Bruising or Ecchymosis

SKIN TEAR PREVENTION

Category I: Skin tear WITHOUT tissue loss

Category II: Skin tear WITH partial tissue loss

Category III: Skin tear with COMPLETE tissue loss, where the

epidermal flab is absent

PARAMETERS OF ASSESSMENT

Prevention is #1 intervention!

Provide a safe environment Perform risk assessment of elderly patients on

admission Implement prevention protocol for patients identified

as AT RISK FOR skin tears and bruising of skin Patients can wear long sleeves or pants to protect

their extremities (if appropriate and applicable) Have adequate light to reduce the risk for bumping

into furniture or equipment Provide a safe area for wandering

STRATEGIES AND INTERVENTIONS

On the correct way of handling patients to PREVENT skin tears

Maintain nutrition and hydration status (if applicable)

Offer fluids between meals (unless contraindicated)

Use lotion, especially on dry skin – arms, legs, BID

Obtain dietary consult (if indicated) – consult with your primary nurse

EDUCATE STAFF OR FAMILY CAREGIVERS

Use a lift sheet (draw sheet) to move and turn patients

Use transfer techniques that prevent friction or shear

Pad bedrails, wheelchair arms, and leg supports

Support dangling arms and legs with pillows or blankets

PROTECT SKIN FROM SELF-INJURY OR INJURY DURING ROUTINE CARE

Use non-adherent dressings on frail skin Apply petroleum-based ointment, steri-strips, or

a moist non adherent wound dressing such as hydrogel dressing with gauze as a secondary dressing (if ordered, indicated and within your scope of practice) telfa type dressings can also be used

If you must use tape, be sure it is made of paper and remove GENTLY. Also, you can apply the tape to hydrocolloid strips placed strategically around the wound rather than directly onto fragile surrounding skin around the skin tear

Use gauze wraps, stockinettes, flexible netting, or other skin protective measures to secure dressing rather than tape

Use no-rinse soapless bathing products (if indicated)

Keep skin from becoming dry, apply moisturizer (if indicated)

PROTECTING SKIN CONTINUED

Gently clean the skin tear with normal saline

Let the area air dry or pat dry carefullyApproximate the skin tear flap (if

indicated)Use caution if using film dressing as

skin damage can occur when removing dressing

Consider marking an arrow on skin tear dressing to indicate the direction of the skin tear to minimize any further skin injury during removal

TREATING SKIN TEARS

When you identify that your patient has bruising and/or skin tears on integument please follow the following protocols:Notify supervisor that a skin tear has occurred by you (via phone)

Notify facility charge nurse (or primary nurse) the occurrence

Fill out incident report form (for QA tracking and trending) and give to supervisor (Joanne)

Document occurrence accurately and thoroughly

AMBERCARE’S REPORTING POLICY

www.hhs.govUS Department of Health and Human Serviceswww.guideline.govwww.ahrq.org

REFERENCES