- Julie Cheney RN
Tears over skin tears
When we are young, we get a scratch or a graze, wipe over it or put an adhesive bandage on it and say "She'll be right.", never thinking twice about it. As we age we think we can do the same and it will be okay. But older skin does not heal in the same way. The protein complexes in our skin (collagen) and those formed to make strong scarring tissue are far more fragile, and slower to form as we advance in age. This can mean skin is easier to tear, prone to a range of damage, and slow to heal.
The term we use in health care is a skin tear when there has been a break in the outer layer of skin mostly as a result of sheering forces. These are graded from skin that is only slightly damaged right up to the serious tears that go down to muscle and underlying tissues, through the full thickness of the skin. Often it looks as though the skin is peeled back from the inner layers like you would see on a half peeled peach. These tears often bleed profusely and have a lot of bruising around them. Many are caused by people catching their arms or legs on things as they walk by or knock into something. Others are caused by less obvious 'sheering', when the clothing they are wearing, or bed clothing, or other people's hands, even rubbing against a piece of apparently soft furnishing, causes the layers of skin to separate. This allows the outer layer to sheer away, like throwing back the top sheet of your bed.
Skin tears are extremely painful. They are often slow to heal and can lead to infections. Often, where people have legs with poor circulation, they can develop into leg ulcers that take a very long time to heal, like months or even years. All skin tears need to be taken seriously. There are 2 things to remember: 1 is what to do if one occurs, and 2 - what to do to prevent them happening.
1. What to do with a skin tear
Once a skin tear occurs, you need to think about how deep it is and if there is a skin flap, or piece of peeled back outer skin. This can appear bunched up at one end or peeled back over the top of the undamaged skin. The more underlying tissue that is recovered the less pain, quicker healing, lowered risk of infection. Remember there's likely to be lots of blood, so its not easy to tell sometimes.
Always wash your hands before you do anything, because you don't want to be the one to introduce bacteria that cause infection. RInse gently over the wound with some salty water, or fresh clean water if you are not able to make up some salt water (e.g. use the cooled water in your kettle, add a half a teaspoon or less to the water, and stir well). Gently dry the wound around the edges by dabbing rather than wiping, until it is fairly dry. If you have make-up wipes they work well, or at the least clean tissues. Try not to use cotton wool as the fluff can stick and drag across the wound.
Decide if there is a skin flap that is easy to move. IF the person can tolerate it, you can try to maneuver the skin flap back by using the ends of cotton tips or tweezers that you have scalded. If it is too painful or if there is no reasonable skin flap, you will need to cover it and secure a dressing.
You are aiming to absorb the blood and fluid, keep the skin from moving any more, and secure it against air and infection. Unless you have a stock of non-adherent dressing products such as impregnated gauzes or specialist non stick weaves, you will need to put a clean and absorbent product over it. Proper dressing material or any dry, soft material will at least keep the wound secure. If you have nothing else, the make-up wipes will work for this also. Tissues are not a great option because they stick, but might be all you have access to.The dressing needs to be soft, have layers enough to draw in blood, and protect the whole area of the tear and at least 2 or 3 cm around its edge. Put a few of the wipes or a few folded tissues over it, then secure it with a bandage or something similar. Never, ever, at all, put sticky tape or a sticky bandaid on it. The bandage is to keep everything in place and apply slight pressure to help stem the bleeding. (If you wrap it too tightly it will hurt, cut off circulation and can pressurize the delicate skin so much it kills it.) This can be left intact for a day or even 2, depending on the level of bleeding and any unpleasant odours. Keep it dry, and keep it rested as much as possible. When the dressing is to be changed by a health professional or carer or yourself, always soak off the old dressing with at least clean water, or salt water if you have it, or even olive oil can be used to soften old stuck dressings. Replace the dressing with another clean, dry, absorbant dressing and leave it intact for more than a day each time if you can, ideally up to 5 days with properly designed dressings. If it continues to cause serious pain, shows no change and continues to bleed or smells unpleasant, see a health professional promptly.
2. Prevent them from happening.
Eating: Skin reflects what we eat and drink. Water intake is essential - enough that your urine is pale yellow and clear. Vegetables and fruits and a vitamin c supplement replace necessary healing nutrients. Protein supports the molecules needed to form new collagen, so eat a balanced diet.
Protection: Look for things that stick out, catch or are sharp; such as finger- and toenails, edges of mobility aids, sharp edged furniture. Cluttered areas can make it hard to navigate through without connecting with something. You might even need to wrap something soft over edges that are always getting bumped.
Clothing options: Use clothing that is not too tight and does not have to be dragged up over the skin. Use long sleeves, long socks and long pants, of light and soft material to act as a barrier to the skin.
Manual handling: Be cautious when assisting movement that you don't grab and twist the skin.
Moisturise, moisturise, moisturise. Use products that are not full of perfumes, and avoid petroleum based ointments such as vaseline petoleum jelly or paw paw ointment. These reduce how much the skin is effected by sheering by adding a barrier film over it. They also put hydration back into the skin so that it 'sticks' to its inner layers better.
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