Long-Term Care Survey Alert

The underlying cause of residents' bruises or skin tears may lie in your staffing ratios or these care techniques.

If you accept that elderly residents just develop skin tears or bruises, you're right - and wrong.

Staff can often prevent such injuries by using the right care techniques or sometimes simply by slowing down the pace of care.

"Elderly people have very fragile skin, but that should not be used as an excuse for skin tears," says Sandra Kay Webb, RN, BS, a consultant with Survey Future Enterprises in Grove City, OH. "For example, skin tears on a patient's hip can be due to rough handling during positioning and turning."

And most rough handling occurs when people providing care get in a hurry, says Webb, who taught nurse aide training for 10 years and knows caregivers are taught to be very gentle with patients. "But sometimes they forget when they have a lot to do," she says.
 
Warning: CNAs who feel pressured for time constantly may reflect a systemic issue in the facility's staffing patterns, Webb avers. Thus, "if the facility has a lot of skin tears or more than usual, look at changes in residents' needs or staffing ratios (higher resident ADL scores, for example, or fewer caregivers per residents)," she advises.

Using correct transfer and care techniques can also help minimize bruising and skin tears. Teach staff to turn patients using the flat of the hand and to handle residents' extremities with the flat of the hand rather than taking hold of the person with the fingertips, Webb advises. To prevent skin tears, "use a turn sheet to pull the person up in bed, with a caregiver on each side and perhaps a third one if the resident is large," she adds.

Never do this: Webb has heard of instances where caregivers put their arms under the resident's arm pits to pull the person up in bed, a technique that can leave bruising on the resident's chest. "Not only that, but the technique is painful - most elderly people have some arthritis in their shoulder joints," she adds.

4 More Ways to Prevent Skin Tears, Bruises

Other measures to prevent skin tears and bruises include:

1. Protect residents' skin by encouraging residents to wear protective sleeves or sweatshirts with long sleeves. Also use ample moisturizer on the resident's skin.

2. Ensure wheelchairs are the correct height and size for residents. A skin tear on a resident's ankle in a wheelchair is a red flag for potentially inappropriate care - either the wrong sized wheelchair or the person needs to be wearing protective stockings or at least plain socks, says Webb.

Reassess residents' wheelchair size and use at least annually or when the person has a significant change, suggests Roberta Reed, RN, MSN, NHA, a nursing and survey consultant with Howard, Hershbale & Co. in Cleveland.

"Facilities often do a good assessment when the person begins to use the wheelchair," Reed says. "But over time, the resident loses or gains weight or functional capacity - and no one reassesses and intervenes to provide a different size of wheelchair or positioning devices," she cautions.

"Some residents lose weight and become so frail that they could really benefit from one of the pediatric-sized wheelchairs," Reed adds.

Patient management tip: If you plan to change a resident's entire seating program, consider doing so while he is on rehabilitation therapy  to get the therapy team involved as part of the resident's treatment plan, advises DON Susan Campione, RN, CDONA, with North Florida Rehabilitation & Specialty Care in Gainesville, FL.

3. Do regular preventive maintenance to keep wheelchairs, Geri-chairs, shower chairs and beds free from hazards, advises Beth Alford, RN, principal, PLIS and Mitigation Solutions in Belton, MO.

Ripped vinyl chair seats and arm rests can cause skin tears, for example. "Check wheelchair footrests for sharp edges and sand or pad them," Alford suggests. "Pad siderails to protect restless residents who may flay their arms against the rails," she adds. And check shower chairs for protruding hardware.

4. Enforce a nursing staff dress code that prevents accidental resident injuries. "For example, insist on short-rounded fingernails and prohibit staff from wearing jewelry that can catch on resident's fragile skin," Alford suggests.