Skin Tear
What is a Skin Tear?
- An acute traumatic wound resulting from external friction and/or shearing forces that separate the epidermis from the dermis
- Usually present on hands and upper extremities
What are the Risk Factors Involved?
- Occurs in individuals with fragile skin
- Older adults at high risk
- Previous skin tears
- Ecchymoses
- Compromised nutrition
- Cognitive impairment
- Multiple medications
- Impaired mobility
- Dry skin/Dehydration
- Presence of pressure or shear
- Impaired sensory perception
- Disease processes such as congestive heart failure, renal failure, and stroke (CVA)
- Prolonged use of corticosteroids
Clinical Pearls:
- LIFT do not drag patients
- Avoid tape or adhesives
- Exercise caution during bathing, dressing, and transferring
- Pad bed rails, wheelchair arm and leg supports
- Maximize nutrition and hydration
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