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• To understand why older people are particularly susceptible to skin tears
• To identify the factors that can increase the risk of an individual developing skin tears
• To ensure your knowledge of best practice regarding skin tear prevention and recognition is up to date
Skin tears, defined as traumatic wounds caused by mechanical forces, can be debilitating for individuals, causing pain and reduced mobility. Although skin tears can develop throughout the lifespan, older age can make the skin increasingly susceptible to this type of injury. Studies have found wide variation in the incidence and prevalence of skin tears, in part because of suboptimal recognition and reporting practices among healthcare professionals. Effective prevention of skin tears requires a standardised approach to risk assessment, prevention, recognition and classification, such as that offered by the International Skin Tear Advisory Panel (ISTAP) best practice recommendations. This article examines the literature on the incidence, prevalence, prevention and recognition of skin tears, and outlines some of the ISTAP best practice recommendations on risk assessment, prevention and recognition. The authors also consider the need for patient and healthcare professional education to optimise the prevention of skin tears.
Nursing Standard. doi: 10.7748/ns.2023.e12066
Peer reviewThis article has been subject to external double-blind peer review and checked for plagiarism using automated software
Correspondence Conflict of interestNone declared
Blackburn J, Ousey K (2023) Preventing and recognising skin tears using a standardised approach. Nursing Standard. doi: 10.7748/ns.2023.e12066
Published online: 13 November 2023
The skin is the largest organ in the human body and serves numerous important functions, including prevention of damage to internal organs and tissues, protection from infection, and protection against mechanical impact and pressure (Bianchi and Cameron 2008, Benbow 2017, Chambers and Vukmanovic-Stejic 2020). Skin tears have been described as ‘traumatic wounds caused by mechanical forces’ (LeBlanc et al 2018). These mechanical forces include shear and friction, where shear is a mechanical force that acts on an area of skin in a direction parallel to the body’s surface and friction is the mechanical force exerted when skin is dragged across a coarse surface (Hess 2004, Gleeson 2016, Davies 2018, Greenwood 2021). Shearing or friction can occur as a result of various actions, including blunt trauma, falls, suboptimal handling and/or injury caused by equipment or removal of dressings (LeBlanc et al 2018).
Skin tears can occur at any point throughout the lifespan, including in neonates (Oranges et al 2015), but are particularly associated with older people. Age-associated issues, such as alterations in the structure of the skin, suboptimal nutrition and limited mobility, are contributing factors to skin tears (Keevil and Kimpton 2012, Lichterfeld et al 2015). Skin tears can be debilitating, for example due to pain and/or reduced mobility, while complex or chronic wounds can result in serious complications, such as severe pain and limited quality of life, if appropriate interventions are not implemented (LeBlanc et al 2013, Wounds UK 2015). Complex or chronic wounds are defined as those that fail to heal within four weeks of sustaining the injury (LeBlanc et al 2018).
Although often preventable, skin tears are frequently seen in clinical practice. Furthermore, such injuries are underreported and can be challenging to identify, largely because of variations in assessment methods and classification systems, as well as some healthcare professionals failing to recognise the significance of skin tears (LeBlanc and Baranoski 2014). Early identification of people at risk of developing a skin tear is fundamental to prevention. To support early identification of those at risk, and to improve diagnosis and reporting of such injuries, an effective prevention programme based on standardised recognition and classification systems and risk assessment strategies is required, as well as education for healthcare professionals and patients (LeBlanc et al 2018).
This article examines the variations in the reported incidence and prevalence of skin tears, and discusses some of the standardised approaches that can be taken to their risk assessment, prevention, recognition and classification. It also emphasises the need for education for patients and healthcare professionals to ensure best practice in the prevention of skin tears.
• Skin tears are traumatic wounds caused by mechanical forces such as shear and friction
• Skin tears are frequently seen in clinical practice, despite often being preventable
• Standardised practice that supports the early identification of risk and timely implementation of prevention interventions can significantly reduce the incidence of skin tears
• Education and awareness of risk factors and prevention strategies among healthcare professionals are vital to ensure effective skin tear prevention
There are variations in the estimated incidence and prevalence of skin tears, due not only to the different patient populations and types of healthcare settings being studied, but also because of inconsistent reporting of these injuries. For example, Strazzieri-Pulido et al’s (2017) systematic review of the incidence of skin tears and risk factors examined five epidemiological studies – published between 1990 and 2014 in English, Spanish or Portuguese – and identified incidence rates ranging from 2% to 92% in long-term care facilities. In the UK, a pilot randomised controlled trial investigating the use of protective socks to reduce skin tears in 90 older adults (aged ≥65 years) living in care homes or in the community reported a skin tear incidence rate of 20% (Powell et al 2017).
The prevalence of skin tears in long-term care settings varies across different countries. For example, a Belgian study reported a skin tear prevalence of 3% (n=24) in 795 nursing home residents (Van Tiggelen et al 2019), while a study in Denmark reported a skin tear prevalence of about 5% (n=6) in 128 nursing home residents (Skiveren et al 2017). Similarly, a cross sectional study in Japan identified a skin tear prevalence of 4% (n=16) in 410 older patients in a long-term care setting (Koyano et al 2016).
There are also variations in the prevalence of skin tears across different types of healthcare setting. For example, Bermark et al (2018) reported a skin tear prevalence of 11% (n=23) in 202 patients aged between 19 years and 99 years in an acute healthcare setting in Denmark, whereas Chang et al (2016) reported a hospital-acquired skin tear prevalence of 6% (n=9) in 144 patients aged between 70 years and 89 years in an acute healthcare setting in Singapore. A later study of skin tears in 380 people in long-term care settings in Canada reported a prevalence of 21% and an incidence rate of 19% (LeBlanc et al 2020).
A standardised approach to recognition and classification of skin tears may improve reporting practices, which could enhance the efficacy of prevalence and incidence studies.
Evidence suggests that standardised practice supporting the early identification of risk and timely implementation of prevention interventions can significantly reduce the incidence of skin tears. For example, Bank and Nix (2006) implemented a range of standardised skin tear risk minimisation measures for patients in a 209-bed urban nursing and rehabilitation centre, which included protective skin covering (‘skin sleeves’) for high-risk patients, the use of skin emollients and staff education. A comparison of pre-intervention and post-intervention skin tear incidence data showed a significant reduction in the mean number of skin tears and associated financial costs (Bank and Nix 2006). In a later study, Carville et al (2014) conducted a cluster randomised controlled trial to evaluate the effectiveness of a twice-daily moisturising regimen in an intervention group (n=420) compared with ‘usual’ skin care in a control group (n=564) for older adults living in care homes in Western Australia. It found a significant reduction in skin tear incidence in the intervention group. The findings of these studies reinforce the benefits of standardised skin tear prevention practices for patients and healthcare organisations.
Undertaking a holistic assessment of the patient is fundamental to the prevention of skin tears. This should include a full assessment of the patients’ general health, including their nutrition status, mobility and skin integrity (LeBlanc et al 2018). Ongoing inspection of the patient’s skin is also important to ensure changes in patients’ health status and/or skin integrity are identified (Wounds UK 2015). Additionally, the holistic assessment needs to consider the individual (intrinsic) and environmental (extrinsic) factors that might increase a patient’s risk of skin tears. For example, extrinsic risk factors may include handling and force or trauma among patients who require assistance with activities of daily living, such as mobilising, washing and dressing (Wounds UK 2015). These extrinsic risk factors may be combined with the intrinsic risk factors, such as the ageing process causing changes in the skin that make it increasingly vulnerable to skin tears.
Measures that nurses can take to reduce the risk of skin tears are outlined in Box 1. Involving the person in their care is also vital for prevention. ISTAP best practice recommendations promote patient self-care, for example through encouraging the use of emollients and raising awareness of environmental risk factors (LeBlanc et al 2018).
• Keep fingernails trimmed and avoid wearing jewellery during contact with the patient
• Apply padding to, or remove, any potentially dangerous furniture or equipment, such as bed rails and wheelchairs
• Cover the patient’s skin with appropriate protective clothing, such as shin guards, long sleeves, retention bandages or stockinette
• Protect the integrity of the patient’s skin by using skin-friendly, pH balanced products and preventative emollients
• Implement an individualised skin care plan that includes the use of a skin-friendly cleanser and warm water. Traditional soap should not be used
• Prevent skin trauma from adhesives, dressings and tapes, for example by using silicone tape and cohesive retention bandages
• Consider medicines that may directly affect the skin, such as topical and systemic corticosteroids
• Avoid friction and shearing by using appropriate manual handling techniques and equipment, such as glide sheets or hoists
• Ensure that the patient wears sensible or comfortable shoes
• Apply clothing and compression garments carefully
• Ensure the environment is safe, for example by removing obstacles and making sure there is adequate lighting
• Educate the patient and their carers on skin tear risk and prevention
• Consider the possible side effects of medicines and polypharmacy on the patient’s skin
Skin tears can be challenging to identify and manage, largely due to differences in assessment and classification methods. LeBlanc et al (2014) conducted a descriptive, cross-sectional survey to explore the skin tear assessment, prediction, prevention and treatment practices of 1,127 healthcare professionals from 16 countries in a range of healthcare settings. Most respondents reported issues with assessing and documenting skin tears in their practice settings and stated they would prefer a simplified method for doing so (LeBlanc et al 2014).
The ISTAP best practice recommendations state that it is crucial to accurately identify and fully document skin tears on presentation to ensure optimal management and treatment (LeBlanc et al 2018). They also advise undertaking a comprehensive assessment of the patient and the wound and establishing the mechanism of injury. Holistic assessment of a patient who presents with a skin tear should include the following areas (Wounds UK 2015):
• History of skin tears.
• General health status and comorbidities.
• Medicines and issues related to polypharmacy.
• Mental health issues.
• Psychosocial and quality of life factors.
• Mobility and/or dependence on assistance for activities of daily living.
• Nutrition and hydration.
Box 2 lists the main elements that should be included in a skin tear wound examination. These factors should be documented as part of a formal wound assessment (LeBlanc et al 2018).
• Cause of the wound
• Anatomical location and duration of injury
• Dimensions of the wound – its length, width and depth
• Wound bed characteristics and the percentage of viable and non-viable tissue present
• Type and amount of exudate
• Presence of bleeding or haematoma
• Integrity of the surrounding skin
• Signs and symptoms of infection
• Associated pain
Several classification systems have been developed to support the recognition and documentation of skin tears. These include the Payne-Martin (Payne and Martin 1993), Skin Tear Audit Research (STAR) (Carville et al 2007) and ISTAP (LeBlanc et al 2018) classification systems.
The Payne-Martin classification system (Payne and Martin 1993) was introduced for use by front-line registered healthcare professionals and was originally designed to be integrated into a holistic assessment. It uses categories of skin tears based on the severity of tissue loss:
• Category 1 – skin tears without tissue loss.
• Category 2 – skin tears with partial tissue loss.
• Category 3 – skin tears with complete loss of the epidermal flap.
The Payne-Martin classification system is not commonly used in practice, mainly due to the challenges in determining percentages of tissue loss and its lack of validation for use in clinical settings or across different countries (LeBlanc et al 2018). These limitations led to the development of the STAR classification system (Carville et al 2007), which has been validated and includes the addition of skin discolouration; that is, whether the skin is pale, dusky or darkened. The STAR classification system has been used effectively in the UK and Australia (Stephen-Haynes and Carville 2011), but has been criticised for having categories that overlap and it has not been widely adopted worldwide (LeBlanc et al 2013, 2018).
Table 1 shows the validated ISTAP classification system, which was designed to provide a simple, ‘user-friendly’ tool for categorising skin tears (LeBlanc et al 2018).
(LeBlanc et al 2018. Reproduced with permission of Wounds International)
The ISTAP classification system was developed through a Delphi process involving 17 experts in tissue viability and wound care from 11 countries (LeBlanc et al 2018). Psychometric testing of the system in different countries, as well as its translation into Danish (Skiveren et al 2015), Swedish (Källman et al 2018) and Portuguese (da Silva et al 2020), have supported its applicability in healthcare practice. Van Tiggelen et al (2020) explored the validity and reliability of the ISTAP system with 1,601 healthcare professionals across 44 countries. Participants were asked to classify 24 photographs of skin tears using the ISTAP system as part of an online survey. Results demonstrated that the ISTAP system was highly accurate in distinguishing between different skin tears and had high inter-rater reliability. Higher diagnostic accuracy and agreement, as well as higher inter-rater reliability, was found in more experienced healthcare professionals, suggesting that experience, knowledge and education in skin assessment are essential to support diagnosis (Van Tiggelen et al 2020).
Education and awareness of risk factors and prevention strategies among healthcare professionals is vital to ensure effective skin tear prevention (LeBlanc et al 2018). Idensohn et al (2019) acknowledged that education should form part of a multidisciplinary approach to wound management centred on maintaining skin integrity and recognising the signs and symptoms of at-risk skin to minimise potential wound complications. Providing healthcare professionals with such knowledge can support effective strategies for minimising the development of skin tears and may prevent the need for escalation to secondary care for specialist treatment. One reason this is important is because such escalation is often associated with health economic effects because of the increased financial resources attributed to inpatient treatment (LeBlanc et al 2018).
Effective prevention also requires patients and/or carers to undertake self-care, which in turn requires education on risk prevention and recognition of wounds to ensure timely intervention (Stephen-Haynes and Carville 2011, LeBlanc et al 2018). Healthcare professionals can support this by advising patients to use emollients on dry skin, avoid injury – for example by covering the sharp edges of furniture or ensuring sufficient lighting to prevent falls – and encouraging the patient and/or carer to monitor their skin for any changes (LeBlanc et al 2018).
Van Tiggelen (2022), who reviewed the research on skin tears, commented on the lack of high-quality evidence to support healthcare professionals in their practice. They also emphasised the urgent need for further research on clinical interventions to enhance this vital area of wound care.
Skin tears are frequently seen in clinical practice but are often preventable. Furthermore, skin tears can be challenging to identify, which may result in underreporting and suboptimal management. Standardised approaches can support prevention, risk assessment and early recognition of skin tears. Appropriate education and training can equip healthcare professionals with the knowledge and skills required to prevent and recognise skin tears, thus supporting risk management and early intervention where required. Additionally, patients and/or carers require education on risk prevention and recognition of skin tears to support effective self-care.
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