“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 partial-thickness (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

Partial Flap loss which

cannot be repositioned

to cover the wound bed

Linear or Flap Tear

which can 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

ISTAP Skin Tear Tool Kit Quick Reference Guide: ISTAP RISK REDUCTION PROGRAM ©

Risk Factor Individual Care giver / provider

General Health Educate patient on skin tear prevention &

promote active involvement in treatment

decisions (if cognitive function not impaired)

Optimize nutrition & hydration

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

Mobility Encourage active involvement if physical

function not impaired

Appropriate selection & use of assistive devices

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

Skin Awareness of medication-induced skin fragility

(steroids)

Wear protective clothing (shin guards, long

sleeves, etc.

Moisturize skin (lubrication & hydration)

Keep fingernails short

Individualize skin hygiene (warm, tepid, not hot,

water; soapless or pH-neutral cleaners; moisturize

skin)

Avoid strong adhesives, dressings, tapes

Health Care setting 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)

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

White et al, 1994

Used with permission sb/kb

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:

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”

83 year old Male

Resident of LTC Facility

Admitted to hospital with Pneumonia & Aspiration

Patient Background

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: Kim LeBlanc(Canada)

President Elect: Karen Campbell(Canada)

Treasurer: Ann Williams(USA)

Secretary: Diane Langemo(USA)

Regional Directors: Africa: Trish Idensohn(Capetown)

Australia/New Zealand: Ann Marie Dunk(Australia)

Europe: Dimitri Beeckman(Belgium)

Samantha Holloway(Wales)

Latin America: Vera Santos(Brazil)

Heidi Hevia(Chile)

North America: 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??