About

➀ Read and Learn

The following course content

Introduction 

Aging is a natural process that affects every living thing. As humans age, our skin becomes frail, thin, and brittle. The skin or integumentary system is the largest organ in our body, on average 20 square feet, and as it is exposed to the world we live in, it may be the most vulnerable organ.

Skin diseases are prevalent; however, in this course, we will discuss only skin tears in the most vulnerable patients, the elderly, chronically ill, and preterm or newborns. Skin tears are common but often undertreated, under-recognized, and poorly reported. They also present many questions on the best prevention and treatment. (6)  Skin tears are most common on arms and lower legs but may be found elsewhere. 

A skin tear occurs when the natural barrier or the top layer of the skin is banged or cut, usually from a bump, friction, or sharp fingernails. Depending on how excessive the wound is, three categories are described. Primary skin tears have two subcategories, and category 2 has only 1. We will discuss these later in the course. (5) Skin tears are considered major traumatic wounds.   

In 2007, the term “dermatophytosis” was created to identify the skin’s normal aging and convey the fragility of skin in the same way osteoporosis conveys the aging of bone. (4) 

System Review 

As nurses, we know the importance of a thorough skin evaluation, which can be done during our initial patient assessment. A good history of skin issues is essential for the most appropriate treatment. We know the skin is the body’s first line of defense against water and wounds and provides immunity by protecting the internal organs from pathogens entering the body. Before we move on, we will do a high-level review of the skin’s physiology and purpose.   

In humans, there are three layers of the integumentary system. The Epidermis, Dermis, and hypodermis or subcutaneous tissues. (1) 

The Epidermis is the outermost layer, measuring approximately 0.1 mm thick. The tough outer layer comprises “stratified epithelial cells”(1), which break down into five more layers. The stratum corneum,  stratum lucidum, stratum granulosum, stratum spinosum, and  stratum basale. (1) This layer of skin has another layer on the soles of the feet and palms of the hands, as these areas need extra protection. 

As previously stated, the central role of the Epidermis is to protect the skin from water and the environment. Immunologically, it is the first line of defense, protecting the body from pathogens. The Epidermis sheds itself daily while generating almost 500 million cells, replacing the shedding from its layers beneath. It also provides the color of our skin since that is where melanocytes live. There are no blood vessels in the Epidermis; therefore, it must receive its nutrients from the lower layers of the skin. (1) 

The Dermis is the next layer, comprised of very loose connective tissue. This layer supports the Epidermis by sending fingerlike projections up into that layer. It contains blood and lymph vessels, sweat glands, hair follicles, nerves, and other structures. (1) This layer also gives the skin its strength and elasticity. The Dermis has two layers:  the papillary layer, which contains collagen, and the reticular layer, which contains blood and dense connective tissue and protein. 

As it sounds, the Hypodermis layer of the skin is the lowest layer of the integumentary system. It is also called the subcutaneous layer, where, as nurses, we administer certain injected medications such as insulin and vaccines. It is also the layer of skin containing fat (adipose) tissue and loose connective (areola) tissue, providing insulation and an additional cushioning layer. It also connects to other tissues in the body, such as muscle. (1) 

Other structures, such as hair, nails, and exocrine glands, are located in the layers of skin. (1) The skin also synthesizes vitamin D from the sun and oral supplements. It also regulates body temperature through its vasodilation and vasoconstriction of blood vessels. (1)   

Epidemiology 

According to The Journal of Clinical and Aesthetic Dermatology, there is limited data on aging skin. (4)  A French study of aging skin, now known as dermatophytosis, was undertaken on patients aged 60-80 to understand the prevalence of aging skin. The result was that 32% of that study group had dermatophytosis. (4) Skin bruising was higher in women than men; as we “baby boomers” age, those numbers will surely increase. (4)  In 1991, it was determined that there were approximately 1.5 million skin tears each year in nursing homes, with 3.3-22% in acute hospitals. (5)  

Skin tears are also prevalent in preterm and newborn infants. (2) An immature immune system, underdeveloped integumentary system, and underdeveloped body temperature regulation are standard in this age group.  

Pathophysiology  

As we have discussed, skin tears are caused by bumps, shears, or friction. When the skin encounters any of these, it may tear. A skin tear has three classifications, types 1, 2, and 3. (5)   

In older people, we find physiological and pathological changes to the skin. (2)  These findings show that older skin has less collagen and fats, causing the skin to decrease in elasticity and the ability to shrink. This causes wrinkles and folds to appear. The skin also becomes drier, which causes it to be more fragile. Also,  blood vessels start to become atherosclerotic, causing a reduction in the supply of blood to the extremities and microcirculation of this system. (2)   

According to the Skin Care Advisory Panel (STAR), there are three classifications of skin tears as follows:(6) 

Type 1 includes skin tears without any loss of the skin and has a flap that can be repositioned and placed back over the wound. 

Type 2 includes skin tears with a flap loss that cannot cover the wound or be repositioned. 

Type 3 includes skin tears with complete flap loss and exposure to the entire wound bed. (6) 

Types 2 & 3 have subcategories as well.  

As an urgent care nurse, I saw many skin tears, and different providers used other treatments. In my own experience, I banged into my dishwasher and had a skin tear on my right shin. It still had a flap, and I could use it to cover the wound, which is ideal for minor tears. I used bacitracin and a non-stick dressing.  

Risk Factors

It is a known fact that skin tears are common in older people, especially those who are institutionalized in a nursing care center. Still, until writing this course, I was unaware of newborns having this same issue. As we previously discussed, newborns have an undeveloped integumentary system and problems with thermoregulation. Their body surface-to-weight ratio is approximately five times greater than a healthy adult, which causes the skin to become damaged. (2)   

In adults, several risk factors contribute to skin tears. The most common risk is aging. These folks may have poor nutrition due to the cost of groceries, especially those on a fixed income. If not, enough protein-rich foods are taken in, and metabolism is affected. Thus, skin integrity suffers, as does the wound-healing process. (2) For people over 70, a diet with at least 1 kg of protein should be ingested daily. (5) In the elderly,  sensory and cognitive functions, such as dementia, hearing, tactile, and vision, are diminished, potentially leading to more accidents and falls. (2)  Females have a higher risk of skin tears than males, and entirely dependent patients are at higher risk.  

Long-term steroid use can cause side effects such as decreased collagen, which is needed for healthy skin. The use of anticoagulants also has side effects that could reduce the skin’s health. 

Some mechanical and non-modifiable factors include transferring the immobile patient, bumping into sharp edges in those with sensory and cognitive impairment, and their use of adhesive tape on wounds. (2) Gentle care must be taken with this group. Senile purpura or easy bruising and repeated skin tears are a concern. This is due to impairment of the dermal extracellular matrix and may lead to vessel rupture and skin tears. (2)  

Dehydration is also a common risk for skin tears, especially in older people. Using the restroom due to mobility issues or “I’m tired of getting up so often” may be difficult for these patients so that water intake could be severely reduced. (2) Photo aging from too much sun or ultraviolet rays is also directly related to skin thinning, putting the patient at risk. (5) 

Modifiable risks are good skin care, such as moisturizing twice daily, drinking enough fluids, and being aware of sharp objects or open appliances, such as dishwashers (in my case) or other mechanical forces that may cause an injury. **Of note: Thinning skin has been linked to estrogen depletion in post-menopausal women, and estrogen replacement has proven to minimize this issue and increase skin thickening. (4) 

Nursing Considerations 

When working with a patient who has skin tears, the nurse uses excellent skin assessments to determine the causes of the injury and should also assess the integrity of the skin, whether it is dry or brittle.   A thorough medical and medication history and the mechanism of the injury should be taken. We should describe the look of the wound and what if any, self-care or first aid was used to help the healing process. The category and type of wound should be well documented along with the above information.   

The state of Pennsylvania implemented an initiative to be utilized state-wide by staff and caregivers titled “Preventing Pressure Ulcers and Skin Tears.” (7) A toolkit was developed that focuses on identifying patients at risk, prevention, and addresses explicitly the immobile patient, the “undernourished and malnourished”(7), those who are incontinent, or have impaired cognition. This tool also educates caregivers and other staff to maintain a safe environment for the patient, use special care to prevent falls and self-injury, and use the facility’s skincare protocol. (7) Keeping the patient’s finger and toe nails trimmed and without jagged edges prevents skin tears from sharp nails that a patient may use to scratch an area of the body. In my Urgent Care practice, I encountered many skin tears due to scratching. 

Suppose the patient is at home or in a nursing facility. In that case, the nurse will educate the caregivers on proper transfers, including using pads on bed rails, wheelchairs, or walkers, and appropriately using skin barriers and protection. (7) Baths and showers should be limited due to the drying of the sweat glands, which causes the skin to become drier and more brittle. Any adhesives on the skin can cause the wound to worsen when removed. It is recommended to wear long-sleeved shirts and long pants to protect the skin. (7)  Good nutrition and hydrating the patient are vital, and using foods that turn to water in the mouth is acceptable. The foods that can be used are ice cream, popsicles, yogurt, and any non-carbonated drinks. (7)  

Lastly, if a skin tear is not healing properly due to other medical problems such as diabetes, poor vascularity, or other conditions that affect the skin, a referral to a wound specialist is indicated.  

 As you can see, skin maintenance is the most essential aspect of preventing skin tears. (7) All of the above suggestions or practices will help the skin remain free of damage, and fall prevention is recommended as part of an assessment. (5) 

Treatment 

Although prevention is the best way to avoid skin tears, how do the experts tell us to care for these wounds? According to an article by Home Health Care Nurse Online (7), the steps to caring for a skin tear are as follows: 

• Cleanse the wound using saline to remove any blood or necrotic debris. If necessary, gently use a syringe to remove any hard debris. The patient could also use a tepid shower to cleanse the area. 

• It is essential to use the intact skin flap, which is not necrotic and fits over the wound, to replace the lost layer of the wound before the dressing.  

• To cover and protect the area, a moisture dressing must be applied. If there is exudate, it needs to be absorbed by the dressing to maintain the moisture, and it should not be on for more than seven days. This absorbent dressing will also allow for pain-free removal and provide healing and cell growth. 

• A petroleum-based product may be used as an alternative to a specific dressing. In Urgent Care, we used bacitracin or mupirocin to treat these tears before dressing.    

• If a skin flap has been placed, it may be useful to put an arrow on the outside of the dressing to indicate which way the dressing should be removed. 

• The dressing may be secured with non-stick Keflex wrapped around the area. 

• Saline should be used to loosen the dressing before removal and evaluation of the wound. (7) 

Research 

There are still a few studies on skin tears; however, in 2013, the International Skin Tear Advisory Panel (ISTAP) established the three categories of skin tears. (5)  Some studies focus on skin characteristics that cannot be modified, such as previous skin tears, bruising, hematoma, and sun damage. (5)  This study also concluded that the common knowledge is that immobile patients and falls put patients at higher risk. (5)   

However, Mayo Clinic’s Regenerative Medicine found that an off-the-shelf “PEP,” which is a “room-temperature-stable exosome (tiny proteins, lipids and other nutrients living in nano-sized vesicles which play a role in physiology and pathology) (3) was used on skin wounds that had lost blood supply and healed wounds without scarring. (6)  This study, done in 2016, showed that this nutrient-filled product targets and delivers messages to damaged tissues that need repair. (5)  It has also shown that blood vessels are restored to these tissues. (5) 

Another study on senile purpura evaluated the efficacy of an oral citrus bio-flavonoid on bruising. The control group experienced a 50% reduction in bruising.   

An author of the article “Chronic Skin Fragility of Aging” through the NIH used a polyethylene film with an acrylic adhesive over the site, then excised the tear, approximated the tear and film margins, sutured through both, and left it in place for two or more weeks. When sutures are removed, this method will likely decrease dehiscence and bolster wound edges for healing. (4) 

Unfortunately, if skin tears are not documented, diagnosed, and treated appropriately, there is an increased chance of pain, delayed healing, infection, and prolonged hospitalization. It also increased healthcare costs, negatively affecting the quality of care. (6)  

Other research concluded that nurses e-trained in skin tears might facilitate the improvement of their skills in the assessment and classification of these wounds. (6)  The research also proved that skin tears are often misdiagnosed as pressure ulcers. In my practice, I learned how very different these two wounds are. One of the most important aspects found in this study was the improvement of communication and data documented in the medical record using the ISTAP classification. (6) “This should be considered so that consistent documentation is guaranteed and more accurate skin tear prevalence and incidence data are obtained. (6) 

Conclusion 

We have reviewed the layers of the skin, specifically the prevention and treatment of skin tears in the elderly. A major consideration is incorporating fall risk and skin integrity in our initial assessment. We have also reviewed the risks and prevention of skin tears and how to care for a cognitive or immobile patient. 

The most common protocol addresses care for skin tears, and we have learned about research performed at the Mayo Clinic. 

The most important piece of skin tears is prevention. Ensuring our patients are well-nourished, hydrated, and handled with extreme care is the key to healthier skin and the prevention of skin tears. 

➁ Complete Survey

Give us your thoughts and feedback

➂ Click Complete

To receive your certificate