LECZENIE RAN 2024; 21 (3)

Discussion of research results

The selected studies focused on evaluating the prevalence of ST and identifying the primary risk factors associated with these types of skin injuries to propose the best practices for preventing their occurrence and mitigating their consequences when they do arise.

Considering the prevalence of ST in various residential care facilities and home care settings, it is often challenging to compare the reported values across studies. These values vary significantly, even among facilities with similar profiles. For instance, Hawk et al. reported that in six facilities in western Pennsylvania, the prevalence of ST ranged from 3% to 16% [25]. Other researchers have described the prevalence of skin injuries using incidence rates expressed as cases per 1,000 patient-days [26]. The considerable variability in published data regarding the prevalence of ST may partly be attributed to suboptimal recognition and reporting practices among healthcare workers [27]. Consequently, the actual prevalence of ST is likely higher than the reported figures [25].

Nevertheless, the prevalence data presented by researchers deserve deeper analysis and highlight the need to implement effective prevention and management strategies for ST into nursing practice. Establishing evidence-based protocols for identifying, reporting, and addressing ST can significantly improve outcomes and reduce the burden of these injuries on patients and healthcare systems.

Prevention of skin tears

High qualifications and clinical experience among nurses are critical for preventing and/or reducing the incidence of ST [28, 29]. Identifying numerous risk factors for ST, especially modifiable internal and external factors, enables the development and implementation of individualized care plans for patients.

The prevention strategy for ST should be based on several pillars:

1. Evaluating the occurrence and progression of changes resulting from the aging process and multimorbidity is crucial.

Soh et al. observed that individuals with dementia might be more susceptible to injuries due to limited awareness and difficulties in cooperating during care. The high risk of falls associated with dementia, potential self-harm, and impaired awareness of hazards further increase the likelihood of skin injuries [18]. Sensory deficits, such as impaired touch, vision, and hearing, also represent significant risk factors [21]. In this context, care should focus on ensuring a safe environment for the patient. Studies confirm that falls are a significant, long-term risk factor associated with skin injuries [7, 19, 18, 21]. Therefore, providing a safe environment and adequate protective measures is essential for preventing potential skin injuries in patients.

Patients with more than one chronic condition tend to exhibit a more complex propensity for developing ST [21]. Furthermore, studies have identified a significant association between the use of corticosteroids and anticoagulants and the occurrence of skin injuries. The use of steroids can inhibit collagen synthesis, reduce the tensile strength of the skin, and impair the viability of tenocytes, thereby increasing susceptibility to skin injuries. Anticoagulants, on the other hand, may lead to soft tissue damage even with minor trauma and negatively affect wound healing processes by modifying blood flow and coagulation mechanisms [15, 20, 21].

Nurses play a critical role not only in informing patients about the side effects and risks associated with the use of steroids or anticoagulants but also in continuously monitoring the condition of the skin. Through regular assessments, they can quickly identify potential skin injuries and take appropriate preventive and therapeutic actions. Their involvement in monitoring skin conditions is essential for ensuring proper care and minimizing the risk of complications in patients using these medications [2].

Particular caution should be exercised when caring for patients with extreme BMI values (<20 or > 30 kg m²). Lower BMI may lead to reduced skin thickness, which increases vulnerability to injuries. Researchers have demonstrated a statistically significant relationship between skin injuries, BMI, albumin levels, and malnutrition. Albumin deficiency has been identified as an independent risk factor for compromised skin integrity. It may contribute to the formation of skin injuries through its association with nutritional status and as a negative acute-phase reactive protein, influencing the mechanism of edema [18, 21]. Regular assessment and optimal nutritional support tailored to the patient’s needs are critical not only for preventing but also for treating ST.

Standardized health assessment tools are valuable in evaluating the patient’s condition. Although the Braden Scale is commonly used in clinical practice for predicting pressure ulcers, it can also effectively serve as a prognostic tool for ST. The scale assesses several key factors: sensory perception, skin moisture, activity, mobility, nutritional status, and the impact of friction and pressure forces. Using this scale, at-risk individuals can be identified, and appropriate preventive measures can be implemented, such as regular repositioning, the use of specialized cushions and mattresses, and skin care routines. The Braden Scale also enables tracking the effectiveness of preventive measures and adapting care plans to ensure the health and integrity of the patient’s skin [23].

2. Maintaining physical activity

Preventive measures in this area include encouraging patients to remain physically active, provided there are no significant functional deficits. Attention should be given to selecting appropriate assistive devices, such as walkers or wheelchairs, and securing the bed with railings during sleep. In patient care, it is essential to provide comfortable footwear, ensure proper lighting in the room, and remove rugs to minimize fall risks [2].

Some nursing interventions and actions increase the risk of ST in patients [30]. In ST prevention programs, special attention should be given to patients who are entirely dependent on others for care. These individuals often experience ST during routine activities such as dressing, bathing, repositioning, and transferring. Frequent manipulation to change positions can exacerbate the effects of shear forces, friction, or other skin injuries resulting from maneuvers performed during patient care.

Skills in positioning and transferring patients should include techniques that reduce pressure on the skin, ensure a safe environment, and use specialized devices and equipment, such as anti-pressure mattresses, hoists, positioning aids, and glide sheets [15, 16, 18, 20, 21].

3. Skin care

Research on the structural and mechanical properties of the skin in individuals with ST has shown that progressive changes result from the fundamental effects of chronological aging as well as environmental and lifestyle influences [31]. With age, the skin gradually becomes less hydrated and thinner. It exhibits water loss in the epidermal layer, reduced elasticity, and a decreased ability to return to its original shape. These changes are associated with the degradation of collagen and elastin structures, which increases susceptibility to damage and weakens the skin’s healing mechanisms. Photoaging, resulting from UV radiation exposure, also contributes to the more frequent occurrence of skin injuries. The effects of photoaging include elastosis, characterized by thickened, scaly, dry, and stiff skin texture, particularly visible in areas exposed to UV radiation [7, 15, 17, 20, 21].

Among vascular skin changes that increase the risk of ST are petechiae (Figure 1), senile purpura, and hematomas. These are primarily caused by vascular fragility, but coagulation disorders and anticoagulant use also contribute to their development. Although hematomas have not always been recognized as a risk factor, they can increase skin tension, which can also lead to tearing (Figure 2) [7, 16, 19, 21, 24]. Edema negatively affects the epidermal barrier, reducing its resistance to external forces, which also increases the susceptibility to ST [16].

Regular assessment of skin condition enables the early detection of risks and allows for a swift and effective preventive response. The foundation of skin care includes maintaining hygiene (using non-rinse cleansers, drying the skin with gentle materials, moisturizing and lubricating regularly, and immediately cleaning contamination caused by urinary and/or fecal incontinence), protecting extremities by wearing clothing with sleeves and long pants, keeping nails trimmed short, and avoiding sharp objects such as jewelry [2, 32, 33, 34].

The use of adhesives/dressings on the skin can increase the risk of ST by as much as 7.05 times due to the external force required for their removal. The type of medical adhesive used also plays a significant role [15].

4. Education of patients and their caregivers

Some studies suggest that the prevalence of ST in home care settings is higher than in institutional care. To prevent ST, systematic education should be conducted in the patient’s environment. Engaging the patient and involving their caregivers in the care process grants them autonomy and enables them to take control of their health [35].

Accordingly, the tasks of nurses, physiotherapists, and medical caregivers include collaboration with the patient and their caregivers. This collaboration involves providing instructions, conducting workshops and training sessions on skin care, repositioning techniques, fall prevention, and informing caregivers of older adults about potential risks associated with skin injuries. Professionalism and care expressed through emotional support for patients at risk of ST can significantly improve their quality of life.