Diagnose of Skin Wounds in Frail Elders Essay

Diagnose of Skin Wounds in Frail Elders Essay

Diagnose of Skin Wounds in Frail Elders Essay

Skin wounds are sometimes challenging for health care providers to diagnose and treat as many have similar presentations. For advanced practice nurses, being able to identify various types of skin wounds, including whether a wound is a colonization or an infection, is critical because it impacts recommended patient care. In your role, you must be able to evaluate skin wounds, determine the diagnosis, and develop an appropriate treatment and management plan according to current evidence-based guidelines.Diagnose of Skin Wounds in Frail Elders Essay

To prepare:

Review Chapter 47 of the Resnick text, as well as the Burr article in this week’s Learning Resources.
Consider how to properly diagnose skin wounds in frail elders, including how to distinguish between a colonization and infection.
Select a type of skin wound, such as bumps, bruises, shingles, herpes, bullous pemphigoid, Stevens-Johnson syndrome, etc. Research the guidelines for treatment of the skin wound you selected. Reflect on how you would treat and/or dress this wound.
Think about factors that might contribute to the development of the skin wound you selected. Consider strategies for the prevention and improvement of this type of wound.
To complete:

Write a 2- to 3-page paper that addresses the following:

Explain how to properly diagnose skin wounds in frail elders, including how to distinguish between a colonization and infection.Diagnose of Skin Wounds in Frail Elders Essay
Describe the type of skin wound you selected.
Explain how you would treat and/or dress this wound based on guidelines for treatment.
Explain factors that might contribute to the development of the skin wound you selected. Include strategies for the prevention and improvement of this type of wound.

According to Eurostat, the percentage of the European population aged 80 years and above is expected to more than double between 2015 and 2080, from 5.3 % to 12.3 %, thus making it the most rapidly growing age group. In 2015, the lowest percentage of young people was recorded in Germany (13.2 %); on the other hand, the percentage of individuals 65 years and older was highest in Italy (21.7 %), Germany (21.0 %), and Greece (20.9 %). Given the rise in life expectancy due to great advances in medical care and economic development, this observation may be attributed to increased longevity. It refers to a phenomenon frequently described as “aging at the top” of the population pyramid (European Statistical System [EUROSTAT] http://epp.eurostat.ec.europa.eu).

In the future, one of the challenges will be to preserve quality of life in people of advanced age. The Global Burden of Disease, a study conducted by the World Health Organization and the World Bank 1, has predicted a considerable increase in disability based on a drastic rise in age‐associated diseases worldwide. Apart from other chronic diseases predominantly occurring in the elderly, such as dementia, metabolic disorders, and osteoporosis, wound healing disorders, too, have been shown to be key contributors to age‐related disability as well as to significant impairment in quality of life. Studies have already shown the considerable economic burden and high rate of morbidity and mortality associated with these disorders 2.Diagnose of Skin Wounds in Frail Elders Essay

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Epidemiology of chronic wounds
Chronic wounds due to wound healing disturbances are characterized by loss of integrity of the skin and, in some cases, of underlying anatomical structures, as well as a lack of recovery within a period of at least eight weeks 3. By definition, chronic wounds are progressive and resistant to multiple treatments, either because of failure to conduct a thorough diagnostic workup or due to the lack of causal treatment options. Given the typical characteristics of elderly individuals – including multimorbidity and polypharmacy – they represent the age group most susceptible to chronic wounds. At an advanced age, the most common forms of chronic wounds include, among others, venous leg ulcers, pressure ulcers, and diabetic foot ulcers. Moreover, as elderly individuals more frequently undergo surgery and as their physical abilities deteriorate over time, they are at greater risk of developing chronic wounds 4.

Study estimates on the prevalence and incidence of wound healing disorders show marked variations. In a recent review of data from 38 studies conducted in eleven countries, the estimated prevalence of pressure ulcers varied from 1.1 % to 26 % among inpatients, from 6 % to 29 % among outpatients, from 7.6 % to 53.2 % among individuals living at nursing homes, and from 13.1 % to 28.7 % among patients in intensive care units 5. On the other hand, the prevalence of venous leg ulcers ranged from 0.05 % to 1 % among outpatients, and was 2.5 % among individuals living at nursing homes and 0.05 % among inpatients. Diabetic foot ulcers showed a prevalence of 1.2–20.4 % among inpatients and of 0.02–10 % among outpatients 5. Data on the prevalence of wounds caused by peripheral artery disease is still sketchy. In individuals above the age of 80, the incidence of venous leg ulcers has been shown to be almost three times greater, that of pressure ulcers five to seven times as high as in 65 to 70‐year‐olds 6.Diagnose of Skin Wounds in Frail Elders Essay

In Germany, Heyer et al. recently reported a steady increase in the annual incidence of chronic wounds, with the probability of sustaining a wound showing a twofold increase between 50 and > 60 years of age. In the context of a national longitudinal survey in Germany, the prevalence of individuals with a diagnosis of “chronic wound” who had a medical prescription for this diagnosis was estimated to be 0.43 % (95 % CI, 0.43–0.44). Here, leg ulcers constituted the most prevalent condition, with 64 % of all documented wounds, followed by pressure ulcers (41 %) and diabetic foot ulcers (17 %). In a three‐year period, the incidence of wounds with a corresponding prescription increased twofold, from 0.13 % (95 % CI, 0.13–0.13 %) in 2010 to 0.26 % (95 % CI, 0.26–0.27 %) in 2012 7.

In a recent pilot study, we set out to ascertain the health status of elderly patients with particular focus on the skin. One hundred and ten multimorbid geriatric inpatients at the Geriatric Hospital “Evangelisches Geriatriezentrum Berlin” were examined to determine the prevalence of skin diseases in this age group. Remarkably, while a large percentage of patients exhibited skin disorders, many patients had previously not consulted a dermatologist, or were unaware of the fact that they had a skin condition. Among a variety of different skin diseases that included infectious and vascular diseases, wound healing disorders (e. g. leg ulcers, pressure ulcers) were observed in 28.3 % of women and 22 % of men 8.Diagnose of Skin Wounds in Frail Elders Essay

Pathophysiology of chronic wounds in the elderly
A complex biological phenomenon, wound healing is characterized by several phases, including hemostasis, inflammation, proliferation, and remodeling 9. Skin cells, extracellular matrix, and systemic factors constitute the key players in this process. Following injury, platelet activation occurs, and the coagulation cascade is unfolded. Neutrophils, macrophages, and T lymphocytes are recruited to the wound site within the first day post injury, their job being phagocytosis and removal of bacteria and damaged tissue. Several cytokines and growth factors that induce proliferation and angiogenesis are subsequently released, including platelet‐derived growth factor (PDGF), transforming growth factor beta (TGF‐b), fibroblast growth factor 2 (FGF‐2), vascular endothelial growth factor (VEGF), interleukin (IL) 1, IL‐6, and tumor necrosis factor alpha (TNF‐a). The migration of fibroblasts and extracellular matrix deposition is facilitated by growth factors such as epidermal growth factor (EGF), keratinocyte growth factor (KGF), and transforming growth factor alpha (TGF‐a). Starting from the wound edges, keratinocytes begin to migrate, their effects primarily augmented by collagenases produced in the epidermis. Rearrangement of integrins and cytoskeletal components is then followed by reepithelialization and remodeling (Figure 1).Diagnose of Skin Wounds in Frail Elders Essay

Figure 1
Open in figure viewerPowerPoint
Summary of the physiological phases of wound healing including the clotting phase, the early and late inflammatory phase, the contraction phase, and the remodeling phase. During the late inflammation stage, the initial wound cover formed is referred to as eschar. Chronic wounds fail to proceed through the normal sequence of wound healing phases, and do not heal within a period of at least eight weeks. They are characterized by a persistent (late) inflammatory phase, marked by the prevalence of proinflammatory M1 macrophages. The reepithelialization and remodeling phases are significantly delayed or do not occur at all.
Inflammation and oxidative stress in chronic wounds
Chronic wounds remain in an inflammatory state, and do not show any signs of progression such as proliferation and remodeling 10. In acute wounds, the inflammatory phase is rather short, and geared towards the removal of bacteria and debris, with neutrophils and macrophages playing a key role. Chronic wounds, however, exhibit persistent inflammation characterized by overactivation of neutrophils and macrophages, a prolonged and more pronounced presence of T cells with a low CD4+/CD8+ ratio 11, 12, increased release of proinflammatory cytokines 13, 14, and elevated production of tissue‐degrading proteases such as elastases, matrix metalloproteinases, and plasmin 11, 15. Compared to acute wounds, the composition of the persistent inflammatory cells is altered, with large numbers of CD20+ B cells, CD68+ macrophages, and CD79a+ plasma cells 11. Subsequently, transition to the next phase – proliferation of fibroblasts and endothelial cells – does not occur.

Macrophages in particular play a pivotal role in the transition from the inflammatory phase to the proliferative phase 16. As they release important agents within the wound, their recruitment is of great importance in terms of wound healing 17. While macrophages are the predominant cell type found at the ulcer margins in diabetic and venous ulcers, they are unable to steer the repair process towards the proliferative phase. Under normal wound healing conditions, macrophages have the ability to switch between different phenotypes, to wit, the classically activated M1 macrophages observed in the early phase of inflammation, and the M2 subsets that produce high levels of IL‐10 and low levels of IL‐12, downregulate inflammation, and initiate tissue repair 18-20. A sustained imbalance between M1 and M2 macrophages in favor of the M1 phenotype has been shown to contribute to nonhealing disorders 21. One of the potential factors leading to such a state may be iron overload, as demonstrated by Sindrilaru et al. in chronic venous leg ulcers (in humans). Such overload results in the increased release of TNF‐α and hydroxyl radical, as well as induction of the p16INK4a‐dependent senescence cascade in resident fibroblasts, which are eventually responsible for impaired wound healing 22. Furthermore, activated macrophages may produce elevated levels of nitric oxide, which – along with superoxide anions generated by neutrophils – may generate the toxic peroxynitrite radical 23, resulting in further tissue damage and impaired inflammation.Diagnose of Skin Wounds in Frail Elders Essay

Chronic wounds are characterized by an imbalance with respect to cytokines and growth factors. Interleukin‐1β and TNF‐α in particular have been shown to be increased, whereas growth factors such as VEGF and basic fibroblast growth factor (b‐FGF) are significantly decreased 24. The subsequent induction of metalloproteinases attenuates cell migration 25, 26. The inflammasome – a protein complex located in the cytosol that activates proinflammatory protease enzymes and IL‐1β in human epidermal cells 27 – also plays a crucial role in wound physiology; its response to tissue damage deteriorates with age 28. Remarkably, vascular endothelial growth factor receptor (VEGFR) type 1 signaling protects from disturbed wound healing in diabetes by inhibiting the production of IL‐1β by recruited macrophages, and regulating the equilibrium between different macrophage phenotypes 29. In addition, members of the sirtuin protein family have been shown to contribute to the wound healing process in diabetic db/db mice through regulation of oxidative stress and angiogenesis 30.Diagnose of Skin Wounds in Frail Elders Essay

High levels of reactive oxygen species (ROS) are primarily released by neutrophils and macrophages, and to some extent by local fibroblasts and endothelial cells 31. By producing agents such as nitric oxide and triggering the hypoxia‐inducible factor‐1α pathway, they assist in the removal of bacteria, the transition into the proliferative phase, and the induction of angiogenesis 32, 33. Other factors that trigger ROS production include local hypoxia and ischemia/reperfusion. In chronic wounds marked by a prolonged inflammatory phase, defective ROS production is very common, and can be measured through the detection of oxidized lipids (e. g. malondialdehyde), proteins (e. g. nitrotyrosine residues), and DNA (e. g. 8‐hydroxydeoxyguanosine). Dysregulated ROS generation may induce several pathological defects, such as damage to endothelial cells, prolonged recruitment of leukocytes to the ulcer site, and delayed keratinocyte migration and reepithelialization 34. Apart from pathologically elevated ROS levels, an increase in free iron in macrophages and in the extracellular matrix at the wound site is also thought to lead to prolonged inflammation, increased connective tissue degradation, and resultant lipid peroxidation in chronic ulcers due to the Fenton reaction 35. In addition, the antioxidative defense system has been shown to be disturbed in chronic wound patients. Measurement of the activity of the antioxidant enzyme glutathione peroxidase in the blood of patients with venous ulcers revealed a 15 % decrease compared to the control group. Furthermore, neutrophils in patients with chronic wounds released up to 170 % more superoxides than control subjects 31.Diagnose of Skin Wounds in Frail Elders Essay

Role of the microbiome in chronic wounds
Besides prolonged and suboptimal inflammation, oxidative stress and hypoxia, polymicrobial wound infection with an ensuing biofilm further contributes to impaired wound healing and the development of chronic wounds. Biofilms predominantly consist of bacteria embedded in a matrix structure made up of polymeric substances (e. g. polymeric sugars, proteins, bacterial DNA) produced by the microbes themselves. These substances create a physical barrier that impedes therapeutic effectiveness, and protects the bacteria from innate host immunity 36. Furthermore, by expressing adhesion molecules, surface complexes, and toxins secreted from several secretory systems – e. g. type III (T3SS) and VI (T6SS) 37 – they have the ability to attach to the host tissue, resulting in delayed wound healing.

There is now strong evidence that the majority of chronic wounds are covered by biofilms. Using a special microscopic technique, it has been demonstrated that 60–90 % of chronic wounds have a biofilm versus only 6 % of acute wounds 38. Routine wound cultures underestimate the overall diversity of the wound microbiota. In a large patient population with wound healing disorders including diabetic, venous leg, and decubital ulcers, as well as nonhealing surgical wounds, Wolcott et al. analyzed the composition of the chronic wound microbiota using 16S rDNA pyrosequencing. The wound samples contained a large percentage of Staphylococcus and Pseudomonas species (63 % and 25 % of all wounds, respectively). The authors also observed a high prevalence of anaerobic bacteria and bacteria usually considered commensalistic 38. In another study of 100 diabetic patients with foot ulcers, it was reported that roughly 80 % of wounds showed colonization with fungi, as measured by high‐throughput sequencing. Furthermore, fungal diversity seems to have a predictive value with respect to the duration of the healing process. In this context, mixed fungal/bacterial biofilms are associated with a poor prognosis 39, 40.Diagnose of Skin Wounds in Frail Elders Essay

Stem cell dysfunction in chronic wounds
Dysfunction and depletion of adult stem cells are related to aging and wound healing disorders. The epidermis in particular contains self‐renewing stem cells. These cells can be found in various anatomical niches, and give rise to progenitor cells that differentiate along distinct lineages of the hair follicle (HF), sebaceous gland (SG), and interfollicular epidermis (IFE) 41. Following injury, stem cells located anywhere in the epidermis are able to differentiate into any given epidermal cell lineage. Aging not only affects stem cells in their potential for self‐renewal and differentiation, it also impacts wound closure. Said effects are primarily attributed to mitochondrial dysfunction and increased oxidative stress 39, epigenetic regulation 42, or disturbances in the resident niche 43. Sequelae may include local depletion of epidermal cells and escape from the quiescence phase, and thus explain the observation that epidermal skin cells at the wound margins of chronic venous ulcers are hyperproliferative, nonmigratory, and healing‐incompetent 44. In addition to epidermal stem cells, adipocyte 45 and melanocyte progenitors 46, mesenchymal stem cells 47, bone marrow as well as endothelial progenitors 48 also contribute to the wound healing process, and are regulated by various specific cytokines and chemokines that have likewise been shown to be affected by aging 49.Diagnose of Skin Wounds in Frail Elders Essay

Cellular senescence in chronic wounds
Characterized by cell cycle arrest and limited proliferative potential, cellular senescence refers to the cell’s response to damage and stress. By inhibiting the proliferation of premalignant cells, senescence plays a role in the prevention of cancer. Studies have demonstrated that cellular senescence may also contribute to wound healing in normal tissues 50. Other – less beneficial – effects include the induction of inflammation associated with aging and cancer progression 51. Senescent cells frequently express p16INK4a, a cyclin‐dependent kinase inhibitor. Thus, they adopt a complex senescent phenotype, which comprises the increased secretion of multiple proinflammatory cytokines and proteases and a reduction in the release of growth factors. These secretory changes are referred to as senescence‐associated secretory phenotype (SASP). Persistent senescent cells are thought to drive aging and age‐associated conditions by altering the tissue microenvironment and impacting the function of normal or transformed cells nearby 52. Unlike persistent senescent cells in chronic wounds, transient senescence of cells in acute wounds even has beneficial effects on the healing process. It is noteworthy that senescent cells in acute wounds are removed by the adaptive immune system, whereas this is most likely not the case in chronic wounds. In the context of acute wound repair, senescent cells exert beneficial effects. For instance, in acute murine wound models, local treatment with platelet‐derived growth factor AA (PDGF‐AA) – an SASP factor secreted by senescent fibroblasts and endothelial cells – induced myofibroblast differentiation and accelerated wound closure in senescence‐free wounds, thus indicating the beneficial effects of SASP in wound repair 50. Senescent fibroblasts and keratinocytes secrete various matrix‐degrading metalloproteinases (MMPs) among them MMPs 2, 3, and 9, which suggests an antifibrotic effect 53. On the other hand, senescent keratinocytes secrete the antiangiogenic factor maspin known to potentially impair wound healing 54. The challenge is therefore to achieve a more in‐depth understanding of cellular senescence that will enable us to utilize its benefits while being able to suppress its drawbacks 51.Diagnose of Skin Wounds in Frail Elders Essay

Angiogenesis and vasculogenesis in chronic wounds
Impaired growth of blood vessels and decreased mobilization of bone marrow‐derived endothelial progenitors are other factors that contribute to wound healing disorders in the elderly 4. Especially in diabetic patients have chronic nonhealing wounds been linked to disturbed angiogenesis and lymphangiogenesis 55. Roughly 15–25 % of diabetics will develop a diabetic foot ulcer, which represents one of the most common complications, and accounts for more than 80 % of all lower leg amputations 56. Exudates from diabetic wounds studied by mass spectrometry revealed an increased expression of proteins with antiangiogenic properties 57. Disturbed angiogenesis leads to hypoxia and subsequently cell death due to apoptosis or necrosis 57.

Potential biomarkers of impaired wound healing
Over the past decade, the rapid development of ‐omics has allowed for comprehensive assessment of skin aging and wound healing, and has contributed to the identification of biomarkers associated with impaired healing 12, 58. Among others, markers downstream of the Wnt signaling pathway (e. g. elevated expression of nuclear β‐catenin and c‐myc 44), epidermal stem cell markers (e. g. decreased expression of leucine‐rich repeats and immunoglobulin‐like domain‐containing protein 1 [LRIG 1] and keratin 15 [K15]), members of the TGFβ superfamily (e. g. decreased expression of the bone morphogenetic protein receptor [BMPR] and TGFβ I and II ligands), immunomodulatory proteins (e. g. decreased expression GATA‐binding protein 3 (GATA3) and of inhibitors of DNA‐binding proteins 2 and 4 (ID2 and ID4) 44, 59), as well as antimicrobial peptides (e. g. decreased expression of cathelicidin 60) have been shown to be clinically associated with impaired healing in patients with chronic wounds. On the other hand, wound fluid markers have also been identified, including increased expression of metalloproteinases (e. g. MMP‐1, 2, 3, 7, 8, 9, 10, 11, 13), decreased expression of their inhibitors (e. g. TIMP‐1) 61-63, increased IL‐1 and IL‐6 64 levels, as well as decreased levels of albumin and total protein 65. Systemic biomarkers associated with a high risk of developing chronic wounds have also been reported, with chronic ulcer patients showing high serum levels of procalcitonin 66 as well as MMP3 and 2 67, and a reduced number of CD34+/CD45‐dim circulating cells 68 and micro RNAs such as miRNA‐200b and miRNA‐191 69.Diagnose of Skin Wounds in Frail Elders Essay

Clinical features of chronic wounds in the elderly
Given the great impact it has on the morphology and function of cutaneous cells, the homeostasis of the extracellular matrix 70, and inflammatory responses 71, 72 per se, aging is considered one of the main contributors to aberrant wound healing. In addition, age‐associated systemic diseases further impair the skin’s wound healing capacity. Table 1 provides a summary of age‐associated diseases and causative factors that may facilitate the development of chronic wounds. Apart from vascular diseases, conditions that may initially present with chronic wounds include hematological and coagulation disorders, vasculitis, neutrophilic dermatoses, metabolic disorders, myeloproliferative diseases, malignancies, and infections.

Skin tears are acute, traumatic injuries, presenting predominantly in the elderly. They occur principally on the extremities as a result of friction and shearing forces which separate the principal layers of the skin.1

Skin tears were first defined in 1993.2 Some are unavoidable, but many are considered preventable.2,3 Although they are perceived to be common among the elderly, these types of wounds often go unreported, especially in the community setting.Diagnose of Skin Wounds in Frail Elders Essay

The majority of prevalence and incidence data originates from the USA and Australia. To date, there is no robust prevalence data available for the UK. Therefore the financial impact of skin tears on the NHS is not fully known.5

The main causes of skin tears are mechanical trauma, often from wheelchair injuries, removal of adhesive tapes or dressing, transfers and falls,1,6-8 though in some cases no apparent cause is found.1

In older people, most skin tears are seen on the extremities, usually the arms, dorsal aspect of the hands, and the lower limbs.

Skin tears cause significant pain and adversely affect quality of life. With an ageing population, it is essential that healthcare professionals ensure they are confident and competent in the management of skin tears.Diagnose of Skin Wounds in Frail Elders Essay

Read more about similar subjects in Independent Nurse’s Woundcare section

Physiology of ageing skin

Box 1. Risk factors for skin tears
Age >75 years.

Gender (more common in females).

History of previous skin tears.

Dehydrated skin.

Impaired mobility.

Reliance on others for personal needs such as bathing or transferring.

Cognitive or sensory impairment (diabetes, dementia).

Visual impairment.

Poor nutrition and hydration.

Medications that can have a thinning effect of the skin (eg steroids).

The skin is the largest and most visible organ in the body, comprising of two principal layers, the dermis and epidermis.Diagnose of Skin Wounds in Frail Elders Essay

As the skin ages, the amount of elastin and collagen reduces, resulting in visible changes, such as sagging and wrinkling, along with dryness, which is a result of lower levels of the dermal proteins which retain moisture.6,10,11

The epidermis thins over time, leaving it more susceptible to mechanical trauma.1 Given the ’tissue paper’ appearance of the skin, even the slightest bump or knock can cause tissue damage.4, 11

Maintaining skin integrity can pose a challenge for healthcare professionals working with older people. The occurrence of skin tears may reflect poorly on the quality of care provided by care homes and other healthcare facilities, so collecting data is considered essential to understand the magnitude of the problem.12

Assessment and classification

Box 2. Payne and Martin classification2
Category 1 A skin tear without loss of tissue, either linear or with a flap that closes the tear to within 1mm of the wound edges.

Category 2 Partial tissue loss, scant when tissue loss is <25 per cent. Moderate or large when the tissue loss is >25 per cent.

Category 3 Complete tissue loss with no epidermal flap covering the injury.

Assessment must follow a comprehensive and holistic approach. Underlying factors which may have contributed to the injury should be determined.6 Conditions such as diabetes, anaemia or postural hypotension need to be addressed to prevent further tears occurring.13

A common sense approach to patient care should focus on addressing the risk factors associated with the development of a skin tear (Box 1), and modifying risks, for example by employing safer manual handling techniques, while assisting older adults with routine activities such as bathing, dressing and repositioning.Diagnose of Skin Wounds in Frail Elders Essay

Creating a safe environment is essential to avoid unnecessary trauma from any bumps or knocks from low lying furniture. Nurses can advise on the padding of sharp corners on furniture. Patients can be encouraged to wear some degree of protective clothing such as long sleeves and trousers in an attempt to cover the vulnerable areas.2,3,11

Care should also be taken when removing tapes and adhesive dressings. Gently grasping one edge and slowly peeling the dressing back rather than up, in the direction of the hair growth will help reduce the trauma of removing adhesive dressings and tapes that are difficult to remove.14 The use of a barrier film or cream can help to moisturise and protect the skin, and using a silicone-based adhesive remover for dressings will minimise trauma to fragile skin.3

The importance of keeping the skin hydrated has been recognised and the use of topical emollients advocated, in conjunction with ensuring an adequate oral fluid intake.11 This can be the difference between a bump resulting in a bruise or a skin tear.11 There are many skin care products available that provide pH-balanced cleansing which further reduces drying effects on the skin.Diagnose of Skin Wounds in Frail Elders Essay

It is essential that the cause of a skin tear is established to enable effective care planning that takes into account the risk factors involved.4,11,14,15

The clinician must thoroughly assess the wound to determine the extent and depth of the damage.6

When assessing a skin tear, it is important to document the position of the skin tear; pain levels; size of the tear; description of the wound bed; level and appearance of exudate; and the integrity of the surrounding skin.

The All Wales Tissue Viability Forum recommends that assessment of the skin tear should include:14

Underlying disease process (eg diabetes, peripheral vascular disease)
Cause of the injury
Time of the injury
Previous skin injury
Status of surrounding skin
Nutritional status
Wound location
Size and category of the wound.
There is no universally accepted classification for the assessment of skin tears.4,6,12,14 The most widely documented is the Payne and Martin tool.2

In recent years however, the formation of the International Skin Tear Advisory Panel (ISTAP) has initiated consensus statements and further work towards an internationally recognised and validated classification system.2 The ISTAP system is concise in that it focuses on three types.8

Type 1: Linear or flap tear that can be repositioned to cover the wound bed.

Type 2: Partial flap loss that cannot be repositioned to cover that wound bed.

Type 3: Total flap loss exposing the entire wound bed.

In 2007, Carville et al published the STAR classification system (Box 3) and it is interesting to note that in recent years it has been disseminated outside of Australia.Diagnose of Skin Wounds in Frail Elders Essay

Managing skin tears

The main aim of managing a skin tear is preserving the skin flap and protecting the surrounding tissue.4 As with any wound, the focus encouraging healing and prevent ing infection.

The All Wales Tissue Viability Forum Best Practice Statement is a useful tool for any practitioner and gives clear guidelines for assessing and managing skin tears.14 It is freely available to download.

With any skin tear, it is essential that treatment is prompt in order to ensure the viability of the skin flap.

The initial treatment process includes:4,6,14

Control bleeding – Apply pressure and elevate the limb.

Cleanse the wound – Use warm tap water or saline to irrigate and remove any debris or remaining clots.

Approximate the flap – Without pulling or applying pressure, gently unfold the flap and smooth it out over the wound. This can be done using a moistened, gloved finger or cotton tip.

Dress the wound with an atraumatic wound contact layer to keep the flap in place. The atraumatic dressing should remain in place for several days to allow the flap to adhere to the wound bed. Ensure that the atraumatic layer is removed in the direction of the skin flap, and not against it.

Sutures and staples are not recommended due to the fragile nature of the tissue.

The wound should be monitored regularly for signs of infection (redness, heat, odour and increased pain and exudate). Particular care should be taken in the immunocompromised and people with diabetes.Diagnose of Skin Wounds in Frail Elders Essay

If the skin flap becomes necrotic, a specialist opinion should be sought from a tissue viability nurse or medical practitioner.

Read more: Managing pain during the removal of wound dressings

Choosing a dressing

Box 3. STAR classification1
Category 1a A skin tear where the edges can be realigned to the normal anatomical position (without undue stretching) and the skin or flap colour is not pale, dusky or darkened.

Category 1b A skin tear where the edges can be realigned to the normal anatomical position (without undue stretching) and the skin or flap colour is pale, dusky or darkened.

Category 2a A skin tear where the edges cannot be realigned to the normal anatomical position and the skin or flap colour is not pale, dusky or darkened.

Category 2b A skin tear where the edges cannot be realigned to the normal anatomical position and the skin or flap colour is pale, dusky or darkened.

Category 3 A skin tear where the skin or flap is completely absent.Diagnose of Skin Wounds in Frail Elders Essay

Dressing selection is important, but due to limited knowledge among some practitioners, inappropriate choices can be made. The ideal dressing should:4,12

Maintain a moist environment.4,6,12,14,15

Protect the surrounding skin.

Control and manage exudate levels.

Prevent trauma on removal.

Give the patient comfort and security and optimise their well-being.

Be easy to apply and cost effective.

The All Wales Tissue Viability Forum advocates the use of an atraumatic contact layer such as Silflex (Advancis Medical) or Mepitel (Molnlycke), or an atraumatic all in one dressing like Mepilex Border (Molnlycke) or Allevyn Gentle Border (Smith and Nephew).14 If using an all-in-one dressing, then it is advisable to mark the dressing with an arrow to indicate the direction in which the dressing is to be removed.

In some cases, the patient may need to be referred to secondary care for further treatment and possible plastic surgery. This is particularly important if there has been full thickness tissue loss or a haematoma has formed.

Read more: Addressing pressure ulcer issues

Preventing skin tears

As with all things, prevention is better than cure. The ISTAP guidelines specify that care needs to be planned and that a comprehensive assessment of the risk factors for skin tears must be conducted for all individuals at risk within the context of their environment.12

The need to ensure that care giving staff are aware of proper handling techniques required for providing care without traumatising the skin in vulnerable older adults is essential and should form part of an annual educational review. Involvement of the multidisciplinary team should be considered to advise on a number of factors such as safer handling equipment that minimises trauma to the skin, and consulting a dietician for advice on maintaining an adequate nutritional and hydration level. Most importantly, involve the individual patient and their family in deciding on and adopting prevention strategies.Diagnose of Skin Wounds in Frail Elders Essay


Skin tears present a challenge for the healthcare practitioner. Care home establishments have a duty to ensure staff are educated in managing the skin of older adults.

Registered nurses should be aware of the risk factors for skin tears (Box 1)and, where possible, work to eliminate these. Environmental factors can be implicated in the aetiology of skin tears. However, education and the enforcement of protocols for managing skin care can result in a reduction in the occurrence of skin tears.1

A better understanding of the classification and treatment required will enable nurses to feel confident and aid decision-making, improving and enhancing the outcomes for the patient. Diagnose of Skin Wounds in Frail Elders Essay