Pressure injuries and skin tears

As we age, our skin can experience changes that make it more vulnerable to damage.

Older people, especially those who are frail, are at significant risk of developing pressure injuries and skin tears.

Hospital acquired pressure injuries and skin tears are considered an adverse event. Most pressure injuries and skin tears can be prevented by following simple steps such as maintaining good nutrition and hydration, regular but careful mobilisation, good skin hygiene and a good moisturising regime.

This topic defines pressure injuries and skin tears and their impacts; describes methods of screening and assessment for risk; and recommends interventions to prevent and manage pressure injuries and skin tears. In addition to following health service policy and procedures, consider the following actions and discuss them with colleagues and managers.

Definitions

A pressure injury is ‘a localised injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, shear and/or friction, or a combination of these factors’.¹ Pressure injuries can also be called pressure ulcers or bed sores.

As pressure injuries usually occur over bony prominences, such as the sacrum or base of the spine, heels and hips, they are often not visible.

The severity of pressure injuries can be classified using a staging system. Management and treatment of pressure injuries depends on the stage.

A skin tear is ‘a wound caused by shear, friction and/or blunt force resulting in separation of skin layers’.²

Skin tear severity can be classified according to the Skin Tear Audit classification system. Management and treatment of skin tears depends on its classification.

Impacts

Hospital acquired pressure injuries and skin tears are considered an adverse event and can have a profound physical, social and psychological impact on the lives of older people.

This is going to affect her mobility, and emotionally this is going to make her shattered.
- Family member, Western Health

Older people who experience pressure injuries and skin tears while in hospital are at increased risk of:

• morbidity and mortality
• pain
• reduced mobility and loss of independence; which increases the risk of developing pressure injuries
• longer hospital stay
• reduced quality of life
• anxiety and worry
• reduced social contact and increased social isolation.
• loneliness.

Skin and ageing

Older people are at risk of skin damage, as changes that can occur to skin as it ages can affect its integrity, making it more vulnerable to damage, and to the development of a pressure injury or skin tears³. In addition, older people in hospital are likely to spend more than 23 hours per day either in bed or sitting⁴.

As skin ages it:

• becomes thinner and less elastic
• loses moisture and can become dry and more vulnerable to splitting and cracking
• develops folds and wrinkles
• loses its cushioning layer of subcutaneous fat
• has decreased sensory perception and is less likely to be able to detect temperature changes or pain
• has decreased temperature control and therefore an older person is less able to regulate their body temperature
• is more easily injured (prone to tearing and bruising)
• is slower to heal^5,6,7.

Pressure injuries and skin tears and discharge planning

We can help patients make a smooth transition from the hospital to their home or residential aged care facility through comprehensive and clear discharge planning and communication.

If a patient is ready to go home with a continued need for wound dressings, talk to the patient and their family and carers about the type of dressing regime that will work for them.

Involve appropriate support services, such as home nursing, and communicate the person-centred care plan to ongoing care providers.

Having a wound increases the risk of a person becoming socially isolated and experiencing loneliness. Find out what social support the person has, and include their engagement with formal or informal supports as part of their discharge plan.

Provide a discharge summary, including the wound management plan, to the patient’s GP. Ensure the patient and their family and carer also receive a copy of the discharge summary and wound management plan.

Make referrals to allied health specialists or other services as appropriate:

• wound specialist or clinic if wound advice is required
• dietitian if malnutrition or dehydration is suspected
• podiatrist if foot care or footwear advice is needed
• physiotherapist if balance or mobility advice is needed
• speech pathologist if there are swallowing problems
• occupational therapist if patient requires specialised equipment at home.

Consider if the person needs personal care, help with other tasks of daily living or appropriate wound dressing, and refer to appropriate services.

Local services such as the council, neighbourhood house or library can link the person to local social activities.