Transcript Skin Tear Prevention

SKIN TEAR PREVENTION
Bruising or
Ecchymosis
PARAMETERS OF ASSESSMENT
 Category I:
 Skin tear WITHOUT tissue loss
 Category II:
 Skin tear WITH partial tissue loss
 Category III:
 Skin tear with COMPLETE tissue loss, where the epidermal flab is
absent
STRATEGIES AND INTERVENTIONS
 Prevention is #1 intervention !
 Provide a safe environment
 Perform risk assessment of elderly patients on admission
 Implement prevention protocol for patients identified as AT RISK FOR
skin tears and bruising of skin
 Patients can wear long sleeves or pants to protect their extremities
(if appropriate and applicable)
 Have adequate light to reduce the risk for bumping into furniture or
equipment
 Provide a safe area for wandering
EDUCATE STAFF OR FAMILY CAREGIVERS
On the correct way of handling patients to
PREVENT skin tears
Maintain nutrition and hydration status (if
applicable)
Offer fluids between meals (unless
contraindicated)
Use lotion, especially on dry skin – arms, legs,
BID
Obtain dietary consult (if indicated) – consult
with your primary nurse
PROTECT SKIN FROM SELF -INJURY OR
INJURY DURING ROUTINE CARE
Use a lift sheet (draw sheet) to move and
turn patients
Use transfer techniques that prevent
friction or shear
Pad bedrails, wheelchair arms, and leg
supports
Support dangling arms and legs with
pillows or blankets
Use non-adherent dressings on frail skin
 Apply petroleum-based ointment, steri-strips, or a moist non
adherent wound dressing such as hydrogel dressing with gauze
as a secondary dressing (if ordered, indicated and within your
scope of practice) telfa type dressings can also be used
 If you must use tape, be sure it is made of paper and remove
GENTLY. Also, you can apply the tape to hydrocolloid strips
placed strategically around the wound rather than directly onto
fragile surrounding skin around the skin tear
PROTECTING SKIN CONTINUED
Use gauze wraps, stockinettes,
flexible netting, or other skin
protective measures to secure
dressing rather than tape
Use no-rinse soapless bathing
products (if indicated)
Keep skin from becoming dry, apply
moisturizer (if indicated)
TREATING SKIN TEARS
Gently clean the skin tear with normal saline
Let the area air dry or pat dry carefully
Approximate the skin tear flap (if indicated)
Use caution if using film dressing as skin
damage can occur when removing dressing
Consider marking an arrow on skin tear
dressing to indicate the direction of the skin
tear to minimize any further skin injury during
removal
AMBERCARE’S REPORTING POLICY
When you identify that your patient has
bruising and/or skin tears on integument
please follow the following protocols:
 Notify supervisor that a skin tear has occurred by you
(via phone)
 Notify facility charge nurse (or primary nurse) the
occurrence
 Fill out incident report form (for QA tracking and
trending) and give to supervisor (Joanne)
 Document occurrence accurately and thoroughly
REFERENCES
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www.hhs.gov
US Department of Health and Human Services
www.guideline.gov
www.ahrq.org