Skin tear project

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Skin tear project

• SHERI SANDISON
• VASCULAR CLINICAL NURSE CONSULTANT

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Project

• Literature search
• Audit current practice
• Develop implement guidelines
• Publish
• Re-audit
• Ongoing education program

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Project team

• Barb Hutchinson
• Deb Muir
• Beth McErlean
• Sheri Sandison
• Wendy Humphreys
• Wound Management Committee

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A skin tear is

• a traumatic wound occurring principally on the
  extremities of older adults, as a result of
  friction alone or shearing and friction forces
  which separate the epidermis from the dermis or
  which separate both the epidermis and the dermis
  from underlying structures.
• Payne-Martin, 1993

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Literature Search

• Payne-Martin Classification system
• facilitate clinical judgement
• provide opportunity to evaluate the effectiveness
  of selected treatments,
• provide consistency of documentation and
  communication
• provide a mechanism for estimating the healing
  time and costs associated with care.

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Payne-Martin Classification Category 1
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Category 2 (A B)
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Category 3
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Literature Search

• Limited acute setting prevalence data
• No optimal treatment but treatment aims to
• Stop bleeding
• Prevent infection
• Recover skin integrity
• Promote healing
• Minimise pain /promote comfort
• Varied healing rates costs

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Audit

• Number of skin tears
• Classification
• Location
• Cause
• Wound management practice
• Documentation

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Results

• 10.7 (3.8 orthopaedic to 27 palliative care)
• Majority class 2A (lt25 epidermal loss)
• 25 from fall
• 63 upper body 36 lower body
• Varying dressing choices 24 no dressing
• Scant documentation

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Guidelines

• Preventative measure
• Immediate action
• Assessment / classification
• Dressing choice
• Discharge
• Documentation

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Preventative Measures

• Protect the Skin
• Use emollients, low pH soaps and moisturisers
• Protect lower limb
• Ensure equipment with any sharp edges is padded
• Apply adhesive tapes without tension and with
  caution
• Remove tapes with caution slowly peel away from
  anchored skin consider use of adhesive removing
  wipes
• Promote shoes that are well fitted and refer to
  Podiatry if required.

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Preventative Measures

• Move without Damage
• Use palms of hands to move patient, avoid pulling
  the skin
• Use Slippery Sam or lifting device
• Promote clutter free environment
• Provide good lighting (e.g. night lights)
• Use care when bathing, dressing, transferring
  transporting at risk patients

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Immediate Action

• Gently cleanse the skin tear site, removing any
  debris
• Gently return skin back into position using
  moistened cotton buds
• Debride non-viable tissue

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Dressing choice

• The Challenge is to consider
• Varied nursing skill level knowledge
• Properties of the dressing product
• (e.g. absorbency, ease of application removal)
• Product availability cost
• Discharge destination

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Product Guidelines

• No single product appropriate for all skin tears.
• Match the dressing choice with the skin tear
  category
• Promote healing
• Reduce trauma
• Manage exudate
• Protect flap
• Protect peri-wound

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Category 1

• Steri-strip approximated skin in position without
  tension.
• Cover with low adherent gauze dressing,
  melolin, tubifast or crepe bandage.
• Change secondary dressing (melolin) prn.
• Complete dressing change on Day 3.
• Leave steri-strips insitu until they curl lift
  off

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Category 2

• Cover with hydrofibre dressing thin
  Hydrocolloid
• Change according to degree of exudate i.e.
  evidence of leakage or hydrocolloid bubbling.
• Low exudate thin hydrocolloid
• Moderate / high exudate Hydrofibre thin
  hydrocolloid

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Category 3

• Cover with hydrofibre and thin Hydrocolloid
• Change according to degree of exudate i.e.
  evidence of leakage or hydrocolloid bubbling.
• Low exudate thin hydrocolloid
• Moderate / high exudate Hydrofibre thin
  hydrocolloid

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On Discharge

• Ensure patient education is provided re wound
  care and prevention strategies (brochure)
• Ensure community nursing is arranged including
  ongoing management plan and dressing supplies

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Documentation

• Cause
• Site
• Classification
• Dressing type
• Progress
• Note specific interventions on bedside folder
  front sheet
• Commence wound management chart
• Activate Excelcare wound management UOC
• Complete AIMS incident report

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Implementation / education program

• Poster
• Wound management folder
• Education
• Ward in-service talks
• Ward wound resource nurses promote
• Wound management course
• Graduate nurse study days
• Ward orientation
• Audit data analysis action plans

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Re-evaluate / audit
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No of tears Category 1 Category 1 Category 2 Category 2 Category 3
Linear Flap lt 25 epidermal loss gt 25 epidermal loss Complete tissue loss
Feb 2004 3 (9) 7 (21) 12 (36.3) 5 (15) 6 (18)
April 2005 7 (53) 0 5 (38) 0 1 (7.7)
August 2005 0 0 3 (37) 3 (37) 2 (25)
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August 2005 Audit results

• Location upper and lower extremities
• Dressing choices improved compliance to
  guidelines.
• Numbers too small for statistical significance.
• Need ongoing education
• 3 x year auditing

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Lessons learnt

• A problem with aging population
• Guidelines are valuable
• Specific to your location
• Ongoing education for prevention management
• Evaluation / audit