Cath Lab Digest

S kin tears cause pain for the individual and increase the cost of care for residents in long-term care facilities.¹ Each year, an estimated 1.5 million skin tears occur among the institutionalized elderly.² By the year 2030, the number of individuals at highest risk for developing these wounds (85 years of age and older) is estimated to reach 8.1 million people in the United States.¹ As the population ages, skin tears become a common concern for those providing care.

Skin tears are defined as traumatic wounds resulting from a separation of the epidermis from the dermis due to friction or shearing.^1,3 Many intrinsic and extrinsic factors converge to increase an aging individual’s risk for acquiring skin tears. Aging individuals experience dermal and subcutaneous tissue loss as well as epidermal thinning.^1,2,4 Sebum composition changes, resulting in less skin surface moisture.² The skin’s elasticity is decreased and tensile strength weakens.¹ Dermal papillae and rete ridges flatten, causing altered cohesion of the dermal-epidermal junction and increasing the risk of separation due to mechanical trauma.^1,4 The risk of trauma is further increased by diminished sensation and reduced fluid intake. ⁵

Extrinsic factors that increase the risk for mechanical trauma include the use of soap, bathing technique and water temperature, and hands-on care such as dressing, toileting, and bed-to-chair transfers.^1,2 Soap removes the skin’s natural lipids; it also decreases natural lubricants which leads to increased transepidermal water loss (measured as water vapor diffuses to the environment through the epidermis).^2,6

The purpose of this retrospective study was to determine the effects of bathing ritual changes on the occurrence of skin tears in bed-bound residents of a 72-bed, long-term care facility. Changes in nursing practice, patient care outcomes, and costs of care also were assessed.

Literature Review

Although research regarding risk factors for skin tears or measures to prevent them is limited, the literature is growing. McGough-Csarny and Kopac¹ found the following six major risk factors for the development of skin tears: 1) advanced age, 2) sensory loss, 3) compromised nutrition, 4) history of previous skin tears, 5) cognitive impairment, and 6) dependency. Other risk factors included senile purpura, altered neuromuscular status, and polypharmacy.

In their study, White, Karam, and Cowell⁵ found three groups of residents at high risk for skin tears. Residents who required care for all activities of daily living experienced the highest number of skin tears (48%). Residents who were independently ambulatory experienced the second highest number of skin tears (41%). Residents who were sight-impaired and required assistance with ambulation had the third highest number of reported skin tears (11%). Implementation of prevention measures resulted in a 50% decrease in the incidence of skin tears in that facility.

In a 4-month prospective crossover study comparing the use of emollient soap (containing moisturizers) with nonemollient soap, Mason⁷ found that residents of a 173-bed, long-term care facility developed fewer skin tears when an emollient soap was used during bathing. When comparing the total rate of skin tears per resident, the rate of skin tears when emollient soap was used was 34.8% lower than when nonemollient soap was utilized.