Sample skin tear prevention and management policy

Purpose

The purpose of this policy is to provide guidelines for the prevention, assessment, and management of skin tears in our healthcare facility. Skin tears are common among elderly residents with fragile skin. By implementing evidence-based practices, we aim to help reduce the incidence of skin tears and promote optimal wound healing.

Definitions

• Skin Tear: A wound caused by shear, friction, and/or blunt force resulting in the separation of skin layers.
• Partial Thickness Skin Tear: The epidermis and dermis are separated.
• Full-Thickness Skin Tear: The epidermis and dermis are separated from underlying skin structures.

Risk Assessment

• Perform a skin tear risk assessment on admission and routinely throughout the resident’s stay.
• Consider risk factors such as age, chronic diseases, fragile skin, history of falls, previous skin tears, impaired mobility, and the need for assistive devices.

Prevention Strategies

1. Skin Assessment:
   • Assess the skin on admission and during regular resident assessments.
   • Document skin condition, including evidence of thin, friable, or dry skin.
2. Nutrition Optimization:
   • Ensure adequate nutrition status through dietary support if needed.
   • Well-nourished skin is more resilient.
3. Moisturization:
   • Regularly use emollients or moisturizers to maintain skin hydration.
4. Protective Measures:
   • Encourage residents to wear long sleeves, knee-high socks, and pants.
   • Consider commercial products like shin guards or padded sleeves for high-risk areas.

Skin Tear Management

1. Assessment:
   • Differentiate between partial and full-thickness skin tears.
   • Realign skin flaps if possible.
   • Assess for signs of infection or inflammation.
2. Treatment:
   • Keep the wound moist using sterile saline.
   • Reposition skin flaps as needed.
   • Consult wound care specialists for viability assessment and possible debridement.
3. Address Underlying Causes:
   • Treat dry skin, address fall risks, and review medications.
   • Individualize care based on resident-centered goals.

Education and Training

• Provide ongoing education to nursing staff on skin tear prevention, assessment, and management.
• Ensure competency in wound care practices.

Documentation

• Document skin tear risk assessments, preventive measures, and wound care interventions in the resident’s medical record.

Customize and expand upon this policy to align with your facility’s specific needs and protocols. Regular staff training and adherence to these guidelines will contribute to better resident outcomes and improved skin health.

Nationwide Resources

• Article: Resident skin tears in senior living communities
• Article: Skin tears: An informational handout for families
• Article: Skin tears in senior living communities: Setting realistic expectations

Additional Resources

• International Skin Tear Advisory Panel (ISTAP). (n.d.).
• WoundSource (2014). Skin Tears: Prevention and Management Strategies
• Advances in Skin and Wound Care. (2019). Empowering and Engaging Nurses Through Nurse-Driven Skin Tear Protocol.