“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

Linear or Flap Tear Partial Flap loss which Total Flap loss exposing which can be cannot be repositioned entire wound bed repositioned to cover the to cover the wound bed 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 Quick Reference Guide: ISTAP RISK REDUCTION PROGRAM © Risk Factor Individual Care giver / provider ISTAP SkinEducate patient onTear skin tear prevention &Tool  SafeKit patient environment General Health promote active involvement in treatment  Educate client +/ circle of care / caregivers decisions (if cognitive function not impaired)  Protect from self harm  Optimize nutrition & hydration  Dietary consult if indicated  Extra caution with extremes of BMI (<20 or >30)  Review polypharmacy for medications reduction /optimization  Encourage active involvement if physical  Daily skin assessment & monitor for skin tears Mobility function not impaired  Ensure safe patient handling techniques/  Appropriate selection & use of assistive devices 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  Awareness of medication-induced skin fragility  Individualize skin hygiene (warm, tepid, not hot, Skin (steroids) water; soapless or pH-neutral cleaners; moisturize  Wear protective clothing (shin guards, long skin) sleeves, etc.  Avoid strong adhesives, dressings, tapes  Moisturize skin (lubrication & hydration)  Keep fingernails short

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

Used with permission sb/kb White et al, 1994 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”

Patient Background

83 year old Male

Resident of LTC Facility

Admitted to hospital with Pneumonia & Aspiration

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,

• 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() North America: Kevin Woo(Canada) Mary Gloeckner(USA) Karen Edwards(USA) EWMA 2017- ,

ISTAP goal: To have skin tears globally recognized as complex acute wounds Thank You!!

QUESTIONS??