winning the welcome battle of skin tears in an aging population … · 2017-06-28 · •skin tears...
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Winningthebattleofskintearsinanagingpopulation
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Overviewoftheproblem...2016ISTAPConsensusStatement...Clinicalsolutions...
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SPEAKER- CLINICALKimberlyLeBlanc,MN,RN,CETN(C),PhD(Cand)
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MODERATORCynthiaSaver,MS,RN
SPEAKER- SOLUTIONSShannonCyphers,RN,BSN,WCC
KimberlyLeBlancMNRNCETN(C)PhD(Cand)
Update2017:Evidence-basedPrediction,Prevention,Assessment,
andManagementofSkinTears
www.skintears.org
Objectives
Attheendofthiswebinar,thelearnerwillbeableto•DefineandclassifyskintearsaccordingtotheISTAPClassificationSystem
• Identifyindividualsatriskforskintears•Discussmethodsforpreventingskintears•Discussinterventionsforpreventingandmanagingskintears
www.skintears.org
Whyareweconcernedwithskintears?
www.skintears.org
FindingaCommonTerminologyTermsthathavebeenusedforskintears• Tears• Abrasions• Lacerations• Stage2pressureulcers• Erosions• Denudation• “justaskintear”• MOREOFTENTHANNOT“NOTHING”
www.skintears.org
PrevalenceofSkinTearsLiteratureReview
• Long-termcaresettings:10-54%(LeBlanc&Woo,2014;LeBlanc&Christensen2013;Grysonetal.,2012;Carville&Smith2004;McErlean
etal.,2004;Everett&Powell1994)
• Communitysettings:4.5%-19.5%inallagegroups(Strazzieri-Pulidoetal.,2015;Grysonetal.,2012;LeBlanc&Christensen2009;Carville&Lewin,1998)
• Acutecaresettings2.2%-22%(Chang,Carville,Tay.2016;Strazzieri-Pulidoetal.,2015;dosSantos,Strazzieri,&Conceição,2012;Gryson
etal.,2012;Hsu&Chang,2010)
www.skintears.org
PrevalenceofSkinTearsLiteratureReview
• Palliativecaresettings:30%(Maida,Ennis,&Corban,2012)
• Pediatricacutecare:• (10daysto17yearsold),prevalenceofpressureinjury4%andskintear17%
• 75%<6yearsofage,and80%ofthose6monthsofageoryounger
(McLaneetal.,2004)
• Intensivecaresettings:Prevalenceunknown
www.skintears.org
SkinTearCharacteristics• Normallyshallowwoundslimitedtothedermisandepidermis(woundsmaybepartialorfullthickness)
• Varyinlocation,size,depth,andamountoftissueloss
• Skinflapmaybepresent• Acutewoundsthatshouldhealinanormalwoundhealingtrajectory(7-14days)butfrequentlybecomecomplexchronicwounds
LeBlancetal.,2015;Newalletal.,2015;Carvilleetal.,2014 www.skintears.org
InternationalSkinTearAdvisoryPanel:SkinTearDefinition
• Askintearisawoundcausedbyshear,friction,and/orbluntforceresultinginseparationofskinlayers.
Askintearcanbe:Partial-thickness(separationoftheepidermisfromthedermis)
orFull-thickness(separationofboththeepidermisanddermisfromunderlyingstructures).
LeBlancetal.,2011 www.skintears.org
www.skintears.org
SkinTearsandPressureInjuries
• Skintearsmaybemoreprevalentthanpressureulcers(Carville2007,LeBlancetal2016).
• Skintearsandpressureinjuriessharemanyofthesameriskfactorsandclinicalcharacteristics.
• Whenskintearsoccuroverabonyprominence,addedpressurecanresultinadditionaltissuedamage.
LeBlancetal.,2016 www.skintears.org
ComplicationsAssociatedwithSkinTears
• Woundinfections
• Skintearsoverbonyprominences—mayincreasetheoddsofdevelopingapressureinjuries
• Skintearsonthelowerlimbsofindividualssufferingfromchronicedemaandarterialinsufficiency—mayleadtocomplexlegulcers
• Increasedpainandsuffering
!
LeBlancetal.,2014
FilePhoto;SharonBaranoski
www.skintears.org
TopCausesofSkinTears
LeBlancetal.,2013
Almosthalfofskintearsarefoundwithoutanyapparentcause.
www.skintears.org
LocationofSkinTears(AgingPopulation)
• Mostskintears(80%)occurin
upperextremities(armsandhands)
• 15%occuronthelowerextremities
• 5%occuronotherareasofthebody
Baranoski,2003;Xiaotetal.,2009;LeBlancetal.,2011;Sanadaetal.,2015;Changetal.,2016
!
FilePhoto;SharonBaranoski
FilePhoto:MaryGloeckner
www.skintears.org
PredictingSkinTears:RiskAssessment
FilePhoto:SharonBaranoski
www.skintears.org
Note:Pathwayvalidationinprogress.
www.skintears.org
Skintearsaremoreprevalentwith,butnotlimitedto,theextremesofage.
LeBlancetal.,2011
RiskFactorsforSkinTears
www.skintears.org
RiskFactorsforSkinTears
LeBlancetal.,2011
FilePhoto;MaryGloeckner
Skintearsarealsofoundinthecriticallyandchronicallyillpopulations.
www.skintears.org
RiskFactorsforSkinTears(AgingPopulation)
Modifiableriskfactors• Xerosis• Pruritus• Typesofmedicaladhesivesused• CareduringADLs• Fallsrisk• Medications• Nutritionalstatus• Trauma• Healthcareprofessionalsapproachtomanagingindividualswithaggressivebehavior/cognitiveimpairment
Non-modifiableriskfactors• Photoaging
• Skinchangeswithaging
• Criticalandchronicillness
• Dementia/cognitiveImpairment
• Visual/auditory/sensoryimpairment
• Aggressivebehavior
• RequiredassistancewithADLs
LeBlancetal.,2015 www.skintears.org
SkinTearPreventionStrategies
www.skintears.org
SkinTearPreventionStrategiesThekeytoanymanagementprogramisanestablishedpreventionprogram.
Bestpractices
• Protectfromtraumaduringroutinecare
• Provideprotectionfromselfinjury
• Ensurepropertransferandliftingtechniquestoavoidshearingandfriction
www.skintears.orgLeBlancetal.,2013
SkinTearPreventionStrategies• Promoteandmonitoradequatenutritionandhydration.
• Avoiduseofadhesiveproductsonfragileskin.
• Createasafeenvironment,suchasclothingorprotectivedevicesthatcovertheextremities;initiatefallprecautionprotocoltoreduceriskoffallsandblunttrauma.
• Ensurecaregivers’nailsarekeptshortandthattheyarenotwearingjewelry,whichcancatchandcontributetoskintearformation.
• Rememberthatextremesofweight(bariatric,cacheticorexcessivelythin)requireextracaretopreventskintears.
LeBlancetal.,2013 www.skintears.org
SkinTearPreventionStrategies
• Minimizebathing,skinhygieneaccordingtoindividualneedusingwarm/tepid,nothot,waterandsoaplessorpHneutralcleanser.
• Applyinghypoallergenicmoisturizeratleasttwotimesperday.• Provideprotection fromtraumaduringroutinecare.• Provideprotectionfromselfinjury,keepnailsshortandfiledtopreventself-inflictedskintears.
• Ensurepropertransferandliftingtechniquestoavoidshearingandfriction.
• Padbedrailsorotherobjectsthatmayleadtoblunttrauma.
LeBlanc,etal.,2013; Carvilleetal.,2014 www.skintears.org
SkinTearPreventionStrategiesHealthcareSetting
• Recognizetheneedforandimplementacomprehensiveskintearreductionprogram.
• Supporttheuseofatraumatictopicaldressingoptionsforthetreatmentofskintearswhentheydooccurtominimizetheriskoffurtherskindamage.
• Includetheprevalenceandincidenceofskintearsincurrentwoundauditprograms.
LeBlancetal.,2013 www.skintears.org
ManagingSkinTears
• Skintearsareacutewoundsthathavethepotentialtobeclosedbyprimaryintention.
• Traditionally,woundsclosedbyprimaryintentionaresecuredwithsutureorstaples.
• Giventhefragilityofelderlyskinsuturesandstaplesarenotaviableoption,andothermethodsarerequired.
LeBlancetal.,2013 www.skintears.org
ISTAPSkinTearToolKit
www.skintears.orgLeBlancetal.,2013
ReapproximateWoundEdges
1
3
2
54Type 1 Skin Tear
www.skintears.org
ApproximateWoundEdges
www.skintears.org
TreatingSkinTears•Donotaddnewrisksfortrauma•Assesscomorbidities(venousdisease,arterialdisease,pressure)
Chooseadressingthatwill:ü Decreasetraumaü Providemoistwoundhealingü Managepain
www.skintears.org
Debridement• Iftheskinflapispresentbutnotviable,itmayneedtobedebrided.
• Careshouldbetakenduringdebridementtoensurethatviableskinflapsareleftintactandfragileskinisprotected.
www.skintears.org
Infection/Inflammation• Woundinflammationfromtraumashouldbedistinguishedfromwoundinfection.
• Woundinfectioncanresultinpainanddelayedwoundhealing.Diagnosisofinfectionshouldbebasedonclinicalassessment.
Inflamed
Infectedwww.skintears.org
EdgeEffect• Skintearsareacutewoundsthattypicallyshouldproceedtowoundclosureinatimelyfashionandfollowanacutewoundclosuretrajectoryof7-21days.
• Awoundcarespecialistshouldbeconsultedtoensureallpotentialfactorsthatcoulddelaywoundhealing(e.g.,peripheraledema)havebeenaddressed.
www.skintears.org
Ensurethatalltopicaldressingsselectedforthemanagementofskintearsarecompatiblewithfragileskin,preventingfurthertrauma.
www.skintears.org
www.skintears.org
ProductSelection:SkinTearTreatmentISTAPProductSelectionRecommendations2015
ThefollowinglistofproductsrecommendedforskinteartreatmentisbasedonanextensiveliteraturereviewandinternationalDelphistudy.
• TheDelphiconsensusgroupincludedthe11memberISTAPgroupandaninternationalexpertreviewgroup(n=105individualsrepresenting8countries).
• Over80%agreementwasreachedoneachproductcategory.Productcategorieswhichdidnotreceivegreaterthan80%agreementwereNOTincludedintherecommendedproductsforskinteartreatment.
Theproductlistisnotallinclusive;theremaybeadditionalproductsapplicableforthetreatmentofskintears,theISTAPPaneldoesnotpromoteanyoneproductorwoundcarecompany.
LeBlancetal.,2016 www.skintears.org
ISTAPSkinTearProductSelectionRecommendations
©ISTAP2015
Productcategories Indications Skinteartype Considerations
2-octylcyanoacrylatetopicalbandage(skinglue)
• Toapproximatewound edges 1 · Useinasimilarfashionassutureswithinfirst24hourspost injury,relativelyexpensive,medicaldirective/protocolmayberequired
Acrylicdressing · Mildtomoderateexudatewithout anyevidenceofbleeding,mayremaininplaceforanextendedperiodoftime
1,2,3 · Use careonremoval· Shouldonlybeusedasdirectedandleft
onforextendedweartime
Calciumalginates · ModeratetoheavyexudateHemostatic
1,2,3 · Maydryoutwoundbedifinadequateexudate
· Secondarycoverdressingrequired
Hydrofibre · Moderatetoheavyexudate 2,3 · Nohemostaticproperties· Maydryoutwoundbedifinadequate
exudate· Secondarycoverdressingrequired
ISTAPSkinTearProductSelectionRecommendations©ISTAP2015
Productcategories Indications Skinteartype Considerations
Hydrogels · Donatesmoisturefordrywounds
2,3 · Caution:mayresultinperi-woundmacerationifwoundisexudative
· Forautolyticdebridementinwoundswithlowexudate
· Secondarycoverdressingrequired
Foamdressing · Moderateexudate· Longerweartime(2-7days
dependingonexudatelevels)
2,3 · Cautionwithadhesiveborderfoams· Usenon-adhesiveversionswhenpossible
toavoidperi-woundtrauma
Non-adherentmeshdressings · Dryorexudativewound 1,2,3 · Maintainsmoisturebalanceformultiplelevelsofwound exudate
· Atraumaticremoval· Mayneedsecondarycoverdressing
ISTAPSkinTearProductSelectionRecommendations©ISTAP2015
SpecialConsiderationforInfectedSkinTearsProductcategories Indications Skinteartype Considerations
Ionicsilverdressings · Effectivebroadspectrumantimicrobialactionincludingantibioticresistantorganisms
1,2,3 · Shouldnotbeusedindefinitely.· Contraindicatedinpatientswithsilverallergy· Usewhenlocalordeepinfectionissuspectedor
confirmed· Usenon-adherentproductswheneverpossibleto
minimizeriskoffurthertrauma
Methylene blueandgentianvioletdressings
· Effectivebroadspectrumantimicrobialactionincludingantibioticresistantorganisms
1,2,3 · Non-traumatictowoundbed· Usewhenlocalordeeptissueinfectionissuspected
orconfirmed· Secondarydressingrequired
Thisproductlistisnotallinclusive;theremaybeadditionalproductsapplicableforthetreatmentofskintears.www.skintears.org
EvidencetoSupportProductsNotIncludedontheISTAPProductGuideforSkinTears
Leptospermumhoneydressings• Johnson&Katzman(2015)reportedcomparablehealingratesusingLeptospermumhoneybaseddressingstothoseofproductsontheISTAPproductguide.
• LeptospermumhoneyactsthroughosmosisanditisthoughtthatitslowpH(3.5–4.5)helpsmodulatethepHofthewound,contributingtoanacidicenvironmentconducivetowoundhealing(Dunbury&Acton,2008;Chaiken,2010).
• Leptospermumhoneydressingsareavailableinvariousformatsincluding:calciumalginatesandhydrogelcolloidalsheetdressing.
www.skintears.org
Polyhexamethylenebiguanide(PHMB)dressings• PHMBhasbeenincorporatedintoarangeofwoundproductsincludinggels,non-adherentcontactlayers,foams,andgauzedressings(Butcher,2012).
• PHMBwasnotincludedintheISTAPproductguideasitdidnotreceive>80%agreementforitsuseinthemanagementofskintears.ISTAPhypothesizedthatthiscouldhavebeenrelatedtolackoffamiliaritygloballyofthevariousformsavailable(LeBlancetal.,2016).
• Giventhathydrogels,non-adherentcontactlayers,andfoamswereincludedintheISTAPproductguideandtheclaimPHMBisaneffectiveantimicrobialproduct,healthcareprofessionalsmaywanttoconsideritsuseiftheydeemitisappropriateforthewoundbedconditions.
www.skintears.org
EvidencetoSupportProductsNotIncludedontheISTAPProductGuideforSkinTears
ProductsNOT RecommendedforSkinTears
Iodine-baseddressings• Iodinehasbeenusedinvariousformsinwoundcaresince1882forthepreventiontreatmentofinfectedwoundswithgreatsuccess(Sibbald,Leaper,Queen,2011).
• Iodinebaseddressingsdidnotreceive80%.• Iodinecausesdryingofthewoundandperi-woundskin.Theinternationalreviewgroupmaintainedthatasamajorriskfactorforskinteardevelopmentislistedtobedryskin,iodinebasedproductsshouldnotbeusedforthemanagementofskintearsorforthosewhoaredeemedatriskforskintears(LeBlancetal.,2016).
www.skintears.org
ProductsNOT RecommendedforSkinTearsFilm/hydrocolloiddressings
• Filmsandhydrocolloidshavetraditionallybeenusedforpartialthicknesswoundsandassecondarydressings;however,theydidnotreceive80%agreement,sowerenotincludedintheISTAPproductguide(LeBlancetal.,2016).
• Filmsandhydrocolloiddressingshaveastrongadhesivecomponentandhavebeenreportedtocontributetomedicaladhesiverelatedskintears(McNichol,Lund,Rosen&Gray,2013).
• Filmsandhydrocolloiddressingsarenotrecommendedforuseinthosewhoareathighriskfor,orwhohave,askintear.
www.skintears.org
ProductsNOT RecommendedforSkinTearsSkinclosurestrips• Expertopinionsuggeststhatadhesivestripsmayincreasetheriskoffurtherskininjury,andwhilemoreresearchisneeded,casestudiesandexpertopinionsuggestadhesivestripsarenolongerapreferredtreatmentoptionofchoiceforskintears (LeBlancetal.,2016;(Rayner,Carville,Leslie,&Roberts,2015;Holmes,Davidson,Thompson,&Kelechi,2013;Ellis&Gittins,2015).
• Quinnetal.(1993)reportedthattopicalskingluewasafasterandlesspainfulmethodwithbetterscarmanagementcomparedtosuturesorskinclosurestripsformanagingskintearsandlacerationsinchildren.
• Giventhefragilityofelderlyskin,suturesandstaplesarenotrecommended(LeBlancetal.,2011;Rayner,Carville,Leslie,&Roberts,2015).
www.skintears.org
SpecialConsideration:PeripheralEdema
• Lowerlegedemaiswelldocumentedtocontributetodelayedwoundhealing,regardlessofthewoundetiology(Lindsay&White,2007).
• Whenskintearsoccuronthelowerlimb,theriskandcauseofpotentialperipheraledemashouldbeassessed(LeBlancetal.,2016;Ellis&Gittins,2015).
www.skintears.org
• Awarenessofmodifiableriskfactorsandassociatedinterventionsisneededtoreducetheincidenceofskintears.
• Topreventskintears,healthcareprofessionalsshouldprovidegentlecare,protecttheskinfromtrauma,andprovidetwicedailymoisturizing.
Conclusion
www.skintears.org
Resources
www.skintears.org
www.skintears.org
www.skintears.org
ShannonCyphers,RN,BSN,WCC
SolutionsforPreventionandManagementofSkinTears
www.skintears.org
PreventiveSkinCare
Sensi-Care®
Perineal/SkinCleanser
Aloe Vesta®
Perineal/SkinCleanser
Aloe Vesta®
Cleansing Foam
Refer to product label for complete information on indications and use of each product.
§ CleanseskingentlywithapHbalancedno-rinsecleanseranddrythoroughly.5
§ ConvaTecoptions§ ContainSurfactantsandHumectants
§ pHbalanced§ Norinse
Cleanse
AP-015502-US 2015 5.GrayM,BlissDZ,DoughtyDB,Ermer-Seltun J,Kennedy-EvansKL,PalmerMH.Incontinence-associatedDermatitis:AConsensus.JWoundOstomyContinenceNursesSociety.2007:34:45-54.
§ Useskinemollientstohydrateskininorder toreduceriskofskindamage7
§ Applyafterbathingandasneeded
§ ConvaTecmoisturizers§ Containhumectants toattractmoisture§ Containemollients topreventmoisture
fromleavingtheskin(petrolatumanddimethicone)
Moisturize
Aloe Vesta®
Daily Moisturizer
Sensi-Care®
Body Cream
Refer to product label for complete information on indications and use of each product.
Step2:Moisturize
AP-015502-US 20157.JunkinJ,SelekofJL.Beyond“diaperrash”:Incontinence-associated dermatitis:DoesithaveyouseeingRED?;Nursing2008.2008;38(11):56hn2-56hn10.
Sensi-Care® StingFreeFamily
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FeaturesBenefits
LeavesNoResidue Does notaffectadhesionofdressingsorappliances.
No TouchRemovalHelps minimizetraumatopatients.Helpsminimizeskinstrippingthatcausespain.
Fragrance&DyeFree Gentle totheskin:designedforsensitiveandfragileskin.
• Easily and rapidly releases appliances or dressings adhered with adhesives*
Sensi-Care® StingFreeAdhesiveReleaser
*Data on File. ConvaTec Inc.
AP-015502-US 2015
NEW
AP-017256-US
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DressingTips
AP-016166-US 2016
AP-014151-US
Thankyouforattendingtoday’swebinarSharetheknowledgewithyourcolleaguesbyaccessingthearchivededitionat
www.AmericanNurseToday.com orwww.WoundCareAdvisor.com.Youwillalsobeabletoaccessourfirstwebinar,Skindamageassociatedwithmoistureandpressure;tips
forhowtodifferentiateandgoalsforprotectionandmanagement
Thisisthesecondinaseriesof fourwoundcarewebinarsthatwewillbepresenting in2017.Plantojoinusagainthissummer forourthirdwebinar.DetailswillbeavailableonAmericanNurseToday.comandWoundCareAdvisor.com
Foradditional informationaboutConvaTec,visitconvatec.com.Additional educationalcoursescanbefound atconvatecacademy.com
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