OTN Wound Care Rounds Mrs' Eugenia Hardacre SKIN TEARS

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OTN Wound Care RoundsMrs. Eugenia HardacreSKIN
TEARS

• Presented by
• Rosemary Kohr, RN, PhD, APN
• London Health Sciences Centre
• November 18, 2008
• rosemary.kohr_at_lhsc.on.ca

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Focus of todays session

• Identify contributing factors to development of
  skin tears
• Identify prevention strategies re skin tears
• Discuss team members to mobilize
• Describe moist wound healing approach
• Identify appropriate dressing choices for skin
  tears.

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Things to take away with you

• Evidence based practice
• Causes of skin tears
• Prevention strategies
• Teamwork
• Dressing options
• Patient-centred care
• Pain management

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Meet Mrs.Eugenia Hardacre, your patient.
86 year old lady, lives in Long Term Care
setting, but has been admitted to hospital re
pneumonia and failure to thrive.
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Skin tears happen

• Moving from stretcher to bed
• Tape
• Wrist ID bands
• IV sites (tape)
• Catching on
• bed-rails

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More ways to tear skin

• Removing dressings
• Bedside table
• Hitting shin on
• walker

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Skin facts

• Largest organ of the body
• Weighs 20 body weight (6 pounds)
• Expands 7 times during lifetime
• Ranges from 3 -100 cells thick
• Can self-regulate and regenerate

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SKIN function

• Protection from bacteria, chemicals, water and UV
  radiation
• Insulation Heat Regulation
• Touch sensation, communication
• Synthesis Vitamin D
• Wrap keeps everything from spilling out!

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Skincomposition

• Three attached layers
• Epidermis keratinocytes.
• Dermis vasculature, sweat glands
• Hypodermis
• subcutaneous layer.

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Skin Layers
STRUCTURE OF THE SKIN

• Epidermis
• Dermis
• Subcutaneous

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EPIDERMIS

• Outermost protective skin layer
• from 3 to 100 cells thick
• Formed by the continuous upward migration of
  keratinocytes
• Takes about I month to migrate to surface
• Avascular layer (no blood supply)

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Epidermis stratum corneum

• Top layer of epidermis
• Composed of keratinocytes, melanocytes and lipids
  (fats and oils)
• Primarily responsible for protection
• normal exfoliation on daily basis by
  mechanical/chemical trauma
• Skin tears are an example of mechanical trauma

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Acid Mantle
IMPORTANCE OF THE STRATUM CORNEUM
Keratin and lipids maintain moisture levels Acid
Mantle provides protection against bacterial
growth, keeps skin smooth. Skin stripping
removes the acid mantle
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The Dermis

• Contains endocrine glands (sweat ducts), hair
  follicles, blood vessels, lymphatics and nerves
• Adipose tissue provides energy, insulation and
  pressure distribution
• Vascularity provides heat exchange, nutritionand
  inflammatory response
• The skin has been called the Third Kidney

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ONE CUBIC CENTIMETER OF SKIN CONTAINS
One cubic centimetre of Skin

• 10 hairs
• 15 sebaceous glands
• 3 yards of blood vessels
• 4 yards of nerves
• 100 sweat glands
• 3,000 sensory cells
• 300,000 epidermal cells

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What happens to the skin as an individual ages?

• Increased dryness
• Easy bruising
• Slower healing response
• Wrinkles
• Skin cancers precancers

Normal aging
Photoaging (ie. Sun damage)
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Skin changes as we age

• Functional Changes
• Altered skin permeability
• Decreased Inflammatory response
• Decreased immunologic responsiveness
• Decreased thermoregulation
• Impaired wound healing
• The Merck Manual of Geriatrics 1995

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Skin changes as we age

• Reduction in
• Decreased Vitamin D synthesis
• Impaired sensory perception
• Decreased sweating and sebum production
• Decreased elasticity
• Thickness and attachments
• The Merck Manual of Geriatrics 1995

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Aging Skin
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Incontinence and skin breakdown

• Moisture and bacteria maceration.
• Macerated skin requires less friction to cause
  damage
• Urea in urine is turned into ammonia
• This results in a high pH (alkaline)

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Incontinence (continued)

• Acid mantle is now alkaline and cannot function
• If feces are present, digestive enzymes can be
  activated
• The skin can no longer function as a barrier to
  bacteria.

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Dressing selection should be based on

• Maintaining optimal temperature for healing
• Decreasing trauma to the fragile granulating
  tissue of wound bed
• Decreasing infection potential
• Decreasing patient pain at dressing change
• Cost effectiveness.

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SKIN SEALANT/BARRIER

• designed for intact skin
• easy to apply
• dries quickly
• inexpensive
• prevents tape damage
• Examples No Sting, Cavilon Cream, ProShield Plus

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Managing Fragile Skin

• FOR SKIN TEARS and FRAGILE SKIN
• AVOID USING ADHESIVE DRESSINGS.
• AVOID SOFRATULLE (adheres to wound bed)
• CHOOSE MEPITEL, cover with gauze Kling.
• (change Mepitel q 5-7 days, cover dressings--
  change as needed)

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What about Adaptic, Jelonet, Opsite, etc.?

• Watch for sensitizers such as Lanolin
• Watch for barriers such as petrolatum and
  paraffin (impair the transfer of moisture to
  evaporate off wound)
• Watch for adherence of transparent dressings
  tape tear the fragile skin on removal
• Watch for maceration of periwound tissue from
  occlusive transparent dressings.

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Dressings other options
Absorbent Acrylic Dressing
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Cleansers, skin protectants
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Skin Care ProductsWhat to choose?

• Look for clinical evidence
• Goal should be to support normal skin functioning
• Look for
• Sensitizers such as lanolin AVOID THEM!
• PH of 4 -7
• Ingredients that support skin functioning

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Cleaning the skin

• Avoid Bar soaps alkaline
• Acid mantle is affected
• skin dries out,
• prone to infections
• Avoid washcloths
• often rough
• Create friction injury
• Use a body wash and a method to wash the skin
  that reduces friction.

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Factors Affecting Skin
Soaps

• Alkaline soaps reduce the thickness and number of
  cell layers in the stratum corneum
• Normal flora washed away
• Normal washing requires 45 minutes for skin to
  restore its acidic pH
• Repeating washing requires 19 to 24 hours to
  restore the skins normal pH

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Soaps look for pH between 4-7
Oil of Olay
DOVE
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Avoid rough washcloths
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Barriers Moisturizers

• Purpose
• Increases barrier function of skin
• Ointment, cream, film
• Petrolatum, zinc or dimethicone
• Eg, NoSting
• can affect function of continence products

• Purpose
• Maintain/support hydrated skin
• Occlusive, Emollient or Humectant
• prevent moisture loss, add moisture, or pull
  moisture from the environment

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Occlusive, emollient or humectant

• Dimethicone
• emollient (hydrates) and occlusive
• Adding more dimethicone ? occlusive
• Not sensitizer
• Uremol
• Example of humectant (urea, lactic acid)
• Pulls moisture from environment
• Can burn if used over large area/large amount.
• Petroleum jelly
• occlusive (but its greasy)
• Apply immediately after bathing

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Moisture has to be just right!

• Skin that is to wet is 5 times more likely to
  ulcerate than dry skin
• Skin that is to dry is 2.5 more likely to
  ulcerate than normal skin

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Skin Assessment

• Asses skin turgor
• Temperature/feel of skin warm dry to touch
• History of nutrition, continence, hydration

• Careful assessment (head to toe) of skin (not
  just the obvious places!)
• Skin folds, creases,
• under breasts, abdominal pannus,
• behind the ears
• Lower legs, feet, between the toes
• Perineal, perianal areas
• joints and over bony prominences
• Around casts, braces, orthotics or prosthetics