A skin tear is a break or rip in the outer layers of the skin (Fig. 24-1). The epidermis (top skin layer) separates from the underlying tissues. The hands, arms, and lower legs are common sites for skin tears. Causes include:

• Friction, shearing (Chapter 13), pulling, or pressure on the skin.

• Falls or bumping a hard surface. Beds, bed rails, chairs, wheelchair footplates, and tables are dangers.

• Holding an arm or leg too tight.

• Removing tape or adhesives.

• Bathing, dressing, and other tasks.

• Pulling buttons and zippers across fragile skin.

• Jewelry—yours or the person’s. Rings, watches, and bracelets are examples.

• Long or jagged fingernails (yours or the person’s) and long or jagged toenails.

Skin tears are painful. They are portals of entry for microbes. Infection is a risk. Tell the nurse at once if you cause or find a skin tear. To prevent skin tears, follow the care plan and the measures in Box 24-1.

Box 24-1 Preventing Skin Tears

• Follow the care plan and safety rules to:

• Move, turn, position, or transfer the person.

• Prevent shearing and friction.

• Use an assist device to move and turn the person in bed.

• Use pillows to support arms and legs.

• Pad bed rails and wheelchair arms, footplates, and leg supports.

• Bathe the person.

• Keep the skin moisturized and apply lotion.

• Offer fluids.

• Keep your fingernails short and smoothly filed.

• Keep the person’s fingernails short and smoothly filed. Report long, tough, or jagged toenails.

• Do not wear rings with large or raised stones. Do not wear bracelets.

• Be patient and calm when the person is confused, is agitated, or resists care.

• Dress and undress the person carefully.

• Dress the person in soft clothes with long sleeves and long pants.

• Provide good lighting so the person can see. The person needs to avoid bumping into furniture, walls, and equipment.

• Provide a safe area for wandering (Chapter 30).

• Remove tape carefully (p. 388).

• Do not apply adhesive tape (p. 388).

See Focus on Older Persons: Skin Tears.

Focus on Older Persons

Skin Tears

Older persons are at risk for skin tears because of thin and fragile skin. Some persons are confused and may resist care. They often move quickly and without warning. Or they pull away during care. Some try to hit or kick. These sudden movements can cause skin tears.

Never force care on a person. Chapter 30 describes how to care for persons who are confused and resist care. Always follow the care plan.

Circulatory Ulcers

An ulcer is a shallow or deep crater-like sore of the skin or mucous membrane. Circulatory ulcers (vascular ulcers) are open sores on the lower legs or feet. They are caused by decreased blood flow through the arteries or veins. Persons with diseases affecting blood flow to and from the legs and feet are at risk. These wounds are painful and hard to heal. Infection and gangrene can develop. Gangrene is a condition in which there is death of tissue.

Circulatory ulcers include:

• Venous ulcers (stasis ulcers) are open sores on the lower legs or feet caused by poor venous blood flow (Fig. 24-2). Stasis means stopped or slowed fluid flow. The heels and inner part of the ankles are common sites. They can occur from skin injury. Scratching and trauma are examples. Venous ulcers are painful. Infection is a risk. Healing is slow.

• Arterial ulcers are open wounds on the lower legs or feet caused by poor arterial blood flow. They are found between the toes, on top of the toes, and on the outer side of the ankle (Fig. 24-3).

• Diabetic foot ulcers are open wounds on the foot caused by complications from diabetes. Diabetes (Chapter 28) can affect the nerves and blood vessels. When nerves are affected, the person can lose complete or partial sensation in a foot or leg. The person may not feel pain, heat, or cold. When blood vessels are affected, blood flow decreases. Tissues and cells do not get needed oxygen and nutrients. Sores heal poorly. Common foot problems (Fig. 24-4) can cause infection and tissue death (gangrene). Sometimes the affected part must be amputated.

FIGURE 24-4 Foot problems common with diabetes.

Prevention and Treatment

Check the person’s feet and legs every day. Report any sign of a foot problem at once. You must help prevent skin breakdown on the legs and feet. Follow the care plan to prevent and treat circulatory ulcers (Box 24-2). The doctor orders drugs and treatments as needed.

Box 24-2 Preventing Circulatory Ulcers

• Remind the person not to sit with the legs crossed.

• Re-position the person according to the care plan—at least every 2 hours.

• Do not use elastic or rubber band–type garters to hold socks or hose in place.

• Do not dress the person in tight clothes.

• Provide good skin care daily. Keep the feet clean and dry. Clean and dry between the toes.

• Do not scrub or rub the skin during bathing and drying.

• Keep linens clean, dry, and wrinkle-free.

• Avoid injury to the legs and feet.

• Make sure shoes fit well.

• Keep pressure off the heels and other bony areas. Use pillows or other devices as directed.

• Check the person’s legs and feet. Report skin breaks or changes in skin color.

• Do not massage over pressure points (Chapter 25). Never rub or massage reddened areas.

• Use protective devices as directed.

• Follow the care plan for walking and exercises.

Persons at risk need professional foot care. You do not cut the toenails of persons with diseases affecting circulation.

Elastic Stockings.

Elastic stockings exert pressure on the veins. The pressure promotes venous blood return to the heart. The stockings help prevent blood clots in leg veins (thrombi). A blood clot is called a thrombus.

If blood flow is sluggish, blood clots (thrombi) may form in the deep veins in the lower leg or thigh (Fig. 24-5, A). A blood clot (thrombus) can break loose and travel through the bloodstream. It then becomes an embolus—a blood clot that travels through the vascular system until it lodges in a blood vessel (Fig. 24-5, B). An embolus from a vein lodges in the lungs (pulmonary embolism). A pulmonary embolism can cause severe respiratory problems and death. Report chest pain or shortness of breath at once.

FIGURE 24-5 A, A blood clot is attached to the wall of a vein. The *arrow* shows the direction of blood flow. B, Part of the thrombus breaks off and becomes an embolus. The embolus travels in the bloodstream until it lodges in a distant vessel.

Persons at risk for thrombi include those who:

• Have heart and circulatory disorders.

Elastic stockings also are called AE stockings (AE means anti-embolic or anti-emboli). They also are called TED hose (TED means thrombo-embolic disease).

The person usually has 2 pairs of stockings. Wash 1 pair while the other pair is worn. Wash them by hand with a mild soap. Hang them to dry.

See Delegation Guidelines: Elastic Stockings.

See Promoting Safety and Comfort: Elastic Stockings.

See procedure: Applying Elastic Stockings.

Delegation Guidelines

Elastic Stockings

To apply elastic stockings, you need this information from the nurse and the care plan.

• What size to use—small, medium, large, or extra-large

• What length to use—thigh-high or knee-high

• When to remove them and for how long—usually every 8 hours for 30 minutes

• What observations to report and record:

• The size and length of stockings applied

• When you applied the stockings

• Skin color and temperature

• Leg and foot swelling

• Skin tears, wounds, or signs of skin breakdown

• Complaints of pain, tingling, or numbness

• When you removed the stockings and for how long

• When you re-applied the stockings

• When you washed the stockings

• When to report observations

• What patient or resident concerns to report at once

Promoting Safety and Comfort

Elastic Stockings

Safety

Apply the stocking so the toe opening is over the top of the toes or under the toes. Follow the manufacturer’s instructions. Use the opening to check circulation, skin color, and skin temperature in the toes.

Stockings should not have twists, creases, or wrinkles after you apply them. Twists can affect circulation. So can stockings that roll or bunch up. Creases and wrinkles can cause skin breakdown.

Loose stockings do not promote venous blood return to the heart. Stockings that are too tight can affect circulation. Tell the nurse if the stockings are too loose or too tight.

Comfort

Apply stockings before the person gets out of bed. Otherwise the person’s legs can swell from sitting or standing. Stockings are hard to put on when the legs are swollen. The person lies in bed while they are off. This prevents the legs from swelling.

Gently handle and move the person’s foot and leg. Do not force the joints (toes, foot, ankle, knee, and hip) beyond their range of motion or to the point of pain.

Applying Elastic Stockings

Quality of Life

• Knock before entering the person’s room.

• Address the person by name.

• Introduce yourself by name and title.

• Explain the procedure before starting and during the procedure.

• Protect the person’s rights during the procedure.

• Handle the person gently during the procedure.

Pre-Procedure

1. Follow Delegation Guidelines:

a. Assisting With Wound Care, p. 381

b. Elastic Stockings

See Promoting Safety and Comfort: Elastic Stockings.

2. Practice hand hygiene.

3. Obtain elastic stockings in the correct size and length. Note the location of the toe opening.

4. Identify the person. Check the ID (identification) bracelet against the assignment sheet. Also call the person by name.

5. Provide for privacy.

6. Raise the bed for body mechanics. Bed rails are up if used.

Procedure

7. Lower the bed rail.

8. Position the person supine.

9. Expose the legs. Fan-fold top linens up toward the thighs.

10. Turn the stocking inside out down to the heel.

11. Slip the foot of the stocking over the toes, foot, and heel (Fig. 24-6, A). Make sure the heel pocket is properly positioned on the person’s heel. The toe opening is over or under the toes.