Friction, Skin Tears, and Medical Adhesive Related Skin Injury (MARSI)
Skin and Wound Care. Produced by the Emory Nursing Wound Ostomy Continence Nursing Education Center.
Transcript
In this class we're going to talk about wound caused by external factors, essentially mechanical factors like friction, moisture, pressure and shear.
Speaker A:It's a lot of content, but we've broken it up into distinct parts so you'll be able to take one bite at a time.
Speaker A:So looking at our objectives, this is for the lesson as a whole.
Speaker A:You should be able to discuss each of the following in terms of pathology, risk factors, characteristics and preventive measures.
Speaker A:Friction skin tears, medical adhesive related skin injury, moisture associated skin damage and pressure shear injury.
Speaker A:We will discuss the concept of top down versus bottom up injury.
Speaker A:We'll talk about normal and abnormal responses of the tissue to a SK and associated clinical indicators.
Speaker A:We'll identify components of an agency wide program for pressure injury prevention.
Speaker A:We'll discuss use of a research based risk assessment tool for identification of patients at risk for pressure injury.
Speaker A:We will hopefully prepare you to develop an individualized pressure injury prevention program for specific patients.
Speaker A:And we'll describe each of the following and implications for selection of an appropriate support surface for an individual patient.
Speaker A:We'll talk about constant low pressure pressure redistribution surfaces, alternating pressure surfaces, low air load surfaces, air fluidized surfaces, continuous lateral rotation surfaces and bariatric surfaces.
Speaker A:Aren't you glad you get to take it one bite at a time?
Speaker A:So here are the video lessons.
Speaker A:The first one will be on friction skin tears and medical adhesive related skin injury.
Speaker A:The second will be on moisture associated skin damage.
Speaker A:The third one will be on pressure shear injuries.
Speaker A:The fourth one will be on pressure injury prevention general concepts.
Speaker A:And the last one will be on pressure injury prevention specifically focused on support surfaces.
Speaker A:There are a lot of online self study learning exercises to make sure you get the critical concepts.
Speaker A:And optional reading includes chapters 16 through 20 in the core curriculum.
Speaker A:Now you're probably tired, but the first bite's a pretty small one, so hang in there.
Speaker A:We're going to talk about causes related to top down injury, friction skin tears and medical adhesive related skin injury.
Speaker A:So friction injuries, what are those?
Speaker A:Well, it's mechanical disruption of superficial skin layers.
Speaker A:I want you to think of it as sanding effects.
Speaker A:So you think if you were refinishing a piece of furniture and you used sandpaper and you would be taking off the finish, the existing finish, one layer at a time.
Speaker A:And that's essentially what happens with friction injuries.
Speaker A:You disrupt the skin surface one layer at a time.
Speaker A:And it occurs when people are rubbing against like a restraint, scrubbing around in the bed, sliding down, being pulled back up.
Speaker A:It can also happen when someone is say drug against a Surface, like in a motor vehicle accident or a motorcycle accident, they come in with road rash and they've got loss of the top layer of skin.
Speaker A:So think of it as a rubbing, dragging injury against the skin.
Speaker A:You get mechanical removal of the skin cells one layer at a time, kind of a dermabrasion effect.
Speaker A:But you also, in response to the damage to the skin, you get an inflammatory response so many times around the wound itself, you'll see evidence of inflammation, you'll see generalized erythema.
Speaker A:You want to realize that patients who have thin skin are much more vulnerable to any kind of surface effect, to any kind of sanding effect.
Speaker A:Also remember that if the skin is over hydrated, macerated, it becomes much more vulnerable when the skin is over hydrated.
Speaker A:Remember that the cell's membrane is stretched because the skin cell is swollen.
Speaker A:So the membrane is stretched and minor trauma can cause disruption of cell membranes, loss of skin cells, loss of skin layers.
Speaker A:This is classified as a top down injury because it literally stop, starts at the skin surface, then takes on the next layer of skin cells, then the next layer of skin cells.
Speaker A:So first you lose the epidermis, then with continued injury, the damage can extend into the dermis.
Speaker A:So clinically what we see is very superficial skin loss.
Speaker A:You don't have crater formation.
Speaker A:There's no significant wound depth.
Speaker A:It literally is an abrasion.
Speaker A:So you've taken off the top layer of skin very frequently.
Speaker A:There will be irregular edges, sometimes there's blister formation.
Speaker A:So just what you see here on this slide, you see the abrasion, you see a blister.
Speaker A:Probably all of you have had blisters when you wore new shoes that were too tight and it kept rubbing up and down on your heel, up and down on your heel, up and down on your heel, until finally you had a blister that then opened to reveal this very surface, painful wound.
Speaker A:And that's the next point.
Speaker A:These wounds are very tender, they're very painful because when you take off, take off the top layers of skin, you expose nerve endings so many times.
Speaker A:These very surface wounds are more painful to the patient than big, deep wounds because of all of the exposed nerve endings.
Speaker A:Typically, the wound bed will be pink red or pink white.
Speaker A:If the damage is confined to the epidermis, it's going to be pink red.
Speaker A:If it extends down into the dermis.
Speaker A:Remember, there's a lot of collagen in the dermis.
Speaker A:Collagen is white.
Speaker A:So if it extends into the dermis, it'll be pink white.
Speaker A:Also, I want you to look at the illustration at the bottom right hand side of this slide, you have some patients who are exposed to chronic friction.
Speaker A:This happens a lot in patients like, who sit in recliners all the time.
Speaker A:And so there's one area that's just exposed to rubbing over and over and over.
Speaker A:And then you get a combination of little patchy areas of surface skin loss and overall thickening of the skin.
Speaker A:That thickening of the skin is known as lecinification.
Speaker A:So you can see in that slide on the bottom right, you can see the thickening of the skin and you can also see little patchy areas of skin loss.
Speaker A:That's chronic friction injury.
Speaker A:The others are acute.
Speaker A:Well, how do you prevent friction injury?
Speaker A:Goes back to some of the things we talked about earlier.
Speaker A:In terms of general skincare, you want to make sure that we are providing gentle skincare, that we're using soft cloths, not abrasive cloths.
Speaker A:That's particularly important when you're caring for a patient who's either very young or very old or a patient who is very fragile, with obviously fragile skin.
Speaker A:Your malnourished patient, your patient on steroids.
Speaker A:Particular caution is indicated when you're providing hygienic care and handling for those patients.
Speaker A:If you have a patient who's very high risk for a friction injury, it can be helpful to put them on a low friction support surface.
Speaker A:One of the good things that's happened over the past couple of decades is that standard hospital mattresses have been reengineered so that currently our mattresses provide a combination of even support and low friction, low shear surfaces.
Speaker A:So even if you have a patient who's agitated kind of thrashing around in bed, or constantly sliding down and then pulling themselves up, or sliding down and being pulled up by the staff, because the underlying surface is very slick, there's minimal friction damage to the skin surface.
Speaker A:So the support surfaces that you probably have on every bed, your agency, is one of your tools in friction prevention.
Speaker A:And it's because it's slick and doesn't create that sanding effect, doesn't drag against the skin surface.
Speaker A:Heels are very prone to friction injuries.
Speaker A:If you're ambulatory, it's typically because you have poorly fitted shoes.
Speaker A:But in the hospital, it's usually because people are kicking around in bed using their heels to push up in bed.
Speaker A:The best protection against friction injuries to the heel is the same thing as the best protection against pressure injuries to the heel, and that is get the heels off the bed.
Speaker A:So wherever you work, I am betting that you have access to a heel elevation device, a heel boot that lifts the heel off the bed so you don't get friction damage and you don't get pressure damage.
Speaker A:I want to take a minute to differentiate between heel elevation devices and heel protectors.
Speaker A:So heel elevation devices are also known as heel offloading devices.
Speaker A:Those are the devices that lift the heel off the bed.
Speaker A:So they're some kind of boot.
Speaker A:They have a little cupped area for the heel so the heel is not dragging against the underlying surface.
Speaker A:It's not sitting on the underlying surface.
Speaker A:In contrast, heel protectors are typically quilted things that fit around the heel, or sometimes foam things that fit around the heel.
Speaker A:That kind of cushion the heel, but do not protect it from friction and do not provide adequate protection against pressure.
Speaker A:So current guidelines are to use heal elevation devices rather than heal protectors.
Speaker A:Hopefully, what you have in stock in your setting are heal elevation devices.
Speaker A:If not, that's something you need to look at.
Speaker A:And finally, if you have an area that is frequently exposed to friction, it can be very helpful to apply a protective dress.
Speaker A:For example, a lot of you are now routinely using your silicone adhesive foam dressings to the sacrococcygeal area as part of your pressure injury prevention protocol.
Speaker A:What do those dressings do?
Speaker A:Because they're adherent across the entire surface of the dressing, they actually act like additional layers of skin.
Speaker A:The outer layer is very slick, so it minimizes friction damage because it doesn't drag against the underlying surface.
Speaker A:You can also use protective dressings to elbows.
Speaker A:You can use protective dressings to heels.
Speaker A:So if you have an area that is at risk for friction damage, think about using protective dressings.
Speaker A:I sometimes come into our ICUs, and when we have a very restless patient, I might find multiple silicone adhesive foam dressings to all of the sites where the staff's concerned that they might develop a friction injury or a pressure injury.
Speaker A:And it's a very valid intervention.
Speaker A:What if you already have a friction injury?
Speaker A:So maybe the patient comes in and they were in a motor vehicle accident or a motorcycle accident, they've been drug across the pavement or you're consulted.
Speaker A:They had to use soft restraints, and now the patient has friction abrasions around the wrist or it's on the heels.
Speaker A:They've developed some friction damage on the heels from constantly kicking against the underlying surface.
Speaker A:Now your goals are to manage any drainage, keep the surface itself moist, and protect against further trauma.
Speaker A:Now, you see, I've listed, or we have listed some of the commonly used dressings, but I Want to assure you if wound care is new to you and all of these dressings sound like Greek, it is not a problem.
Speaker A:We are going to talk about them in detail.
Speaker A:Right now I want you to focus on what are you trying to do.
Speaker A:You're trying to protect against further trauma, you're trying to manage any drainage and you're trying to keep the wound surface itself moist.
Speaker A:Now things you could use, you could use your non adherent dressings either like your Vaseline gauze, your oil and emulsion gauze, your Xeriform gauze.
Speaker A:You could use a silicone adhesive contact layer or a silicone adhesive foam dressing.
Speaker A:Silicone adhesive foam dressing is very widely used because they manage exudate, they maintain a moist surface and they protect against further friction.
Speaker A:What if it's in the perineal area?
Speaker A:Then you might use a zinc oxide based moisture barrier ointment.
Speaker A:That would be appropriate.
Speaker A:Again, I don't want you to get lost in this.
Speaker A:We're going to come back to this and we're going to discuss it in detail.
Speaker A:I want you to stay prevention focused, big picture focused.
Speaker A:So we've talked about friction damage.
Speaker A:Another type of top down mechanical damage are skin tears.
Speaker A:Whatever care setting you're in, I am betting that you see a number of patients with skin tears.
Speaker A:And you know what they are.
Speaker A:It literally is when the skin is torn away.
Speaker A:So you get traumatic separation between the epidermal and dermal layers or occasionally between the dermal layer and the sub Q tissue.
Speaker A:More commonly it's epidermis torn off of dermis.
Speaker A:But occasionally you will see dermis torn off of subcu.
Speaker A:Very common at extremes of age in your neonatal population, in your elderly population.
Speaker A:Why we talked about this, Remember that what protects most of us against skin tears is that interlocking configuration between the epidermis, dermis and the dermis.
Speaker A:In the infant population, that interlocking configuration is incompletely developed.
Speaker A:In the elderly, it's lost.
Speaker A:No matter whether it's incompletely developed or lost, the end result is tissue layers that move against each other with very minor trauma.
Speaker A:And so it's very easy to tear epidermis from dermis or occasionally can get dermis from subcube.
Speaker A:And that's why it says partial versus full thickness.
Speaker A:This is a term we haven't used yet, but we will use it a lot more when we talk about wound healing.
Speaker A:So what do we mean when we say a wound is partial thickness?
Speaker A:It's actually a term coined by dermatology and burn physicians.
Speaker A:Partial Thickness means you've lost part of the skin layers, but not all.
Speaker A:So by definition, a partial thickness skin tear means you've torn epidermis from dermis.
Speaker A:A full thickness skin tear means you have lost all of the skin layers and it would mean you have pulled APIs off of subcube.
Speaker A:The vast majority of skin tears are partial thickness.
Speaker A:Now, for many years we just call them skin tears or we try to describe them, but now we have an official classification that's been developed by the International Skin Care Advisory Panel, the istap three types of skin tears and their classification system makes so much sense from a management perspective.
Speaker A:If you have a type 1 skin tear like you see on top, it means that you have no loss of skin.
Speaker A:The edges can be completely reapproximate.
Speaker A:It might be a linear tear or it might be a flap tear, but any flap remains viable and you can easily roll it back into position so you end up with no open wound, just a fragile skin flap.
Speaker A:Type 2 is a partial skin loss.
Speaker A:So you can see you've got a flap, it was rolled back into position, but it did not complete completely cover the injury.
Speaker A:So you have partial wound exposure, partial flap loss, you have an open wound and then type 3, there's total flap loss.
Speaker A:So sometimes you might have a patient with a skin tear, they have a flap, the flap is still there, but this flap is non viable.
Speaker A:If it's non viable, you have to trim it away and then that can converts that skin tear to a type three.
Speaker A:So type one, there's no exposed open wound, the skin tear is completely covered by the re approximated flap.
Speaker A:Type 2, there's partial skin and flap loss.
Speaker A:So you do have an open wound, it's not extensive, but there is an open area, type 3, total skin or flap loss and a large open wound.
Speaker A:Who's at risk?
Speaker A:Well, we've already talked about some of this.
Speaker A:Patients at the extremes of age.
Speaker A:We explained why patients who are critically ill or chronically ill simply because their skin becomes much more fragile, much more vulnerable.
Speaker A:Any patient who is dependent on others for daily care.
Speaker A:So if this patient requires someone else to come in, move them, help them get out of bed, help them bathe, help them dress, think about all of the handling that is done and bathing the patient, dressing the patient, getting the patient up on the side of the bed, getting a patient out of bed, when we're handling patients, then we are at risk for causing skin tears because these are people with fragile skin.
Speaker A:So I might just be trying to help you out of bed.
Speaker A:But I might create a skin tear.
Speaker A:I might just be trying to start an iv, but I might create a skin tear.
Speaker A:The last one is patients who have purpuric lesions.
Speaker A:Remember how we talked about the fact that with aging, it's very common to see those big purple areas, those purpuric lesions.
Speaker A:When you see those, you know that your vessels in your skin is very fragile, because pipuric lesions are caused by vessel disruption and bleeding under the skin.
Speaker A:So anytime you have pipuric lesions, you have more vulnerable skin and it's very easy to create a skin tear.
Speaker A:So just remember your risk factors so that you're very aware when you're caring for an at risk patient.
Speaker A:Risk factors mean I'm more likely to get a skin tear.
Speaker A:Causative factors as what actually does the damage.
Speaker A:So many times it's a wheelchair injury.
Speaker A:So many times when you have a skin tear on the lower extremity or the thigh, they'll say, I bumped my wheelchair or my caregiver bumped my leg against the wheelchair.
Speaker A:Getting me in bed rails can be a huge problem.
Speaker A:So sometimes we need to pad the bed rails, especially if someone's agitated and hitting against the bed rails.
Speaker A:Sometimes it's staph induced if we use inappropriate adhesive products or we take them off incorrectly.
Speaker A:And we'll come back to that a little bit later.
Speaker A:So how can we minimize tape damage to fragile skin, recognizing that adhesives are one of the causative factors?
Speaker A:First of all, whenever possible, and you'll keep hearing us say this, we should be using gentle tapes.
Speaker A:So I know sometimes when I go into the supply room and I'm looking for tape, I'm tempted to grab the first one I see.
Speaker A:But I should be thinking, which type of tape is most appropriate for this patient and for an infant, for an elderly patient, for a critically or chronically ill patient, for a patient with obviously thin skin or purpuric lesions, whenever possible, I should be reaching for paper tape or silicone tape because they're much gentler and much easier to remove.
Speaker A:Your fabric tapes like Medipor Primipor can also be appropriate for people with fragile skin.
Speaker A:But what if this is a critically important device?
Speaker A:What if it's a critical cannula?
Speaker A:What if it's a critical device for monitoring arterial pressures?
Speaker A:What if I'm securing an endotracheal tube?
Speaker A:Then you're going to have to use a more aggressive adhesive.
Speaker A:But you should always put that aggressive adhesive against a thin hydrocolloid, something to protect the skin.
Speaker A:You'll see respiratory therapy doing this a lot.
Speaker A:So that when they have to fit a patient for a non rebreathing mask or whatever, a positive pressure device, that they will put down hydrocolloid across the bridge of nose, across the cheeks, so that there's protection.
Speaker A:We can do the same thing under tape.
Speaker A:So a thin hydrocolloid dressing as a base if we have to use a more aggressive tape.
Speaker A:Secondly, we're always trying to keep the skin soft and supple.
Speaker A:So you go back to what you see on the top.
Speaker A:If you look to the far left, that's normal skin with normal concentrations of skin lipids, especially ceramides.
Speaker A:Look how plentiful they are.
Speaker A:Those ceramides give that skin elasticity, make it much more supple and more able to withstand minor mechanical trauma.
Speaker A:Look at the next one down where you have dry skin.
Speaker A:You see there's a marked drop off in the ceramides.
Speaker A:Now you have skin that's more vulnerable.
Speaker A:Look at what you see in damaged skin.
Speaker A:So again, if we routinely provide skincare that replaces lost lipids, we help to keep the skin soft, supple and resistant.
Speaker A:And that has been shown long term care facilities to make a huge difference in the instance of skin tear.
Speaker A:So you want to incorporate that into routine care.
Speaker A:It's usually trauma that actually causes the skin tear.
Speaker A:So what can we do?
Speaker A:We want to minimize any kind of mechanical trauma.
Speaker A:We want to be very careful when we get the patient in and out of a wheelchair.
Speaker A:We want to pad side rails, pad any areas of the wheelchair that might be causing damage.
Speaker A:And finally, of course, just making everybody alert to gentle skin tearing.
Speaker A:Skin care, not skin care.
Speaker A:Gentle skin care.
Speaker A:Gentle handling sleeves can be helpful.
Speaker A:So a lot of you have commercial sleeves in your agency that you can put on patients who are at risk for skin tears.
Speaker A:It really does two things.
Speaker A:It provides a layer of protection, but it also alerts me, the caregiver, that this patient's at risk and I need to be very gentle in handling this patient if you don't have them.
Speaker A:If you're in a home care setting, people can make little arm sleeves.
Speaker A:They can take knee socks and cut little thumb holes so that they have protection.
Speaker A:You can even wrap the arms with a soft gauze wrap like cling.
Speaker A:Anything you can do to help protect areas that are very high risk for skin tears.
Speaker A:How do you manage skin tears once they occur?
Speaker A:Because that's typically when you get consulted, you usually don't get consulted for prevention.
Speaker A:You can help write the protocols for prevention.
Speaker A:You get Consulted for a skin teacher that has occurred.
Speaker A:So routinely you're going to cleanse with normal saline.
Speaker A:You're going to roll the flap into position and see how much of the underlying wound can be covered with viable skin.
Speaker A:Why are we covering it with viable skin?
Speaker A:Because that is the best dressing you can find.
Speaker A:If you can cover the wound with skin, you cannot get a better dressing.
Speaker A:Now, in the past, we used to say that you should secure the flap with Steri strips, but Steri strips are fairly aggressive adhesive, and the most recent guidelines specifically state that Steri strips are not recommended for stabilizing the skin flap.
Speaker A:So roll it back in place and you can use your gentle adhesive contact layer dressings to secure it or your things like Vaseline gauze or whatever, but probably move away from Steri strips and anything with aggressive adhesion.
Speaker A:So once you get it rolled back into place, everything's cleaned, everything's rolled back into place, then you're going to cover it either with a non adherent.
Speaker A:There you go with your Vaseline gauze, adaptic seriform gauze, your silicone adhesive contact layer or a gentle adhesive foam.
Speaker A:Now types two and three.
Speaker A:These are the ones with partial flap loss or total flap loss.
Speaker A:So you have some degree of an open wound.
Speaker A:So that means you're going to have exudate.
Speaker A:So you're going to manage your exudate.
Speaker A:You're going to keep the wound surface itself moist to promote healing.
Speaker A:You're going to make sure that any dressing you remove or any dressing you use will not cause trauma with removal.
Speaker A:So there's specific guidance against using transparent adhesive dressings like tegaderminoxide because they cause a lot of trauma with removal and they don't handle exudate.
Speaker A:There's specific guidance against using hydrocolloid dressings because they manage only minimal amounts of exudate and they cause very traumatic removal.
Speaker A:So you should be looking at something that will provide exudate management, a moist wound surface, atraumatic removal.
Speaker A:It's going to come back to the same thing.
Speaker A:So could you use Vaseline gauze, adaptive Xeriform or one of your silicone adhesive contact layers, cover it with gauze, secure with wrapped gauze and change daily or as indicated?
Speaker A:Yes, you could do that.
Speaker A:That would be appropriate.
Speaker A:Any of those stressing combinations provide for exudate management help to keep the wound surface moist and provide a traumatic removal as long as you change at an appropriate frequency.
Speaker A:Could you also use a gentle adhesive foam dressing?
Speaker A:That would mean eject, keep the wound surface moist and provide a traumatic removal.
Speaker A:Yes.
Speaker A:So don't get lost in the topical therapy.
Speaker A:I'm trying to provide you with general concepts and big picture options.
Speaker A:The third thing we're going to talk about in this part of this lesson is medical adhesive related skin injury, which is now its own classification.
Speaker A:It's known as MARCI for short.
Speaker A:It's defined as erythema or other indications of skin damage that persist more than 30 minutes following removal of an adhesive product.
Speaker A:Now, the most common type of medical adhesive related skin injury, mechanical disruption of the skin, where you really peeled off the skin.
Speaker A:So you hear this called tape stripping or a tape blister, very commonly seen.
Speaker A:You might also see a contact dermatitis.
Speaker A:You might also see maceration.
Speaker A:But our focus is primarily going to be on mechanical disruption of the sk, the skin stripping, because that's what's most commonly seen.
Speaker A:Now look at these risk factors and see how much these risk factors remind you of the risk factors for skin tears.
Speaker A:And remember, both of these are traumatic damage to the skin, starting top down.
Speaker A:So it's not surprising that the risk factors for MARSI and the risk factors for skin tears are very much the same.
Speaker A:The extremes of age, very fragile skin intervention, intense care areas like the intensive care unit, the emergency department, the operating room, simply because there are many adhesive products applied in those areas.
Speaker A:Patients with fragile skin, so people who are malnourished, patients who have dermatologic conditions, patients on steroids, again, extremes of age, and patients who are on cytotoxic therapy like chemo or radiation.
Speaker A:All of those patients very, very high risk for tape damage.
Speaker A:So MARSI is the big term.
Speaker A:Tape damage is the abbreviation.
Speaker A:We want to prevent tape damage, we want to prevent Marcy.
Speaker A:We want to prevent anything that can be prevented.
Speaker A:And there's a lot we can do.
Speaker A:We now have many options for adhesive products.
Speaker A:So we can say to a patient, are there tapes to which you're sensitive?
Speaker A:How many of your patients will tell you, oh, don't put that on me, I break out every time, or that pulls my skin off every time, or that kills me when you take that off.
Speaker A:So I have patients who tell me, you can use paper tape or you can use that kind of cloth back tape that you tear off, but don't use silk tape, don't use that plastic tape, don't use that adhesive tape.
Speaker A:So pay attention.
Speaker A:What does your patient tell you?
Speaker A:Which products have caused some problems in the past.
Speaker A:When possible, use non adhesive securement Options.
Speaker A:So if you have a patient with extremely fragile skin and you're looking to secure an IV line, can you maybe use one small transparent adhesive dressing with the antimicrobial disc and then secure the site and the tubing with wrap gauze?
Speaker A:They do that a lot in pediatrics, they do it a lot in burn care.
Speaker A:So could we do that more?
Speaker A:And finally think, we already said this.
Speaker A:Think when you select your tape, what are the clinical requirements if it's a non essential device?
Speaker A:Paper or silicone tape, because they're much easier to remove, they cause much less trauma, that's what they were designed for.
Speaker A:But if it is an essential device, think about using silk or cloth tape and protecting the skin.
Speaker A:Your hydrocolloid.
Speaker A:I know you keep hearing the same thing.
Speaker A:It's because it applies to more than one type of injury and it's so critically important.
Speaker A:Now, a couple of things.
Speaker A:Paper tape has a unique adhesive.
Speaker A:It's an acrylic adhesive that is pressure activated.
Speaker A:So when you put down paper tape, you need to go back and press gently over the surface of the paper tape to seal it.
Speaker A:Secondly, you want to realize that the level of adhesion increases over time with paper tape.
Speaker A:So when you put it on Monday morning, it might not feel all that secure.
Speaker A:You might be wondering if it's going to last.
Speaker A:But when you come back on Wednesday afternoon, you might be like, wow, I hope I can get this off without causing problems.
Speaker A:So paper tape can be a very effective securement device if you apply it correctly.
Speaker A:When we're applying tape, we should be sure that the skin is clean and dry.
Speaker A:And it can be very helpful to put down a liquid skin barrier.
Speaker A:Like skin prep.
Speaker A:Sure, prep Cavalon, any of those, because that gives you an extra layer of protection against adhesive trauma.
Speaker A:So clean the skin, dry the skin, think about putting down a liquid skin barrier, then apply the tape without tension.
Speaker A:So when I apply it with tension, when I put it here, stretch it and put it down, I'm going to get tape trauma because it's going to create friction all the way around the borders or shear all the way around the borders of the tape.
Speaker A:And I'm going to get tape blisters.
Speaker A:So it should be applied without tension.
Speaker A:The only time we should be applying tape with tension is if we're trying to do a pressure dressing to stop bleeding.
Speaker A:And here's possibly the most critical element.
Speaker A:Teach everyone proper removal, which is low and slow.
Speaker A:So that means I should not grasp the tape and pull up, I should fold it back on itself and literally roll it off the skin.
Speaker A:So that's the low and slow removal technique.
Speaker A:And probably everybody is also familiar with what we call the push pull removal technique.
Speaker A:So we peel it back, pull it slowly and press the skin away from it so that we're not creating a lot of traction against the skin.
Speaker A:So apply to clean dry skin, protect the skin first with a liquid skin barrier, apply the tape without tension, use low and slow removal technique and that will prevent a lot of tape damage.
Speaker A:So in summary, we've talked about three types of top down injury.
Speaker A:We've talked about friction damage, skin tears and tape damage.
Speaker A:Friction damage affects areas that exposed to rubbing, which is a lot of areas for your bed bound patient, buttocks, elbows, heels, if they have fragile skin, if their skin is over hydrated, macerated, much more vulnerable.
Speaker A:So we need to think about do we have them on a low friction surface, should we be using protective dressings?
Speaker A:We also want to provide gentle skincare.
Speaker A:Skin tears, much more common in the infants and the elderly.
Speaker A:We want to do everything we can to prevent skin tears.
Speaker A:We can use sleeves.
Speaker A:We should be routinely moisturizing the skin, replacing lost skin lipids so the skin is supple.
Speaker A:We should teach everybody gentle handling.
Speaker A:And finally, tape damage.
Speaker A:We see a lot of this and most of it is preventable.
Speaker A:So we should use gentle tapes when possible.
Speaker A:We should apply to clean dry skin.
Speaker A:We should apply without tension and we should use low and slow removal.
Speaker A:Okay, that's it for this one and the next one.
Speaker A:We'll talk about moisture associated skin damage.
Speaker A:Thank you.
