Skin Tear Treatment for Elderly Patients

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Introduction 

As we age, our skin becomes frail and thin. In elderly patients, skin tears are a common healthcare concern. In the U.S., 22% of long-term care patients had skin tears. As nurses, how can we prevent and care for these wounds? This educational program will address skin tear treatment and prevention for elderly patients.  

Integumentary System  

In order to fully understand the value of skin tear treatment and prevention, let’s briefly review the integumentary system.  

The integumentary system, or skin, is the largest organ in the body. It averages about 20 feet in length and plays many important roles such as preventing the invasion of microorganisms, keeping our temperature in normal ranges, and allowing the secretion of sebum and sweat. The skin also helps to maintain internal homeostasis (1). 

There are three layers of the skin, and each layer performs a specific role.   

1. Epidermis 
2. Dermis 
3. Subcutaneous tissue or Hypodermis 

Epidermis

The outermost layer of the skin; it is only about 0.1mm thick, but consists of 5 layers:  

1. Stratum corneum 
2. Stratum lucidum 
3. Stratum granulosum 
4. Stratum spinosum 
5. Stratum basale 

The epidermis provides a waterproof barrier, and from the production of melanin by melanocytes, it also gives our skin its color (2). Additionally, it receives oxygen and nutrients from the lower layers of skin. The epidermis sheds itself daily, generating approximately 500 million new cells from the layers below.  There are no blood vessels in this layer of skin, and its primary job is to protect the body from the invasion of microorganisms, pathogens, heat, UV sun rays, and water loss. There are many nerve endings in the epidermis which give the body our sense of touch.  

Dermis

The dermal layer is approximately 1-5mm thick and has a vast supply of blood vessels and other connective tissues. It is attached to the epidermis by a multilayer structure called the dermo-epidermal layer or basement membrane. The dermis protects the epidermis from friction and shearing as well as providing communication between the layers of the skin. On top of this, this layer protects the body from stress and gives the skin its strength and elasticity; when considering cases of pregnancy or obesity, the skin in the dermal layer can stretch quite a bit. However, when this amount of stretching occurs, it can be torn, and leave ‘stretch marks.’ It is made up of connective tissue and allows us to detect heat and painful stimuli (2). The dermis is where blood vessels, hair follicles, lymphatic vessels, and sebum and sweat glands are located. 

There are two layers of the dermis: the papillary and reticular regions. 

The papillary region is where we will find loose connective tissue, as well as some collagen and blood vessels. It has “finger-like projections,” which push up to the epidermis and gives us our fingerprints (2).  

The reticular region is composed of dense connective tissue which contains protein to give skin its strength and elasticity. This region also contains more collagen and larger blood vessels. 

Subcutaneous Tissue

Also identified as the hypodermis, this is the deepest layer of skin. The subcutaneous tissue’s main roles are to attach to the dermis, provide thermoregulation and fat storage. Each person and body part has a different amount of tissue at the subcutaneous level.  

Subcutaneous tissues include (3): 

• Collagen and elastin 
• Blood vessels 
• Sebaceous glands 
• Nerve endings (3) 

What is a Skin Tear? 

As we age, our skin thins, atrophies, and becomes brittle. The epidermis becomes fragile, and the dermis thickness decreases by 20% (4). Elasticity is decreased as well as strength, and the basement membrane flattens. Bumps, scrapes, and friction can cause a skin tear; they can occur on patients just from scratching with sharp fingernails. Most acute skin tears are seen on the tops of hands and front of the lower legs. A skin tear appears as if the top layers of skin have been peeled back.   

Skin tears can be primary or secondary, meaning they can include only the epidermis but the dermis as well. In order to provide proper skin tear treatment, it is important that we recognize the signs, conduct proper assessments, and under the various risk factors associated with these wounds. 

Risk factors for skin tears (1):

• Elderly 
• Females 
• PMH of skin tears 
• Steroids and other medications causing the skin to thin 
• Bruising 
• Inadequate nutrition and hydration 
• Deficiencies in cognition of senses 
• Comorbidities such as heart disease, renal impairment or CVAs 
• Patients who are dependent on showering and dressing, etc. from others (1) 

Depending on the severity of the wound, skin tears are categorized into classifications (1): 

Category 1

This is defined as a tear where no tissue is lost and there is a flap that remains within 1mm of the margin, and the tissue can be restored as a covering to the wound. There are two types of tears within this category: linear and flap. 

Category 2

This category is defined as a tear that has partial loss of tissue, either less or more than 25% loss of tissue. 

Category 3 

This is defined as a tear that has full loss of tissue. 

Skin Tear Treatment in Nursing 

First, nurses should assess and document the category of wound type, control bleeding, cleanse the with saline and dry the surrounding skin. If intact, the flap should be returned to cover the wound carefully using a cotton tip or tweezers to apply a bandage. A skin barrier is appropriate to use, ascertaining that it will not stick to the wound.  Any petroleum-based product, as well as an antibiotic ointment, is frequently used to protect the wound. The physician may also use sutures or staples if the wound is a deep full-thickness tear. Waterproof dressings may be used to protect the wound on top of the barrier, allowing the dressing to remain intact for 24-48 hours.   

Upon follow-up, the dressing should be removed very gently, using saline or water, and removing away from the flap. Monitor the wound for improvement or worsening; document any exudate, bleeding, or further disruption of tissue.   

If there is a category 2 tear, bleeding, or poor healing ability from the patient (potentially due to poor vascularity, diabetes, or other chronic conditions) a referral to a wound care center should occur.  

Preventing Skin Tears 

Skin tear prevention is of the utmost importance. As nurses, part of initial assessments on new patients should be skin assessment, documenting skin integrity, dryness, and any other abnormalities. The environment should be free of any impediments, especially in sensory-deprived patients. Sharp borders on furniture should be padded, and if the patient is unable to transfer independently, care should be taken to avoid any undue pressure on the skin. Also, protective clothing, socks, shoes, etc., should be encouraged to maintain skin integrity.   

Hydration, good nutrition, and the avoidance of harsh soaps are good ways to keep fragile skin intact.  Moisturizers and/or skin barrier cream could be used as well. Covering the thin areas with soft tubular or rolling bandages is also recommended. 

Conclusion 

Skin tears can be seen in any setting where a patient may be admitted to a long-term care facility, independent living home, or outpatient clinic; they are a common type of wound. However, they can be costly and cause further damage to the skin and patient if not cared for correctly and quickly. Nurses are often the first caregiver to assess the skin’s integrity, so it is paramount that they are informed on the risk factors, outcomes, skin tear treatments available to patients, as well as general preventative methods. Learning how to prevent and provide skin tear treatment, as well as educating patients on how they can care for their skin can help decrease the commonality of these wounds. 

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