PREVENTION, ASSESSMENT AND MANAGEMENT · SKIN TEARS | Prevention, Assessment and Management 4 TARGET AUDIENCE This workbook is suitable for any practitioners and carers working in

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SKIN TEARS PREVENTION, ASSESSMENT AND MANAGEMENT

Workbook to record your training and personal development in prevention, assessment and management of skin tears

SKIN TEARS | Prevention, Assessment and Management 2

Version 3 (Updated October 2018)

© NHS Education for Scotland 2018. You can copy or reproduce the information in this document for use within NHSScotland and for non-commercial education purposes. Use of this document for commercial purposes is permitted only with the written permission of NES.


CONTENTS

INTRODUCTION

LEARNING OUTCOMES

SECTION 1 SKIN TEARS: PREVENTION, ASSESSMENT AND MANAGEMENT

SECTION 2 WHAT ARE SKIN TEARS?

SECTION 3 PREVALENCE OF SKIN TEARS

SECTION 4 AGE RELATED SKIN CHANGES ASSOCIATED WITH SKIN TEARS

SECTION 5 AT-RISK GROUPS

SECTION 6 PREVENTION OF SKIN TEARS

LEARNING ACTIVITY 2

LEARNING ACTIVITY 3

SECTION 7 CLASSIFICATION OF SKIN TEARS

SECTION 8 PRINCIPLES FOR MANAGEMENT OF SKIN TEARS

LEARNING ACTIVITY 4

LEARNING ACTIVITY 5

LEARNING ACTIVITY 6

SECTION 9 WHEN TO SEEK HELP

LEARNING ACTIVITY 7

IN SUMMARY

QUESTIONS AND ANSWERS TO LEARNING ACTIVITIES

ASSESSMENT

ASSESSMENT PART 1: MULTIPLE CHOICE QUESTIONS

ASSESSMENT PART 2: CASE STUDY TO DEMONSTRATE CLINICAL REASONING

ASSESSMENT PART 1: MULTIPLE CHOICE ANSWERS

ASSESSMENT PART 2: CASE STUDY ANSWERS

ACKNOWLEDGEMENTS

REFERENCES

APPENDIX 1

22

23

24

25

27

28

31

34

38

43

44

45

4

5

7

8

9

10

11

12

15

16

17

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21


TARGET AUDIENCEThis workbook is suitable for any practitioners and carers working in Scotland to learn about skin tears and their prevention, assessment and management.

Accompanying this workbook is a video which supports the workbook and offers more in-depth information including a case study on effective management of skin tears.

The video can be accessed at:https://vimeo.com/107907101

It is recommended that you watch the video before completing the workbook.

HOW TO USE THE WORKBOOKThe purpose of this workbook is to support your learning around skin tears and their prevention, assessment and management.

It is a resource where you and your Line Manager / Mentor can assess your current level of knowledge of skin tears and agree your developmental needs. These should be recorded on the Statement of Completion at the end of the workbook.

COMPLETING THE WORKBOOK There are learning activities within the workbook which include:

� Multiple choice questions � Questions where you can reflect on your current practice and compare

it to the new recommendations for practice � A case study to demonstrate clinical reasoning

The answers to the multiple choice questions can be found under “Assessment Part 1: Multiple Choice Answers”. You will self-mark these questions.

Once you have successfully completed the learning activities your Line Manager / Mentor will review your activities and assessment answers. They will sign your workbook as completed, using the Statement of Completion at the end of the workbook to record your achievement. You can use the Statement of Completion to evidence achievement of the learning outcomes.

NHS staff can scan and upload a copy of the Statement of Completion into e-KSF or in their own evidence of learning folder. Non-NHS staff can record it in their Practice Training and Learning Record or in their own evidence of learning folder.

It is estimated that it will take about 4 hours to complete the workbook.

INTRODUCTION


Before we move on, please take time to read the learning outcomes for this workbook. These will give you clear direction on what it covers and the learning we hope will result from it.

LEARNING OUTCOMES

By the end of this workbook, you will be able to:

1. Identify patient / client groups who are at risk of developing skin tears

2. Relate age-associated skin changes to skin tears

3. Demonstrate an understanding of skin tear prevention

4. Categorise skin tears using the recommended assessment tool

5. Demonstrate an understanding of best practice in assessment and management of skin tears


YOUR DETAILS

Name:

Job Title:

Line Manager / Mentor:

Organisation:

Department:

Date workbook commenced:

Date workbook completed:


Skin tears are viewed as an increasing problem by healthcare workers and if appropriate treatment is not given, these injuries may become chronic wounds with prolonged healing - subsequently causing unnecessary pain and distress.

Traditional management of skin tears can cause new damage and slow down the healing process. This type of injury usually happens in pre-term infants, newborns (infants in the first 28 days after birth) and in older people.

As our population changes and the number of older people increases, whether we are caring for people in their own home, a care home or hospital, we need to be aware of best practice in prevention, assessment and management of skin tears.

SECTION 1 SKIN TEARS: PREVENTION, ASSESSMENT AND MANAGEMENT

This image of a skin tear has been provided for inclusion with kind permission from the Silver Chain Group


SECTION 2 WHAT ARE SKIN TEARS?

An international consensus panel has defined skin tears as:

They occur most commonly: � At the extremes of age � In critically ill or medically compromised individuals � In those who require assistance with personal care

Prevention of skin tears, where possible, should be our priority. When skin tears occur, accurate assessment and appropriate management will minimise further trauma and preserve viable tissue.

A skin tear is a traumatic wound caused by mechanical forces, including removal of adhesives. Severity may vary by depth (not extending through the subcutaneous layer).

International Skin Tears Advisory Panel (ISTAP)


Studies often try to determine how common a condition is in a population. This is referred to as prevalence. The studies which have been conducted to identify the prevalence of skin tears indicate that in elderly care settings, skin tears commonly occur.

The evidence on prevalence and incidence of skin tears is limited and generally dated. Estimates of skin tear prevalence vary across different care settings:

� In long term care: 2.23-92%, although estimates vary and may be lower (Strazzieri et al, 2017; LeBlanc, 2017; LeBlanc et al, 2013; Sanada et al, 2015; Skiveren et al, 2017; Woo et al, 2015)

� In the community: 4.5-19.5% in known wounds in all age groups (Carville and Lewin, 1998; LeBlanc et al, 2008)

� In acute care: 6.2-11.1% (Chang et al, 2016; Hsu and Chang, 2010; McErlean, 2004; Santamaria et al, 2009)

� In palliative care: 3.3-14.3% (Amaral et al, 2012; Maida et al, 2012)

� In intensive care and operative theatres: prevalence is unknown

Work carried out in Australia led by Carville et al (2007) stated that skin tears are perceived to be common wounds and occur more frequently than pressure ulcers. To date, there are no prevalence data available for the UK, therefore the true extent of patients requiring hospital attendance, or the resource impact or cost to the patient or the NHS due to skin tears, is still not fully known.

SECTION 3 PREVALENCE OF SKIN TEARS


Changes to the skin due to the ageing process make the skin more vulnerable. These changes include:

� Thinning of the epidermis (top layer of the skin) and dermis (middle layer of the skin)

� Shrinkage of subcutaneous / fatty tissue (bottom layer of skin)

� Small blood vessel walls widen, shrink and become disorganised

� Decrease in collagen (natural protein component of the skin) amount and quality

� Reduced sebum (natural lubricant) production

Pre-term and newborn infants have immature skin and are also vulnerable to skin tears.

SECTION 4 AGE RELATED SKIN CHANGES ASSOCIATED WITH SKIN TEARS


Both internal and external factors make the skin more vulnerable. The following groups have a heightened risk of skin tears:

OLDER PEOPLE � The epidermis gets thinner and takes longer to repair itself � The dermis gets thinner � The fatty layer of the skin becomes thinner to certain areas of

the body such as the face, neck, hands, arms and lower legs

PRE-TERM INFANTS AND NEWBORNS � Pre-term infants and newborns have underdeveloped skin.

Furthermore, although full term infants are born with a competent skin barrier, their skin is still developing through the first year of life

THOSE SUFFERING FROM LOWERED IMMUNE SYSTEM, MALNUTRITION, CIRCULATION PROBLEMS AND POOR OXYGEN INTAKE

� People with advanced kidney disease � Overweight or under nourished people � People with who have had a stroke or have

poor circulation in the lower legs � People with heart failure

LEARNING ACTIVITY 1

Please select the ONE correct answer

Skin tears occur most commonly:

A) As a result of sport injuries

B) As a result of surgery

C) In critically ill and medically compromised individuals

D) In school age children

SECTION 5 AT-RISK GROUPS

Answer =


SECTION 6 PREVENTION OF SKIN TEARS

Prevention of skin tears starts with early identification of individuals who are at risk. Based on available evidence, the consensus statement of an international panel suggests certain strategies should be part of prevention.

The following strategies should be considered for skin tear prevention:

1. Assess for risk upon admission to care setting and whenever the individual’s condition changes and document in person centred care plan

2. Implement a systematic prevention protocol including a person-centred care plan (use the quick reference guideline over the page)

See table over page...


Quick reference guide for the International Skin Tears Advisory Panel (ISTAP) risk reduction programme

Risk factor Individual Caregiver / provider

General health � Educate patient (if cognitive function not impaired)

� Optimise nutrition and hydration

� Safe patient environment � Educate client and caregivers � Protect from self harm � Dietary consultant � NB extreme BMI (under / overweight) � Review polypharmacy

Mobility � Encourage active involvement (if physical funtion not impaired)

� Appropriate selection and use of assisstive devices

� Daily skin assessment and monitor for skin tears � Safe patient handling / equipment, including proper

transferring and repositioning � Fall prevention programme (remove clutter, proper lighting) � Pad equipment � Avoid sharp fingernails / jewellery

Skin � Encourage awareness of medication-induced skin fragility

� Wear protective clothing � Moisturise skin � Keep fingernails short

� Skin hygiene - warm / tepid water, soapless pH-neutral cleansers, moisturise skin

� Avoid strong adhesives, dressings, tapes � Avoid sharp fingernails / jewellery


Patient choice is a very important factor to consider in emollient therapy. Consideration should also be given to optimising the patients nutrition and hydration.

Individuals with dementia or mental health issues who also have fragile / aged skin, and are at risk of skin tears will also require extra measures to prevent skin tears where possible.

The box below describes a self care checklist for individuals at risk of skin tears.

Self care checklist for patients at risk of skin tears(adapted from Wounds UK, 2015)

Have I been given an individualised skin care plan?

Am I using an emollient every day?

Am I eating sensibly and drinking enough water?

Am I keeping as active and mobile as possible?

Have I thought about wearing clothing to protect my skin - e.g. long sleeves, shin guards or tubular bandages?

Has my environment been made as safe as possible - e.g. adequate lighting, no obstacles and using padding on furniture if required?

Am I wearing sensible / comfortable shoes to avoid falls?


LEARNING ACTIVITY 2

Think of an individual / person in your care with high risk of developing a skin tear. In the space provided list the strategies taken to reduce the risk to that individual and compare it to the recommendations for prevention of skin tears.

Practical advice on maintaining a safe environment to minimise the risk of skin tears is also available. Where relevant, these techniques should be noted on the patient’s care plan. The following should be considered to prevent skin tears:

� Ensure adequate lighting and position small furniture (night tables, chairs) to avoid bumps or knocks. Remove rugs and excessive furniture

� Upholster or pad sharp borders of furniture or bed surroundings with padding and soft material

� Use appropriate aids when transferring patients and safe patient handling techniques according to local manual handling policy

� Never use bed sheets to move patients as this can contribute to damage by causing dragging effect on the skin. Always use lifting device or slide sheet

� Where possible reduce or eliminate pressure, shear and friction using pressure relieving devices and positioning techniques


LEARNING ACTIVITY 3


Which of the following intervention should be part of skin tear prevention?

A) Have individuals at risk wear short sleeves, short trousers / skirts or short socks to let the skin breathe

B) Assessment of the risk of skin tears if admission is greater than one month

C) Keep skin well lubricated by applying skin moisturiser at least twice a day

D) Use limb protectors for individuals considered at risk of skin tears

Answer =


SECTION 7 CLASSIFICATION OF SKIN TEARS

The most important aspect of assessment and management is to minimise further trauma and preserve viable tissue. It is important to classify the type of skin tear as this will determine the severity of the skin tear and aid in planning appropriate treatment. The International Skin Tears Advisory Panel (ISTAP) Classification System is a validated classification tool recommended by the National Association of Tissue Viability Nurse Specialists (Scotland) for use throughout Scotland.

The ISTAP skin tear classification is outlined below:

TYPE 1: NO SKIN 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

TYPE 2: PARTIAL FLAP LOSS

Total flap loss exposing entire wound bed

TYPE 3: TOTAL FLAP LOSS

Images have been provided for inclusion with the kind permission of the Silver Chain Group


The same principles used to manage other wounds should be employed when treating skin tears. The treatment algorithm below is designed to help in the assessment of skin tears.

SECTION 8 PRINCIPLES FOR MANAGEMENT OF SKIN TEARS

SKIN TEARS

ASSESSCONTROL BLEEDING

CLASSIFY (MEASURE AND DOCUMENT)

CLEANSE

APPROXIMATE WOUND EDGES

GOALS AND TREATMENT

� TREAT THE CAUSE � IMPLEMENT PREVENTION � PROTOCOL

� MOIST WOUND HEALING � AVOID TRAUMA � PROTECT PERIWOUND SKIN

� MANAGE EXUDATE � AVOID INFECTION � PAIN CONTROL

TYPE 1: NO SKIN LOSS TYPE 2: PARTIAL FLAPLOSS TYPE 3: TOTAL FLAP LOSS

TREATMENT OPTIONS IN ACCORDANCE WITH LOCAL WOUND CONDITIONS

Skin tear decision algorithm (LeBlanc et al, 2013)The algorithm has been provided for inclusion with the kind permission of the International Skin Tears Advisory Panel (ISTAP)


A skin tears / first aid trauma box containing an appropriate dressing should be available in the care setting. The following are the additional recommendations for management of skin tears:

� Apply aseptic technique

� Assess the wound and the skin flap and determine the category of skin tear using a validated documentation system (ISTAP)

� Cleanse the skin tear following assessment using sterile saline or water at body temperature to remove debris and any residual haematoma

� Manage infection / inflammation

� Depending on healthcare setting, a tetanus immunoglobulin may be administered

� Approximate the skin flap by gently easing the flap back into place using dampened cotton bud or gloved finger

� If the skin flap is difficult to align, consider applying using a sterile moistened non-woven swab for 5-10 minutes first to rehydrate the skin flap

� Encourage moist wound healing by applying a dressing such as soft silicone-based mesh or foam dressing, lipido-colloidal based mesh

and foam dressing, calcium alginate, adsorbent clear acrylic and skin glue, hydrogel or gelling fibre

� Avoid the use of adhesive strips. Sutures or staples are generally not recommended; however they may be required in the treatment of deep, full thickness skin tears

� If possible, dressings should be left in place for several days to avoid disturbing the flap

� If an opaque dressing is used, mark an arrow to indicate the preferred direction of removal and record in notes

� Compression therapy should be considered if wound is on the lower leg. Before applying compression, a full leg assessment including vascular assessment e.g. ankle-brachial pressure index (ABPI) – should be carried out

� Dressings should be held in place with stocking-like products (e.g. tubular viscose retention bandage)

� Pain assessment should be carried out and appropriate analgesia should be provided

� Complete formal wound assessment form

� Document in care plan, complete accident / incident documentation and where relevant discuss with family or next of kin


Think of a patient / client in your care who has developed a skin tear. In the space provided describe the care which was given and compare it to the recommendations for management.

For ongoing management of skin tears, at each dressing change the dressing should be gently removed. If it does not remove easily, consider the use of saline soaks or silicone-based adhesive removers. The wound flap may be friable (fragile and bleed easily) so care should be taken to prevent disturbing it. The wound should be observed for signs of infection. Any changes in the colour of the tissue of the flap that may indicate that it is becoming non-viable tissue.

LEARNING ACTIVITY 4


LEARNING ACTIVITY 5

Look at the photographs from the ISTAP Skin Tear Classification tool below. From the list of categories below, write the category number of the skin tear next to each photograph.

LEARNING ACTIVITY 6


When dressing a skin tear:

A) Use adhesive strips

B) Leave dressing in place for several days

C) Hold dressing in place with tape

D) Use products to encourage dry wound healing

Answer =

Images have been provided for inclusion with the kind permission of the Silver Chain Group

You may wish to refer to page 17 to assist you in answering the question.


If any of the following occur, you should seek help from other services.

� If the skin tear is extensive or associated with a full thickness injury and / or

� If there is uncontrolled bleeding or large haematoma formation

Action: a referral to the General Practitioner if you are in the community or to surgical /plastic surgery in the hospital setting may be required.

� If the skin tear is on the lower leg and fails to progress over a two week period

Action: consider referral to local leg ulcer clinic or vascular nurse specialist for leg ulcer assessment.

� If the wound fails to progress towards healing over a two week period

Action: consider referral to tissue viability specialists.

SECTION 9 WHEN TO SEEK HELP


LEARNING ACTIVITY 7

From the information you have read in this workbook how will this change the prevention and management of skin tears in your workplace?


Skin tears are common wounds, particularly at the extremes of age. We should be aware of the risk factors associated with skin tears and where ever possible minimise risk to patients / clients. When a patient / client develops a skin tear, the use of a skin tear classification system will aid our decision-making, and ensure we are all using the same language to describe skin tears.

You have now completed the workbook.

Please review your answers to the LearningActivities on the following page.

Once you have done this please complete the workbook assessment.

IN SUMMARY


LEARNING ACTIVITY 3


Which of the following intervention should be part of skin tear prevention?

A) Have individuals at risk wear short sleeves, short trousers / skirts or short socks to let the skin breathe

B) Assessment of the risk of skin tears if admission is greater than one month

C) Keep skin well lubricated by applying skin moisturiser at least twice a day

D) Use limb protectors for individuals considered at risk of skin tears

Correct answer = C

QUESTIONS AND ANSWERS TO LEARNING ACTIVITIES

LEARNING ACTIVITY 1


Skin tears occur most commonly:

A) As a result of sport injuries

B) As a result of surgery

C) In critically ill and medically compromised individuals

D) In school age children

Correct answer = C


LEARNING ACTIVITY 5

The order the images is as follows:

3

2

1

LEARNING ACTIVITY 6


When dressing a skin tear:

A) Use adhesive strips

B) Leave dressing in place for several days

C) Hold dressing in place with tape

D) Use products to encourage dry wound healing

Correct answer = B


On successful completion of this assessment, learners will have demonstrated achievement of the following learning outcomes.

� Identify patient / client groups who are at risk of developing skin tears

� Relate age-associated skin changes to skin tears

� Demonstrate an understanding of skin tear prevention

� Categorise skin tears using the recommended assessment tool

� Demonstrate an understanding of best practice in assessment and management of skin tear

There are 2 parts to the assessment below:

Part 110 multiple choice questions – 10 marks

Part 2Case study to demonstrate clinical reasoning – 10 marks

The pass mark is 70% which is 14 marks in total.

ASSESSMENT


Choose the correct response to all the questions by selecting the ONE correct answer.

Read each question, instructions and all possible answers carefully BEFORE you choose the correct answer.

There are 10 questions.

ASSESSMENT PART 1MULTIPLE CHOICE QUESTIONS

1. Which of the following groups are not considered at risk of suffering from skin tears?

A) Overweight patients / clients

B) Elderly patients / clients

C) Children

D) Pre-term babies

2. Which of the following factors may not impact on fragility of the skin?

A) Malnutrition

B) Taking antibiotics

C) Clothing worn

D) Mobility

3. If individuals experience repeat skin tears on shins:

A) Make sure legs are shaved to decrease the risk of infection

B) Provide limb protectors

C) Advise to wear short socks

D) Apply moisturiser once a day

Answer =

Answer =

Answer =


4. Which of the following practical advice can be given on maintaining a safe environment to minimise the risk of skin tears?

A) Only use bed sheets to move patients

B) Advise patients not to change position too much

C) Encourage the use of rugs on the floor

D) Ensure adequate lighting

5. According to the ISTAP skin tears classification tool, a category 1 skin tear is when the:

A) Edges cannot be repositioned

B) Edges can be repositioned to cover the wound bed

C) Skin flap is completely absent

D) Wound has partial flap loss



B) Edges can be repositioned

C) No skin loss

D) Total flap loss exposing entire wound bed

7. Which of the following describes the recommended management of skin tears:

A) Encourage bleeding, assess the wound, cleanse the skin, approximate the skin flap using a clean finger, apply dressing and leave for several days

B) Control bleeding, assess the wound, cleanse the skin, approximate the skin flap using a gloved finger, apply dressing and leave for several days

C) Encourage bleeding, assess the wound, cleanse the skin, approximate the skin flap using a dry cotton bud, apply dressing and leave for several days

D) Control bleeding, assess the wound, cleanse the skin, approximate the skin flap using a dry cotton bud, apply dressing and leave for several days

8. A General Practitioner, surgical / plastic surgery referral may be required when a skin tear is:

A) Associated with a superficial injury

B) Associated with a full thickness injury

C) Occasionally has light bleeding

D) Superficial and no more than 2cms in length

Answer =

Answer =

Answer =

Answer =

Answer =


9. When removing an opaque dressing for skin tears:

A) Remove in the preferred direction

B) Remove quickly to prevent prolonged pain

C) Bleeding is a good sign that the circulation to the area is good

D) Keep the area dry, even when the dressing is sticking

10. Dressings for skin tears should:

A) Encourage moist wound healing

B) Be held firmly with adhesive tape

C) Be changed every day

D) Always be clear so that you can see the wound

Mark = /10

Answer =

Answer =


ASSESSMENT PART 2CASE STUDY TO DEMONSTRATE CLINICAL REASONING

Read the case study below and then list 10 factors that would be important for you, the nurse or carer, to consider when assessing this situation involving a skin tear and deciding upon appropriate management.

CASE STUDY

Mrs Cook is a patient / client in your care home. She has cut her leg after bumping into a coffee table. Mrs Cook is 75 years old, has rheumatoid arthritis and needs help with mobility. Mrs Cook doesn’t eat well and her daughter, who visits twice-a-week, is worried about this.

If, after working on the answer to this question for at least 10 minutes, you cannot list 10 relevant factors; you may consult with peers or receive prompts from your line manager / mentor until you have identified at least 10 relevant factors.


Mark = /10

RELEVANT FACTORS:

Total mark combining multiple choice questions mark and case study mark = /20

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.


You have now completed the assessment. Please check your answers against those provided on the following page and mark your assessment.

Following this, meet with your line manager / mentor and discuss your current level of knowledge and any development needs you may have.

SKIN TEARS | Prevention, Assessment and Management


ASSESSMENT PART 1 MULTIPLE CHOICE ANSWERS

Check your answers against the answers below. Allocate one mark for each correct answer.

If your answer is incorrect, revisit the section of the workbook indicated below with the correct answer.

1. Which of the following groups are not considered at risk of suffering from skin tears?

A) Overweight patients / clients

B) Elderly patients / clients

C) Children

D) Pre-term babies

Correct answer = CWorkbook Section 5

2. Which of the following factors may not impact on fragility of the skin?

A) Malnutrition

B) Taking antibiotics

C) Clothing worn

D) Mobility

Correct answer = BWorkbook Section 6


Correct answer = DWorkbook Section 6

4. Which of the following practical advice can be given on maintaining a safe environment to minimise the risk of skin tears?

A) Only use bed sheets to move patients

B) Advise patients not to change position too much

C) Encourage the use of rugs on the floor

D) Ensure adequate lighting




B) Edges can be repositioned to cover the wound bed

C) Skin flap is completely absent

D) Wound has partial flap loss

Correct answer = DWorkbook Section 7

6. A Category 3 skin tear according to the ISTAP skin tear classification tool:


B) Edges can be repositioned

C) No skin loss

D) Total flap loss exposing entire wound bed

3. If individuals experience repeat skin tears on shins:

A) Make sure legs are shaved to decrease the risk of infection

B) Provide limb protectors

C) Advise to wear short socks

D) Apply moisturiser once a day



7. Which of the following describes the recommended management of skin tears:

A) Encourage bleeding, assess the wound, cleanse the skin, approximate the skin flap using a clean finger, apply dressing and leave for several days

B) Control bleeding, assess the wound, cleanse the skin, approximate the skin flap using a gloved finger, apply dressing and leave for several days

C) Encourage bleeding, assess the wound, cleanse the skin, approximate the skin flap using a dry cotton bud, apply dressing and leave for several days

D) Control bleeding, assess the wound, cleanse the skin, approximate the skin flap using a dry cotton bud, apply dressing and leave for several days


8. Identify the incorrect answer. A surgical / plastic referral may be required when a skin tear is:

A) Associated with a superficial injury

B) Associated with a full thickness injury

C) Occasionally has light bleeding

D) Superficial and no more than 2cms in length



Correct answer = AWorkbook Section 8

9. When removing an opaque dressing for skin tears:

A) Remove in the preferred direction

B) Remove quickly to prevent prolonged pain

C) Bleeding is a good sign that the circulation to the area is good

D) Keep the area dry, even when the dressing is sticking

Correct answer = AWorkbook Section 8

10. Dressings for skin tears should:

A) Encourage moist wound healing

B) Be held firmly with adhesive tape

C) Be changed every day

D) Always be clear so that you can see the wound


ASSESSMENT PART 2 CASE STUDY ANSWERS

Read the case study below and then list 10 factors that would be important for you, the nurse or carer, to consider when assessing this situation involving a skin tear and deciding upon appropriate management.

CASE STUDY

Mrs Cook is a patient / client in your care home. She has cut her leg after bumping into a coffee table. Mrs Cook is 75 years old, has rheumatoid arthritis and needs help with mobility. Mrs Cook doesn’t eat well and her daughter, who visits twice-a-week, is worried about this.


RELEVANT FACTORS:

1. Role of family / carers

2. Type of clothes worn

3. Nutrition

4. Age

5. Circulation

6. Cause of the skin tear

7. Pain level

8. Eyesight

9. Other medical conditions

10. Ability to self care

Correct answer: 10 factors to be identified

If you were unable to identify any of the factors please review the table on the next page which identifies the reasons why these factors are relevant and revisit Sections 5, 6 and 8 of your workbook.


Guideline answer:

Relevant factors Reasons for relevance

Role of family / carers � Carers may need to be educated about the importance of good skin care � Carers may need information about risk factors � Carers may need information about the management plan

Type of clothes worn � Skin may not be covered during moving and handling procedures

Nutrition � Impact on condition of the skin � Impact on healing � Impact on energy levels / ability to self-care

Age � Skin more prone to tearing due to age-related changes � Other age-related changes may increase risk (for example hearing loss may have an impact on communication with carers)

Circulation � Impact on condition of the skin � Impact on skin sensation / awareness

Cause of the skin tear � Has to be identified to prevent further occurrence � Has to be identified to inform management (e.g. safe moving and handling as part of the management plan)

See rest of table over page...


Relevant factors Reasons for relevance

Pain level � May give an indication of the depth of the tear � May give an indication of sensory levels � Pain must be managed

Eyesight � May affect ability to transfer safely � May affect ability to read any written instructions about a dressing etc.

Other medical conditions

� Impact on mobility � Impact on circulation, skin condition � Possible impact on communication

Ability to self-care � Moving and handling may be a risk that needs to be managed � May not be moving safely in bed � May affect ability to keep dressing clean


Ward / Unit / Department:

Date of Completion:

Signature of Line Manager / Mentor:

STATEMENT OF COMPLETION OF THE SKIN TEARS PREVENTION, ASSESSMENT AND MANAGEMENT WORKBOOK

Pass mark of % obtained:

Agreed development needs:

Name of Organisation:

Name of person who completed the learning outcomes and 4 hours learning time:

Job title:


ACKNOWLEDGEMENTS

NHS Education for Scotland would like to acknowledge the support they received from the International Skin Tears Advisory Panel (ISTAP) and the National Association of Tissue Viability Nurse Specialists (Scotland).


Amaral AFS, Pulido KC, Santos VLCG (2012) Prevalence of skin tears among hospitalized patients with cancer. Rev Esc Enferm. Available online at: www.scielo.br/pdf/reeusp/v46nspe/en_07.pdf (accessed 18.12.2017)

Carville K, Lewin G, Newall N et al (2007) STAR: a consensus for skin tear classification. Primary Intention 15:1:18-28

Carville C and Lewin G (1998) Caring in the Community: a prevalence study. Prim Intent 6: 54-62

Chang YY, Carville K, Tay AC (2016) The prevalence of skin tears in the acute setting in Singapore. International Wound Journal 13(5): 977-83

Hsu M, Chang S (2010) A study on skin tear prevalence and related risk factors among inpatients. Tzu Chi Nursing Journal 9(4): 84-95

LeBlanc K et al. Best practice recommendations for the prevention and management of skin tears in aged skin. Wounds International 2018. Available to download from www.woundsinternational.com

LeBlanc K (2017) Skin tear prevalence, incidence and associated risk factors in the long term care population. http://hdl.handle.net/1974/22678 (accessed 26.01.2018)

REFERENCES

LeBlanc K, Baranoski S, Christensen D et al (2013) International Skincare Advisory Panel: A tool kit to aid in the prevention, assessment, and treatment of skin tears using a Simplified Classificaiton System. Advances in Skin and Wound Care 26; 10:459-476

LeBlanc K, Christensen D, Orstead HL et al (2008) Best Practice recommendations for the prevention and treatment of skin tears. Wound Care Canada 6(1): 14-32

Maida V, Ennis M, Corban J (2012) Wound outcomes in patients with advanced illnesses. International Wound Journal 9(6): 683-92

McErlean BS (2004) Skin tear prevalence and management at one hospital. The Australian Journal of Wound Management 12(2): 83-8

National Association of Tissue Viability Nurses Scotland (2009), Prevention and Management of Pressure Ulcers Best Practice Statement

Santamaria N, Carville K, Prentice J (2009) Woundswest: identifying the prevalence of wounds within western Australia’s public health system, EWMA Journal 9(3): 13-8

Strazzieri K, Picolo G, Goncalves T et al (2017) Incidence of skin tears and risk factors: A systematic literature review. Journal of Wound Ostomy Continence Nursing 44; 1 :29-33


STATEMENT 1Intrinsic and extrinsic factors contribute to the cause of skin tears; some of these factors are yet to be determined.

STATEMENT 2Skin tears occur more frequently, but are not limited to, patients at the extremes of age, as this affects the skin’s ability to resist shear, friction and / or blunt force.

STATEMENT 3Individuals with impaired activity, mobility, sensation, or cognition –or with comorbidities and polypharmacy issues – have increased risk of skin tears.

STATEMENT 4An assessment of risk factors for skin tears should be conducted for all individuals within the context of their environment.

STATEMENT 5A collaborative interdisciplinary approach – including patient, carers and family – should be utilised for skin tear prevention and management.

APPENDIX 1UPDATED 2018 INTERNATIONAL SKIN TEARS ADVISORY PANEL (ISTAP) BEST PRACTICE RECOMMENDATIONS

STATEMENT 6Skin tears should be assessed and documented on a regular basis according to an internationally standardised system.

STATEMENT 7Evidence-informed wound care principles should guide treatment of skin tears.

STATEMENT 8Patients, families, caregivers and healthcare providers should be educated regarding prevention and management of skin tears.

STATEMENT 9Not all skin tears are preventable.

STATEMENT 10Further research is needed to expand scientific knowledge to determine best practice in skin tear prediction, prevention, assessment, treatment and documentation.

ISTAP Best Practice Recommendationswww.skintears.org/news/ (accessed 28.01.2018)

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Published December 2018.NESD0934

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PREVENTION, ASSESSMENT AND MANAGEMENT · SKIN TEARS | Prevention, Assessment and Management 4 TARGET AUDIENCE This workbook is suitable for any practitioners and carers working in