You are helping your parent out of their wheelchair to the bed when you notice blood running down their arm. Your eyes automatically travel upwards to the source and you see a wound that looks as if someone peeled back the top layer of skin. A skin tear, probably the most common of skin injuries among the elderly due to changes that occur as we age. The skin becomes more fragile, less elastic, and thinning of the fat layer just below the surface, increase the risk for injury.
Skin tears are a painful injury where the top layer of skin (the dermis), is torn from the layer just below the skin (epidermis), often leaving a skin flap. While they usually aren’t serious, they are painful and disfiguring. Dressing changes may be painful and if not done right, may cause further damage and pain. And as with any break in skin integrity, there is the risk of infection.
According to a study done by the Patient Safety Authority, 88% of all skin tears reported by healthcare facilities occurred in patients 65 years of age or older. “The Authority chose to highlight the skin tear issue because of the high number of patients who experience these painful wounds, especially among older and more fragile populations,” said Alan B.K. Rabinowitz, administrator of the Patient Safety Authority.
Risk factors include:
- Advanced age
- Poor nutritional status
- Dry skin
- Mental impairment
- Loss of vision, sensation, searing
- Long-term use of steroids
- Multiple medications and/or disease processes
- gitation and restlessness
Most skin tears occur on the arms and legs so particular effort should be made to protect these areas.
- Wear long-sleeve shirts and pants
- Apply moisturizer twice a day
- Drink plenty of fluids
- Adequate nutrition
- Wearing glasses and/or hearing aids as indicated
- Check equipment such as bed rails and wheelchairs for rough edges that could cause injury
- Be especially careful when handling a person such as for personal care or transfers
- Keep pathways clear of objects
- Avoid wearing rings, watches or bracelets when providing care
- Keep fingernails trimmed and smooth
- Gently clean the area with normal saline or water (Never use peroxide on an open wound unless dirt is visible and doesn’t come off with water or saline).
- Gently replace the skin flap. The flap may not cover the entire wound, but should be positioned to increase the chance for it to “take” in the wound bed.
- If bleeding cover with gauze and apply light pressure
- Apply a dressing
Choosing the type of dressing to apply involves several factors including skin fragility, amount of drainage, size and location of injury.
If you parent’s skin is relatively healthy, my favorite dressing is a clear, semi-permeable dressing that allows you to see the wound, air to get to the wound, and contains drainage. Tegaderm and Opsite are the two I have worked with the most.
They are a little tricky to handle at first because the plastic will stick to itself and you will never get it unstuck. Be very careful when peeling off the backing. Place it over the wound pressing it in place and then remove the top paper or the one around the edges, depending on the product you use. These can stay on 3-7 days unless drainage is leaking from them. Decreasing the number of dressing changes reduces the risk of reinjuring the wound and infection.
These types of dressings will not stick if there is lotion or oil on the surrounding skin, so you made need to gently wash around the wound with soap and water. Rinse well to avoid leaving soap on the wound. To protect the surrounding skin, I like to use a skin barrier such as Skin Prep. This is an impressive and underutilized tool in my opinion. It forms a protective barrier between the skin and the adhesive, so that when you remove the dressing the Skin Prep comes off instead of more skin. And yet, it actually helps the dressing to stick better.
I had a patient who was allergic to Tegaderm, but as long as we put Skin Prep on first, he could wear it up to a week with no problem. I use it under tape all the time. Skin Prep should be in the medicine cabinet of every caregiver’s home! (No, I am not a representative of the product).
Another dressing I use, especially if the drainage is heavy, is to place Vaseline gauze over the wound, cover with dry gauze, and wrap it with rolled gauze. There is also netting that you can slip over the extremity to hold the dressing in place but if the person is restless or moves a lot, it probably will not work.
Whatever type dressing you apply, remove it slowly and carefully. Peel it off in the direction the skin flap is growing to avoid peeling the skin flap back and causing further damage.
Always monitor skin tears for signs of infection, which can lead to cellulitis, a serious infection of the skin. That is a topic for another day.