| 43
Pensar Enfermagem / v.27 n.01 / july 2023
DOI: 10.56732/pensarenf.v27i1.214
Review article
How to cite this article: Tavares A, Olivença L, Vilas Boas M. Cuidados de enfermagem na prevenção de
quebras de pele no idoso: revisão integrativa da literatura. Pensar Enf [Internet]. 2023 Jul; 27(1): 43-53.
Available from: https://doi.org/10.56732/pensarenf.v27i1.214
Nursing care in the prevention of skin tears in the
elderly: integrative review of the literature
Abstract
Introduction
Skin tears are considered injuries of traumatic etiology that can result from a variety of
mechanical forces, such as shear or friction forces, blunt trauma, falls, improper handling,
injury caused by equipment or removal of adherent dressings.
These are acute wounds that have a high probability of becoming complex chronic wounds.
They cause pain, increase healthcare costs, reduce quality of life and are a source of stress
for the person. They lengthen hospital stay and increase the risk of morbidities. Skin Tears
are a growing problem, making it crucial to invest in this topic in order to promote their
prevention and proper treatment.
Objective
To identify nursing care and strategies to prevent skin tears in the elderly.
Methods
A bibliographic survey of publications was carried out in the EBSCOhost search engine,
which incorporates the CINAHL Complete, MEDLINE Complete and Cochrane Database
of Systematic Reviews databases and in the PubMed database, carried out in June 2022. 26
records were returned, five meeting the inclusion criteria. The included studies (n=5) were
carried out between 2012 and 2022.
Results
In the sample of articles, it was possible to identify the benefits of twice-daily application of
topical products, moisturizing creams and emollients, and the relevance of oral
administration for 8 weeks of an oral nutritional supplement in the hydration of the stratum
corneum and in the elasticity of the skin, as well as the importance of primary prevention
and the promotion of health education in elderly skin care.
Conclusion
Preventive care to avoid skin tears in the elderly focuses on the daily topical application of
moisturizing creams and emollients, nutrition (administration of oral nutritional
supplements with 10g of collagen peptides) and adequate hydration; to prevent cutaneous
traumas by providing a safe environment with adequate devices, and through the promotion
of health education.
Keywords
Skin Tears; Prevention; Effectivity; Elderly; Health Care; Nursing Care.
Ana Carina Tavares1
orcid.org/0000-0003-4328-0957
Luísa Olivença2
orcid.org/0000-0002-8762-9148
Marisa Vilas Boas3
orcid.org/0000-0001-6690-0018
1 ACES Amadora / UCC Amadora+, Amadora,
Portugal.
2 Hospital das Forças Armadas Pólo de Lisboa /
Serviço Medicina Subaquática e Hiperbárica, Lisboa,
Portugal; Diaverun Portugal, Sintra, Portugal.
3 Hospital das Forças Armadas Pólo de Lisboa /
Departamento Cirúrgico Ala A, Lisboa, Portugal
Corresponding author
Ana Carina Tavares
E-mail: anacarinatavares@gmail.com
Received: 17.11.2022
Accepted: 03.05.2023
44 | Tavares, A.
Review article
Introduction
Ageing is characterized by natural, dynamic and progressive
decline in which morphological, physiological, biochemical
and psychological modifications occur, thus increasing the
vulnerability of the elderly and causing a greater occurrence
of pathological processes.
With advancing age, according to Papaléo,6 the skin tends to
become thinner and more flaccid. There is a decrease in the
thickness of the epidermis-dermis, in the size of the
keratinocytes, in cell proliferation in the stratum basale and
in structural and architectural alterations of the elastic fibers
that make the collagen system vulnerable to mechanical
forces. There is also a strong compromise of the collagen
metabolism, and consequently, the skin becomes less elastic
and thinner.
For Oriá et al.,7 the barrier function of the skin is also
affected. There is a decrease in the hydration of the stratum
corneum, a compromise of the sebaceous and sweat glands
and a decrease in the vascular bed along with the fragility of
the blood vessels. According to LeBlanc et al., 8 these
physiological changes that occur with ageing lead to an
increase in the occurrence of skin tears and, consequently,
to the compromise of the human body's homeostasis.
Skin tears are considered injuries of traumatic etiology that
can result from a variety of mechanical forces, such as shear
or friction forces, blunt trauma, falls, improper handling,
injury caused by equipment or removal of adherent
dressings. These may occur in any anatomical region, but are
more frequent in the extremities, particularly in the upper
limbs, where they occur 70 to 80% in the hands and
forearms.5,9,10
Skin tears are a problem with some prevalence in the elderly
and with a negative impact both on their quality of life and
on the increase in costs for the person and the health system.
It is therefore essential to address this subject and analyze
the scientific evidence, in national and international studies,
about nursing care in prevention for the elderly.
Considering the different professional contexts of the
reviewers, it was consensual that skin tears are increasingly
prevalent and transversal to distinct services, raising the
need to deepen the knowledge and improve the quality of
the nursing care provided, in order to prevent possible
complications.
The starting question for this study was: "What are the
nursing care practices in the prevention of skin tears in the
elderly?", where the general objective is to assess the state of
the art regarding the prevention of skin tears in the elderly.
As a specific objective we aim to identify nursing care
practices and strategies in the prevention of skin tears in the
elderly. This integrative review is divided into four parts: the
methodology, where a description of the research
elaboration method and a presentation of the flowchart of
the article selection process are carried out; the sample
results organized by the name of the article, year, objective,
sample, type of study, methodology and the main
conclusions; the discussion of the main results of the review
and the limitations of the study; the conclusion, which
includes the general interpretation of the results, their
relevance for clinical practice, implications for future
research and the strengths and limitations of the review.
Methods
According to Soares et al.11 a integrative literature review is
developed with the purpose of gathering and synthesizing
results from studies carried out using different
methodologies to deepen the knowledge on the chosen
subject.
Based on the starting question: "What are the nursing care
practices in the prevention of skin tears in the elderly?", a
search was conducted in the EBSCOhost search engine
integrating the CINAHL Complete, MEDLINE Complete
and Cochrane Database of Systematic Reviews databases
and in PubMed, to identify the articles on the subject, using
natural language words and terms indexed by the PEO
elements described, applying the Boolean operators "OR"
and "AND" and the use of truncations (see Table 1).
Pensar Enfermagem / v.27 n.01 / july 2023 | 45
DOI: 10.56732/pensarenf.v27i1.214
Review article
Table 1- OR and AND combination across the key concepts identified for the research strategy
AND
E - Exposure
AND
O - Outcomes
Skin Tears Prevention
Nursing Care
Prevent*
OR
Effectiv*
'Skin tears"
OR
"skin laceration"
"nursing care"
OR
'nursing strategies"
OR
"nursing tasks"
OR
nursing procedures"
OR
'nursing guidelines"
OR
"nursing involvement"
OR
"nursing activities"
OR
"Nurses's Role"
OR
'Nursing"
OR
"nursing interventions"
OR
"nursing instructions"
OR
'nursing recommendations"
"Health care"
All articles addressing the research question were
considered, in full text available for free online in the
databases used, published between 2012 and 2022, written
in Portuguese, English and Spanish, as these were the
languages mastered by the reviewers.
The age range was defined as the research inclusion
criterion: the elderly (over 65 years old) and without social
context, that is, people in an outpatient basis or admitted to
hospitals, day centers, convalescent units or other health
institutions were included.
From this search conducted in the aforementioned
databases in June 2022, the sum of twenty-six articles was
obtained, among which one was duplicate, twelve were
excluded by reading the title, five rejected by reading the
abstract and three eliminated by reading the full text. The
final result was the inclusion of five articles for review, after
their full reading, as explained in figure 1.
AND
OR
46 | Tavares, A.
Review article
Figure 1 - Flowchart of the article selection process after applying the inclusion criteria.
Pensar Enfermagem / v.27 n.01 / july 2023 | 47
DOI: 10.56732/pensarenf.v27i1.214
Review article
The search steps on the retrieved articles were carried out
independently by the three reviewers, to assess compliance
with the eligibility criteria for the present review. After this
first selection, the full texts (of potentially relevant evidence)
were extracted and assessed thoroughly in order to detect
any deviations from the inclusion criteria.
For an article to progress to the full reading stage, it was
necessary for at least two of the three reviewers to consider
it eligible.
Results
The sample results are presented in the table below,
organized by article name, year, objective, sample, type of
study, methodology and the main conclusions regarding the
final articles that were included in this integrative review.
Table 2 – Results of the final articles included in the integrative review
Article
name
Objective
Sample
Type of
Study
Methodology
Main conclusions
The effectiveness of a twice-daily skin-moisturizing regimen for reducing the incidence of skin tears; Carville K,
et al, 2014 4
To assess
the
effectivenes
s of a
standardize
d twice-
daily
hydration
regimen in
preventing
skin tears in
hospitalized
patients in
health
facilities.
980
hospitalized
patients in 14
Western
Australian
health
facilities
Cluster randomized controlled clinical trial
Elderly care facilities were divided into 7
pairs, defined by number of beds and
provision of high or low clinical care. One
healthcare unit from each matched pair
was randomized to the intervention group
and the other to the control group.
In the intervention group, the elderly
received a twice-daily application of a
standardized pH-neutral, perfume-free
moisturizer on the extremities of the body,
applied in a gentle, downwards direction.
The elderly in the control healthcare units
did not receive any standardized skin
hydration regimen.
SPSS, version 19 application software was
used to analyze the data collected over the
course of 6 months.
Applying moisturizer twice-daily, reduced the
incidence of skin tears in almost 50% of the users
living in the health facilities.
The highest percentage of skin tears on the
extremities of the lower limbs was observed in the
facilities with low clinical care.
The most dependent elderly showed skin tears at arm
level.
The main contributing factor to skin tears in both
groups was age-related skin fragility.
48 | Tavares, A.
Review article
Skin tear prevention in elderly patients using twice-daily moisturizer; Finch K, et al, 2018 12
To test the
efficacy of a
twice-daily
application
of
moisturizer
to the
extremities
of
hospitalized
elderly
patients
over a 12-
month
period
(January to
December
2013).
Included 762
eligible
patients in
the
intervention
group and
415 users in
the historical
control group
(over 65 years
old)
Prospective intervention study
The prospective intervention study was
conducted and compared with the results
of historical controls (study conducted
from July to December 2011, involving 415
patients, with a duration of 6 months).
Patients were admitted to a Brisbane
private hospital (45 beds in the
rehabilitation ward and 30 in the
acute/subacute ward).
The following exclusion criteria were
applied: patients who did not sign the
consent form; those who had a day
admission to the rehabilitation ward; those
deemed unsuitable by medical officer; and
those who could not apply the cream due
to medical conditions. Inclusion criteria:
patient's age; gender; inpatient ward;
pressure ulcer risk assessment (using the
Waterlow Scale); patient's risk of falls;
cognitive status; skin characteristics such as
dry or discolored skin; number of skin
lesions; day and time of skin tear
occurrence; anatomical location of skin
lesions; the STAR Skin Tear Classification;
factors that may have contributed to a skin
lesion (assessed by a team member after
discussion with the patient) and the
location of the ward where the skin lesion
happened. Patients in the intervention
group were subject to a twice-daily
application of a pH-neutral, non-perfumed
moisturizer on their arms and legs, while
users in the control group were not subject
to any cream application.
Monthly incidence rates of skin lesions
were calculated as number of skin
lesions/days of occupied beds and the
statistics were carried out with IBM SPSS
for Windows, Version 2.3.
Applying a pH-neutral, non-perfumed moisturizing
cream on a twice-daily basis reduced skin tears by
almost 50%. This frequency helps maintain skin
hydration and supports and repairs the skin's barrier
function, regardless of the healthcare facility.
It produces evidence to support the benefits of
applying twice-daily moisturizing cream to the
extremities of hospitalized elderly patients when the
goal is to reduce the incidence of skin tears.
This relatively low-cost intervention has the potential
to reduce healthcare costs and improve healthcare
outcomes.
Pensar Enfermagem / v.27 n.01 / july 2023 | 49
DOI: 10.56732/pensarenf.v27i1.214
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Effect of an Oral Nutrition Supplement Containing Collagen Peptides on Stratum Corneum Hydration and Skin Elasticity in
Hospitalized Older Adults: A Multicenter Open-label Randomized Controlled Study; Nomoto T, Iizaka S., 2020 13
To
investigat
e the
effect of
the oral
administr
ation of a
nutritiona
l
suppleme
nt
containin
g collagen
peptides
on
stratum
corneum
hydration
.
39 inpatients 65
years or older
Open-label randomized controlled study
A multicenter, open-label, randomized
controlled study was conducted to
examine the effect of 8-week oral
administration of an oral nutrition
supplement, containing 10g of collagen
peptides on stratum corneum
hydration and skin elasticity in 39
elderly inpatients in convalescent
rehabilitation wards.
Comparison with residents in the
control group.
IBM Statistical Package for the Social
Sciences (SPSS) version 19 was used to
analyze the data.
Oral nutritional supplements containing collagen
peptides can reduce skin vulnerability in the elderly and
thus helping to prevent problems such as skin tears
After 8 weeks, stratum corneum hydration and skin
elasticity were significantly higher in the intervention
group that consumed oral nutritional supplements than
in the control group that did not. This indicates that oral
nutritional supplements containing collagen peptides can
reduce the vulnerability of the skin of the elderly, helping
to prevent problems such as skin tears.
The mechanisms of such improvements are unknown,
but the intake of collagen peptides contained in oral
nutritional supplements may stimulate the growth of skin
fibroblasts and the synthesis of hyaluronic acid.
50 | Tavares, A.
Review article
Skin Tear in the Elderly; Spin M, e et al ; 2021 14
To identify, in the
scientific literature, the
knowledge produced
about skin tears in the
elderly.
Eight articles were
selected, grouped
into qualitative and
quantitative
categories, and
categorized into
themes, according
to the similarity of
the conclusions of
the analyzed
studies.
Integrative literature review
Research was carried out
on the
platforms/databases
National Library of
Medicine, Biomedical
Answers Virtual Health
Library, with descriptors
and the Boolean
operators "and" and "or"
between the years 2014
and 2019, using the
following inclusion
criteria: full articles made
available free of charge
and in full in Portuguese,
English and/or Spanish.
The research question
was defined based on
the PICO strategy.
Patients who presented malnutrition, hydration and low levels of
serum albumin, were more prone to the appearance of skin tears.
Activities performed during daily care can halve the incidence of
skin tears, (the use of topical skin products such as hypoallergenic
moisturizers based on lactic acid or urea twice-daily).
For bathing, the use of soaps can affect the physiological
characteristics of the skin and make it prone to the appearance of
tears. The use of alkaline, antibacterial, or perfumed soaps can
alter the skin’s microbiome, so it is recommended to replace them
with pH-neutral soaps, to use lukewarm water and to reduce the
duration and frequency of the bath (bathing every two days is
recommended).
For the prevention of skin tears in the elderly emerged the
following pillars of care:
• maintaining organic and tissue homeostasis with a focus
on proper nutrition and hydration;
• avoiding trauma to fragile skin, providing a safe
environment with suitable devices;
• systematization of health care and education for elderly
skin care.
• prevention mechanisms that encompass primary
prevention through a unique care plan and healthcare
education activities, focused on risk factors and
vulnerabilities, minimizing damage and complications.
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Preventing skin tears among older adults in the community; Palmer SJ, 2021 15
Preventing skin tears
among the elderly in the
community - guidance
from 2018 from
Wounds UK and
Wounds International.
Not applicable
Expert opinion
Not applicable
The prevention of skin tears should focus on the risk factors for the
person with skin tears.
Emollient therapy promotes general skin health and twice-daily
application reduces the incidence of skin tears by 50%.
The bath should be carried out with emollient and pH-balanced
products when necessary. Frequency of bathing should be
minimized. The water temperature should not be too hot, so as not
to damage the epidermis, and care should be taken to dry the
patient's skin (not rub), with the use of soft cloths and towels that
are not abrasive on the skin.
The skin tear prevention regimen should also involve holistic
elements that consider the patient's general health, adequate
nutrition and hydration, and polypharmacy.
Educating the patient about preventive measures and general skin
health can be beneficial, so that they can monitor their own skin for
changes. Patients can also be encouraged to be aware of potential
risks and attentive to their environment, therefore avoiding self-
injury to fragile skin.
A self-care checklist can be provided to patients who are able to
comprehend and use it, so that they can monitor their own skin
health and wellbeing.
The risk of trauma can be mitigated with a few considerations: avoid
friction and shearing, and perform good manual handling
techniques, resorting to equipment when necessary. Equipment with
sharp and moving surfaces can be padded to provide a safe
environment, as well as proper and unobstructed lighting.
Education and awareness are vital, both for the patient and for the
health professional, to minimize the risk of skin tears.
Discussion
The discussion of results aims to provide the most relevant,
current and credible information obtained by reading the
entire sample, in order to answer our starting question:
“What are the nursing care practices in the prevention of
skin tears in the elderly?”
The sample consists of articles from different types of
studies, namely: prospective intervention; cluster-
randomized controlled clinical trial; multicenter, open-label
and randomized controlled study; integrative literature
review; and expert opinion article.
Of the final studies: two assessed the benefits of applying
topical products, moisturizing and emollient creams;
another about the effect of oral administration of a
nutritional supplement for 8 weeks on stratum corneum
hydration and skin elasticity; the integrative review identified
in scientific literature the knowledge produced on the
prevention of skin tears in the elderly; and finally, an expert
opinion article addressed the prevention of skin tears among
the elderly in the community.
Studies that have evaluated the benefits of using topical
preparations show that the incidence of skin tears in the
elderly has decreased dramatically, regardless of the place of
hospitalization.4,12 It is important to emphasize that the
studies applied the topical preparations to the upper and
lower limbs, since skin tears are more likely to occur at these
anatomical sites.
The study by Finch et al.12 showed that applying moisturizer
twice-daily in a sample of 762 users reduced skin tears by
almost 50%, highlighting the benefits associated with
applying it regardless of the healthcare setting.
Carville et al.4 found that in a sample of 980 elderly people
in 14 residential facilities in Western Australia, over a six-
month period, a gentle, downwards application on the upper
and lower limbs twice-daily of a standardized, pH-neutral,
perfume-free moisturizer reduced the incidence of skin tears
by almost 50% in the elderly. The highest percentage of skin
tears on the extremities of the lower limbs was observed in
the facilities with low clinical care. The most dependent
elderly showed a higher percentage of skin tears at arm level.
The use of topical skin products, such as hypoallergenic
moisturizers based on lactic acid or urea, twice-daily can
52 | Tavares, A.
Review article
halve the incidence of skin lesions, and the use of alkaline,
antibacterial or perfumed soaps can alter skin’s microbiome,
so it is recommended to replace them with pH-neutral
soaps, to use of lukewarm water and to reduce the duration
and frequency of the bath, (bathing every two days is
recommended), advocated by Spin et al..14
This conclusion is also reached in Palmer's15 article, stating
that emollient therapy promotes general skin health and
twice-daily application reduces the incidence of skin tears by
50%. The frequency of bathing should be minimized and
only performed when necessary, with the use of pH
balanced emollient products. The water temperature should
not be too hot, so as not to damage the epidermis, and care
should be taken to dry the skin of the patient (not rub), with
the use of soft cloths and towels that are not abrasive on the
skin.
According to Palmer,15 the prevention of skin tears should
involve holistic elements that consider the patient's general
health, proper nutrition and hydration.
Advising the patient about skin tears and preventive
measures can be beneficial so that patients are able to
monitor changes in their own skin and avoid self-injury to
fragile skin.
The risk of potential trauma can be mitigated with a few
considerations: avoiding friction and shearing, good manual
handling techniques resorting to devices such as hoists and
transfers; equipment and furniture should be padded; and
ensuring a safe environment (for example, with proper and
unobstructed lighting).
Nomoto & Iizaka's13 study, concludes that administering
oral nutritional supplements containing collagen peptides
for 8 weeks can reduce skin vulnerability among the elderly
and thus prevent skin tears. The mechanisms of such
improvements are unknown, but the intake of collagen
peptides contained in oral nutritional supplements may
stimulate the growth of skin fibroblasts and the synthesis of
hyaluronic acid.
Spin et al.,14 state that patients who present malnutrition,
dehydration, and low levels of serum albumin are more
prone to the appearance of lesions, as the body mass index
contributes to the premature ageing of the skin.
Therefore, and according to Spin et al.,14 for the prevention
of skin tears in the elderly emerged four pillars of care:
▫ maintaining organic and tissue homeostasis with a focus
on proper nutrition and hydration;
▫ avoiding trauma to aging skin, providing a safe
environment with suitable devices;
▫ systematization of health care and education for elderly
skin care.
prevention mechanisms that encompass a unique care plan
and healthcare education activities, focused on risk factors
and vulnerabilities, minimizing damage and complications.
Education and awareness are vital, both for the patient and
for the health professional, to minimize the risk of skin
tears.
Conclusion
The development of this integrative literature review
allowed us to obtain some answers to the initially proposed
PEO question.
From the analysis of the articles, which were part of the
sample, we conclude that there is a relationship between the
topical application of skin care products, such as
moisturizing creams and emollients, and the reduction in the
prevalence of developing skin tears, by about 50%.
Though the study had a small sample size, it showed that
administering oral nutritional supplements with 10g
collagen peptides can reduce skin vulnerability among the
elderly and thus prevent skin tears.
Primary prevention and the promotion of healthcare
education for elderly skin care play a critical role in
preventing skin tears in this age group. The holistic view
towards the person with skin tears, promotion of skin care,
hygiene care management, a safe environment and a
balanced diet are pivotal to the prevention of skin tears in
the elderly regardless of whether they are in a home or
institutional setting.
After the systematic literature review, the scarcity of studies
to support nursing care in the prevention of skin tears in the
elderly was evident.
Considering that skin tears are painful, affect the quality of
life of the person with the injury and the caregivers, can be
a source of infection and cause burdens for the
person/family and the health system, further studies on this
issue are essential in the future.
This study, for the health professionals who carried it out,
was enriching in the sense that knowledge was obtained
about the benefits applying of skin care products, such as
moisturizing and emollient creams (mainly by following a
twice-daily application), serving as a basis for the
development of technical guidance in their respective health
facilities.
As nurses, we have the responsibility to educate families and
caregivers, as well as health operational technicians, on the
prevention of skin tears. This study will serve as a basis for
the development of future in-service training on the subject,
targeting health professionals from the multidisciplinary
team and/or informal caregivers.
With low-cost, easy to apply care, we can reduce the
incidence of skin tears by about 50%, increase the quality of
life of individuals, and reduce the burden of this type of
tissue damage on the health system and patients/families.
Authors’ contributions
ACCT: Elaboration of the article, from data collection,
analysis and interpretation of data, writing of the work and
revision of the article.
LMSCO: Elaboration of the article, from data collection,
analysis and interpretation of data, writing of the work and
revision of the article.
MIRVB: Elaboration of the article, from data collection,
analysis and interpretation of data, writing of the work and
revision of the article.
Pensar Enfermagem / v.27 n.01 / july 2023 | 53
DOI: 10.56732/pensarenf.v27i1.214
Review article
Conflicts of interests
No conflict of interest declared by the authors.
Change history
In 8th of May 2024, a correction to this paper has been
published: https://doi.org/10.56732/pensarenf.v28i1.327.
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