 weeks prior to death (Hanson et al., 1991). In one hospital's 10-bed palliative care unit, 5% of their patients.

Pressure Ulcer Risk Factors

    No single factor puts a patient at risk for pressure ulcer skin breakdown. Nonnenmacher et al. (2009) are addressing the question of what combination of factors increase the risk and they are exploring 12 factors that seem to have the most impact on predicting pressure ulcer risk. 

    Historically, pressure ulcers occur from a combination of intensity and duration of pressure as well as from tissue tolerance (Bergstrom, Braden, Laguzza, & Holman, 1987; Braden & Bergstrom, 1987, 1989). 

    Immobility as seen in bedbound or chairbound patients and those unable to change positions leading to shear, under- nourishment or malnutrition, incontinence, friable skin, impaired cognitive ability, and decreased ability to respond to one's environment are some of the important identified risk factors for pressure ulcers (Braden, 1998). 

    True pressure ulcers need to be distinguished from moisture associated dermatitis or surface injury in the buttocks region caused by the contact irritation of local friction and moisture factors.

    A study of 20 hospitals of patients waiting for surgery determined a higher incidence of pressure ulcers for longer surgery waiting times or time in an intensive care unit (ICU; Baumgarten et al., 2003). 

    Most pressure ulcers, in one study of 84 surgical patients, occurred within the first three postoperative days (Karadag & Gümüskaya, 2006).

Patients With Hip Fracture and Pressure Ulcer Risk

In a study of nine hospitals, the cumulative incidence of Stage 2 or higher pressure ulcer in older adults with hip fractures was 36.1% (Baumgarten et al., 2009). 

    The less time that patients waited to go to the operating room (OR) for their repair of a hip fracture, the fewer the number of associated Level 4 pressure ulcers (Hommel, Ulander, & Thorngren, 2003). 

    The length of time on the OR table also increased the risk for pressure ulcers in patients with hip fracture (Houwing et al., 2004). 

    Campbell, Woodbury, and Houghton (2010b) found that one-third of their sample of patients with hip fracture developed Stage 2 or higher-pressure ulcers. 

    Implementation of a heel pressure ulcer prevention program (HPUPP) for orthopedic patients in Canada resulted in complete elimination of heel pressure ulcers compared to reimplementation level of 13.8% (Baumgarten et al., 2008). 

    However, this was not designed for sustainability after the original study of a wedge-shaped lower leg positioner to lift the heel off the bed. 

    Critically III, Intensive Care Unit Patients and Pressure Ulcer Risk In a case control study of medical patients in two hospitals, Baumgarten and colleagues (2008) found that the odds of developing a pressure ulcer were twice as high for those having an ICU stay. 

    In contrast, Shalin, Dassen, and Halfens (2009) found a low incidence of pressure ulcers in their 121 ICU patients that they concluded were caused by using foam and alternating air pressure mattresses. 

    APACHE II scores, physiological criteria and Glasgow Coma Scale to predict ICU outcomes with higher scores having poorer outcomes, were higher in patients who developed pressure ulcers. 

    In contrast, other researchers found no relationship between pressure ulcer development and APACHE II scores (Kaitani, Tokunaga, Matsui, & Sanada. 2010). 

    Shanks, Kleinhelter, and Baker (2008) found that despite the consistent implementation of pressure ulcer prevention protocols in their critically ill patients, the patients that developed more hypotensive episodes were more likely to develop subsequent pressure ulcers.

Regulatory and Government Initiatives

    Recent regulatory and government initiatives continuously support the importance of pressure ulcer prevention. Beginning October 1, 2008, the Centers for Medicare and Medicaid Services (CMS) no longer pays a higher diagnosis-related group (DRG) for pressure ulcers acquired during hospitalization (CMS Hospital Acquired Conditions, 2011). 

    Recording of location and stage of any stage 3 and 4 pressure ulcers present on admission (POA) is now holding clinicians legally responsible for establishing the medical diagnosis accountable for documenting this information in the patient's medical record; otherwise, the hospital will not be reimbursed (Russo, Steiner, & Spector, 2006). 

    Data from the Healthcare Cost and Utilization Project (HCUP) statistical review reveal that over the past 11 years, pressure ulcers have increased in hospitalized patients by 80%, even though the number of hospitalizations during this period of 1993-2006 only increased by 15% (CMS Hospital Acquired Conditions, 2011). 

    In the state of New Jersey (NJ), pressure ulcers, Stage 3 or 4, are now reportable in acute care (NJ Department of Health and Senior Services, 2004). 

    Pressure ulcers are one of the 12 targeted areas to reduce harm to hospitalized patients in the United States as part of the Institute for Healthcare Improvement's (IHI) “5 Million Lives Campaign” launched in December 2006 (IHI, 2006). 

    The former head of IHI is now the head of CMS. Thus, at the beginning of the 21st century, appropriate risk assessment and preventative care take on even more important meaning. Several successful initiatives to decrease pressure ulcer incidence are reported in the literature (Lyder & Ayello, 2009; McInerney, 2008). 

    Nurses will find the Agency for Healthcare Research and Quality (AHRQ) toolkit helpful in developing quality initiatives to decreased pressure ulcer incidence (Pancorbo-Hidalgo, Garcia-Fernandez, Lopez-Medina, & Alvarez-Nieto, 2006).

When To Do an Assessment

    The assessment of the relative pressure ulcer risk is the first step of any individual patient or health care system plan for prevention. Some pressure ulcer clinical guidelines recommend that patients are assessed for pressure ulcer development on admission to a facility, on discharge, whenever the patient's condition changes, then reassessed.

Pressure Ulcer Risk Assessment Tools

    Guidelines recommend that a comprehensive assessment for pressure ulcer risk include a history and physical examination, skin inspection, and a pressure ulcer risk assessment calculation using a valid and reliable assessment tool. 

    Both the Braden (Norton et al., 1962) and Norton scale (Norton et al., 1962; Norton, McLaren, & Exton-Smith, 1975) are considered reliable and valid. A study of 429 patients in acute care found the modified Braden scale to be a better predictor than the Norton scale (Kwong et al., 2005). 

    Although Kottner and Dassen (2010) found that the Braden scale was more valid and reliable than the Waterlow scale, they do not recommend either of these scales for ICU patients. Research to create new scales specific to ICU patients continue (Suriadi. Sanada. Sugama. Thigpen, & Subuh, 2008).

    The Braden scale created in 1987 (Bergstrom et al., 1987) as part of a research study has six factors and is the most widely used in the United States. Sensory perception, mobility, and activity address clinical situations that predispose the patient to intense and prolonged pressure. 

    Moisture, nutrition, and friction and shear address factors that alter tissue tolerance for pressure. Each of the six categories is ranked with a numerical score, with 1 representing the lowest possible sub score with the greatest risk. The sum of the six sub scores is the final Braden scale score, which can range from 6 to 23.

    A low Braden scale score indicates that a patient is at risk for pressure ulcers. The original onset of risk score on the Braden scale was 16 or less (Braden & Bergstrom, 1987). Further research in older adults (Bergstrom & Braden, 1992) and in persons with darkly pigmented skin (Lyder et al., 1998, 1999) support a score of 18 or less. 

    Research by Chan, Tan, Lee, and Lee (2005) also found that the total Braden scale score was the only significant predictor of pressure ulcers in hospitalized patients. 

    In 2009, Chan, Pang, and Kwong (2009) found that using a modified Braden scale, with a cutoff score of 19 in 107 bed orthopedic department of an acute care hospital in Hong Kong, 9.1% of patients developed pressure ulcers. 

    In a retrospective study of intensive care patients in Korea using a cutoff score of 13, the Braden scale had low-to-moderate positive predictive performance without a more comprehensive approach to patient-risk assessment (Cho & Noh, 2010). 

    Risk was associated with pressure ulcer development in ICU patients where they had low Braden scale scores on the first day of hospitalization and low Glasgow scale scores (Fernances & Caliri, 2008).

    Once risk is identified, either for overall score or in any low subscales (CMS, 2004), prevention interventions need to be implemented. 

    However, one study found that despite identification of pressure ulcer risk using the Norton scale, only 51% of the sample of the 792 patients, 65 years and older hospitalized patients, had a preventive device in place (Rich, Shardell, Margolis, & Baumgarten , 2009).

Does Race Make A Difference?

    When it comes to severity of pressure ulcers, race may make a difference. Ayello and Lyder (2001) analyzed and summarized the existing data about pressure ulcers across the skin pigmentation spectrum. 

    Blacks have the lowest incidence (19%) of superficial tissue damage classified as Stage 1 pressure ulcers, and Whites have the highest incidence at 46% (Barczak, Barnett, Childs, & Bosley, 2007). 

    The more severe tissue injury seen in Stages 2-4 pressure ulcers is higher in persons with darkly pigmented skin (Barczak et al., 2007: Meehan, 1990, 1994). Three national surveys showed that Blacks had 39% (Barczak et al., 2007), 16% (Mechan, 1990), and 41% (Meehan, 1994) higher incidence of Stage 2 pressure ulcers compared to Caucasians. 

    Subsequent studies by Lyder and colleagues (1998, 1999) continue to support a higher incidence of pressure ulcers in persons with darkly pigmented skin. 

    Fogerty, Guy, Barbul, Nanney, and Abumrad (2009) found that not only was there a higher prevalence of pressure ulcers, but also that they occurred in younger African Americans as compared to Caucasians.

    Inadequate detection of Stage 1 pressure ulcers in persons with darkly pigmented skin may be because clinicians erroneously believe that dark skin tolerates pressure better than light skin (Bergstrom, Braden, Kemp, Champagne, & Ruby, 1996), or that only color changes indicate an ulcer (Bennett, 1995; Henderson et al., 1997; Lyder, 1996; Lyder et al., 1998, 1999; Rich et al., 2009). 

    Research has begun to validate these assessment characteristics in the Stage 1 definition. 

    In 2001, Lyder and colleagues (2001) reported a higher diagnostic accuracy rate of 78% using the revised definition compared with 58% with the original definition. Sprigle, Linden, McKenna, Davis, and Riordan (2001) found changes in skin temperature; in particular, that warmth then coolness accompanied most Stage 1 pressure ulcers.

    Clinicians should pay careful attention to a variety of factors when assessing a client with darkly pigmented skin for Stage 1 pressure ulcers. 

    Differences in skin over bony prominences (eg, the sacrum and the heels) as compared with surrounding skin may be indicators of a Stage 1 pressure ulcer. 

    The skin should be assessed for alterations in pain or local sensation. In addition, a change of skin color should be noted by being familiar with the range of skin pigmentation that is normal for your particular patient (Bennett, 1995; Henderson et al., 1997).

Interventions And Care Strategies

    Determining a patient's risk for developing a pressure ulcer is only the first step in providing best practice care. Once risk is identified, implementing a consistent protocol to prevent the development of a pressure ulcer is essential. 

    A nursing standard of practice protocol for pressure ulcer prevention is presented to facilitate proactive interventions to prevent pressure ulcers. A change in attitudes of health care professionals may be required to facilitate prevention (Buss, Halfens, Abu-Saad, & Kok, 2004). 

    Educating nursing students (Holst et al., 2010) as well as nurses in an ICU unit resulted in decrease in pressure ulcers (Uzun, Aylaz, & Karadag, 2009). Several clinical guidelines on preventing and treating pressure ulcers exist (EPUAP & NPUAP. 2009; Wound, Ostomy, and Continence Nurses Society, 2010). 

    Components of a pressure ulcer prevention protocol should minimally include interventions targeting the following: skin care (including addressing moisture and friction), pressure redistribution, repositioning, and nutrition.

Skin Care

    Skin that is too dry or too wet has been associated with pressure ulcers. Although there is limited research, dry skin is believed to predispose ulcer formation (Allman, Goode, Patrick, Burst, & Bartolucci, 1995: Reddy, Gill, & Rochon, 2006). 

    The type of cream used on the skin for different parts of the body may make a difference as evidenced by a study of 79 patients treated with dimethyl sulfoxide cream who had an increase in pressure ulcers when this cream was used on the heels as compared to the buttocks (Houwing. Van der Zwet, van Asbeck, Halfens, & Arends, 2008). 

    Other researchers (Stratton et al., 2005) found that a silicone-based dermal nourishing cream reduced the proportion of hospital-acquired pressure ulcers to zero after 8 months. Each of these creams are lubricating, adding an external ointment type of layer preventing insensible losses. 

    The stratum corneum has 10% moisture content and when this level goes below a critical level, the skin integrity is lost with defects between the keratin layers (dry skin, winter itch, cracked eczema). The second way to moisturize the skin is with urea or lactic acid preparations. 

    These are humectants that actually bind water to the stratum corneum but will sting or burn when applied to open skin because of their hydroscopic properties. Skin can also be too wet with macerated stratum corneum, decreasing the cutaneous barrier and subjecting affected individuals to increase risk of yeast and bacterial infections.

     Use of a soft silicone dressing on the sacrum of critically ill patients resulted in zero. pressure ulcers in one ICU (Brindle, 2010). Hydrocolloid dressings decreased pressure ulcers from nasotracheal intubation (Huang, Tseng, Lee, Yeh, & Lai. 2009). 

    When hydrocolloid or film dressings were applied to the skin under face masks, there were fewer pressure ulcers (Weng, 2008).

Repositioning and Pressure Redistribution

    Because immobility is a risk factor in the development of pressure ulcers in hospitalized patients (Lindgren, Unosson, Fredrikson, & Ek, 2004), efforts must be implemented to address pressure. 

    Although repositioning patients is a key intervention to redistribute the pressure and prevent pressure ulcers, the best frequency for turning and repositioning as well as which support surface to use remains a challenge (Defloor, De Bacquer, & Grypdonck, 2005: Norton et al., 1975: Young, 2004). 

    Patients on a particular support surface may not have to be repositioned every 2 hours, depending on the persons' tolerance to pressure. There is no one repositioning timetable for all, it needs to be individualized (EPUAP & NPUAP, 2009). 

    The use of a wedge-shaped cushion rather than a pillow may be more effective in decreasing pressure ulcers in some patients (Heyneman, Vanderwee, Grypdonck, & Defloor, 2009).

    Redistributing pressure is a key component of preventing pressure ulcers. When compared to alternating pressure overlays, alternating pressure mattresses reduced length of stay for hospitalized patients, thus, decreasing costs as well as the added benefit of delaying the time to when a pressure ulcer appeared (Iglesias et al., 2006; Nixon et al. , 2006). 

    The incidence of heel pressure ulcers have been decreased when the appropriate heel suspending device has been used to relieve pressure (Gilcreast et al. 2005). In 2010, a prospective 150-patient, 6-month study by Campbell. 

    Woodbury, and Houghton (2010a), pressure ulcer incidence was 16% being significantly lower (p=.016) for those who received help with pressure relief interventions. 

    In a single study, when persons with a body mass index (BMI) greater than 35 were placed on appropriate size low air loss equipment, no new pressure ulcers developed (Pemberton, Turner, & Van Gilder, 2009). 

    In Australia where real medical sheepskin is available. one study that had some questionable methodology demonstrated that patients randomly assigned to the real sheepskin mattress overlay during their hospital stay had a 9.6% incidence risk of pressure ulcers compared to the control group that had 16.6% (Jolley et al., 2004). 

    A similar increased attention to pressure redistribution also needs to be brought into the OR.


    There is lack of consensus about the best way to assess nutritional impairment but. generally, consultation by a dietician for nutritional status, determination of any unintended weight loss, and evaluation of laboratory values such as serum albumin or prealbumin should be considered. 

    Cordeiro and colleagues (2005) found that the concentrations of ascorbic acid and alpha-tocopherol were significantly decreased in patients with pressure ulcers or infection. 

    In a randomized double-blind study on the effect of daily supplement with protein, arginine, zinc, and antioxidants versus water-based placebo supplement in patients with hip fractures, the incidence of Stage 2 pressure ulcers demonstrated a 9% difference between the nutritionally supplemented group and the placebo group (Houwing et al., 2003). 

    The Cochrane Database reviewed the role of nutrition in pressure ulcer prevention and treatment. The analysis of the database was inconclusive because of the lack of high-quality trials (Langer, Schloemer, Knerr, Kuss, & Behrens, 2003). 

    When and how patients should be nutritionally supplemented to prevent pressure, ulcers remains unclear (Houwing et al., 2003; Reddy et al., 2006; Stratton et al., 2005), but at times the literature is contradictory. The NPUAP nutritional recommendations (EPUAP & NPUAP 2009) for pressure ulcer prevention are included in Protocol 16.1.

Skin Tears

    Skin tears are traumatic wounds caused by shear and friction (O'Regan, 2002). This skin injury occurs when the epidermis is separated from the dermis (Malone, Rozario, Gavinski, & Goodwin, 1991). 

    Because aging skin has a thinner epidermis, a flatter dermal-epidermal junction and decreased dermal collagen, older persons are more prone to skin injury from mechanical trauma (Baranoski, 2000; Payne & Martin, 1993; White, Karam, & Cowell, 1994). 

    Therefore, skin tears are common in older adults, with more than 1.5 million occurring annually in institutionalized adults in the United States (Thomas, Goode, LaMaster, Tennyson, & Parnell, 1999), although the incidence in acute care is unknown. Skin tears are frequently located at areas of age-related purpura (Malone et al., 1991; White et al., 1994).

Assessment of Skin Tears

    The following areas should be assessed for skin tears: shins, face, dorsal aspect of hands, and plantar aspect of the foot (Malone et al., 1991). 

    Besides older adults, others with thinning skin who are at risk for skin tears are patients on long-term steroid therapy. women with decreased hormone levels, persons with peripheral vascular disease or neuropathy (the decreased sensation making them more susceptible to injury), and those with inadequate nutritional intake (O'Regan, 2002).

    The three-group risk assessment tool was developed during a research study by White and colleagues (1994). Because of its length, it is not always used clinically to assess for risk of skin tears (White et al., 1994). 

    Within the tool, there are three groups delineated by level of risk: Groups 1, 2, and 3. Group 1 refers to a positive history of skin tears within the last 90 days or skin tears that are already present. 

    A positive score in this group requires that the patient be put on a skin tear prevention protocol. Group 2 requires four of the next six criteria to identify an increased risk: 

(a) decision-making skills are either impaired or slightly impaired, or extensive assistance and total dependence for activities of daily living (ADLs) is noted

(b) wheelchair assistance needed

(c) loss of balance

(d) bed or chair confined

(e) unsteady gait

(f) bruises. 

    If a patient has a score of 4 or more items in Group 2, then implement a skin tear prevention protocol. Group 3 includes the following 14 items requiring any five for an increased risk: 

(a) physically abusive

(b) resists ADL care

(c) restlessness

(d) hearing impaired

(e) decreased tactile stimulation

(f) wheels self

(g) manually or mechanically lifted

(h) contractures of arms, legs, shoulders, and/or hands

(i) hemiplegia and hemiparesis

(j) trunk, partial, or total inability to balance or turn body

(j) pitting edema of legs

(k) open lesions on extremities: 

    Three or four discrete senile purpura lesions on extremities; and (m) dry, scaly skin. An increased risk has also been identified in individuals with a combination of three items in Group 2 and three items in Group 3. 

    Positive responses to five or more items in Group 3 or three items in both Groups 2 and 3 should also trigger the implementation of a skin tear prevention protocol (White et al., 1994).

    Several authors have suggested protocols to prevent skin tears (Baranoski, 2000; Battersby, 1990; Mason, 1997; O'Regan, 2002; White et al., 1994). 

    Lacking research in acute care, some nursing home research supports the value of skin ulcer care protocols to reduce the incidence of skin tears (Bank, 2005; Birch & Coggins, 2003; Hanson. Anderson, Thompson, & Langemo, 2005). 

    After changing from soap and water to a no-rinse, one step bed product. skin tears declined from 23.5% to 3.5% in one nursing home (Birch & Coggins, 2003). 

    Hanson and colleagues (2005) also found that skin tears could be reduced in two different nursing homes when staff were educated in appropriate skin cleaning and protection strategies. 

    A reduction in monthly average of skin tears from 18 to 11 after using longer lasting moisturizer lotion sleeves to protect the arms, and padded side rails was reported in yet another nursing home study (Bank, 2005). 

    One study claims a decrease in skin tears when skin is treated with cream (Groom, Shannon, Chakravarthy, & Fleck, 2010).

Interventions for Skin Tears

    If a skin tear does occur, it is important to correctly identify it and begin an appropriate plan of care. The Payne-Martin classification system (Payne & Martin, 1993) can be used to describe skin tears. The three categories are the following:

Category 1: A skin tear without tissue loss

Category 2: A skin tear with partial tissue loss

Category 3: A skin tear with complete tissue loss where the epidermal flap is absent

    The usual healing time for skin tears is 3-10 days (Krasner, 1991). Although skin tears are prevalent in the older adult patient, there is no consistent approach to managing these skin injuries (Baranoski, 2000; O'Regan, 2002). 

    Research is just beginning to provide evidence on which dressing is best to use for skin tears. One study (Edwards, Gaskill, & Nash, 1998) compared the use of four different types of dressings in treating skin tears in a nursing home.

    Three occlusive (transparent film, hydrocolloid, and polyurethane foam) and one nonocclusive dressing of Steris trips covered by a non-adhesive cellulose-polyester material. 

    The nonocclusive dressing facilitated healing at a faster rate than the occlusive dressings. Another study by Thomas and colleagues (1999) studied older adult skin tears in three nursing homes and identified that there was a higher rate of complete healing that occurred with foam dressings compared to transparent films.

    Goals of care for skin tears include retaining the skin flap if present, providing a moist, nonadherent dressing, and protecting the site from further injury (O'Regan, 2002). 

    A consensus protocol for treating skin tears based on suggested plans of care have been developed by several authors (Baranoski, 2000; Baranoski & Ayello, 2008; Edwards et al., 1998; O'Regan, 2002) and can be found in Protocol 16.2.

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