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Trainer's tip: How to treat skin tears

LTC Nursing Assistant Trainer, December 15, 2011

Your goal is to promote healing with the least amount of trauma, while minimizing pain and preventing infection. No single research-based treatment exists, so most facilities develop their own protocol based on existing research. Treatment may consist of the following:

• Gently clean the skin tear with normal saline or pH neutral cleanser.
• Assess and stage the skin tear.
• Approximate the flap. Avoid stretching the skin. Use an applicator moistened in normal saline to cover the wound and approximate the edges, if necessary. Avoid folding the skin over onto itself as this will prevent adherence.
• Apply steristrips, if necessary, for Category I and Category IIA skin tears. Allow them to fall off on their own as the wound heals. Once applied, do not attempt to remove them.
• Apply petroleum-based ointment, hydrogel, or a moist, nonadherent dressing.
• Select a dressing based on wound size, characteristics, your assessment, and facility policy. Many products can be used to promote a healing environment, including nonadherent dressings, hydrogels, petroleum-based gauze, collagen dressings, foams, transparent films, hydrocolloids, and steristrips.

While the steps outlined above will help when a skin tear has already occurred, your facility should have a policy describing how to identify residents who are at risk for skin tears. Residents who have experienced one skin tear are usually at risk of reoccurrence. Once a risk factor is identified, develop an individualized, preventative care plan. If the resident develops subsequent skin tears, reevaluate and modify the plan. Do not leave an ineffective plan in place.

This is an excerpt from the HCPro book, The Long-Term Care Nursing Desk Reference, Second Edition, by Barbara Acello, MS, RN.

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