Caring for Skin Tears and Burns in Nursing Homes
Skin tears and burns are among the most painful and preventable injuries in nursing homes. Poor care and lack of training often make them worse, leading to long-term damage or even death. In this week’s episode, nursing home abuse lawyer Rob Schenk welcomes guest Suzanne Mitchell to discuss how these injuries happen, the warning signs families should look for, and the steps facilities must take to prevent them.
Mitchell:
Much like in the general population, the most common type of burn or mechanism of burn injury is a skull, and that’s pretty much the same for patients that are in residential facilities, nursing homes, assisted living facilities, et cetera. And that could be a skull injury from a hot liquid, hot soup, hot food to a skull injury during bathing or showering.
Intro
Schenk:
Hey, out there. Welcome back to the Nursing Home Abuse Podcast. I’m Rob. I’ll be your host. And today we are talking about the stepchild of wounds in nursing homes and that being skin tears. And burns. And I say that not as a joke, but we tend on this EPIs on this show to talk about pressure injuries.
Like anytime we’re talking about wounds, we’re talking about pressure injuries. But today it’s not the case. We’re talking about how skin tears and burns happen in nursing homes and how we can recognize them and treat them. But we’re not doing that alone.
We have the fantastic Suzanne Mitchell on the show. Suzanne is a seasoned nurse practitioner with over four decades of experience specializing in burn care and complex wounds. She earned her BSN from George Mason University, her MSN, from Georgetown University, and a PhD in nursing with a focus on telemedicine and burn care.
A board certified wound specialist and clinical associate or assistant professor Susanna is passionate about education in 2022. In 2022, I should say, she founded the Mitchell Nurse Consulting, providing expert support and burn and wound litigation, and we’re so happy to have her on today. Suzanne, welcome to the show.
Mitchell:
Thank you.
Schenk:
We have talked a lot on this podcast about. Wounds. But 95% of the time that we’re talking about wounds in the show, it’s pressure injuries. So I’m super excited to have you on the show to talk about the cousins of wounds, that being burns and your typical skin tears and where they come from and how they’re treated and how we can prevent them in long-term care.
What are the typical causes of skin tears in nursing homes?
Schenk:
So the first thing is, this is in your experience, how is the typical skin tear happening in a nursing home?
Mitchell:
I feel like I should start off by mentioning what a skin tear is. So a skin tear is essentially that shearing force. So if you can imagine an object shearing across an individual’s skin or friction, or blunt trauma where an individual or nursing home resident bumps their arm or leg against a solid object. And I think it’s underappreciated in the sense that, the skin’s normal aging physiology associated with that is that the skin gets thinner as we get older. And, it’s much easier to separate that outer layer of skin, the epidermis and dermis from the layers underneath the subcutaneous tissue.
So skin tears typically will occur on an extremity, upper extremity, and lower extremity. It could occur because. A nursing home staff is transferring a patient from the bed to a wheelchair or a chair, and they’re using the patient’s arms instead of a gate belt. And there’s that shearing friction.
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Or it could be. That the resident is a fall risk and they have fallen and bumped their arm on a bedside table, or they’re in a wheelchair and they’ve scooted past the doorway and they’re shearing their arm against the doorway. Or it could be a lower extremity thin skin, or it could be somebody that has a lot of edema in their lower legs and they get some shearing that occurs that way.
It can also be that. Inadvertently they have a dressing or an IV site on that arm. And when the staff go to remove that adhesive, they, for lack of a better word, rip off that outer layer of skin. That’s how skin tears occur.
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Schenk:
Tell me about how we can minimize skin tears during that transfer process.
You mentioned people maybe not using a gait belt, but what about when people when nurses use or CNAs use sheets to move people? Talk about how we can take care to, to prevent those.
Mitchell:
I think in preventing, I think the, I think one of the biggest things in preventing is identifying those residents that are at risk of developing a skin tear.
So you want to be doing an assessment of patients that have sensory deficits related to like spina bifida or spinal cord injuries, or. Multiple sclerosis those kinds of things. Patients that are on certain medications that are going to thin their skin more so than the normal aging process.
So patients that are on chronic steroid use for COPD pulmonary issues or patients that are that are on cancer treatments are typically on corticosteroids to reduce the risk of rejection. Identifying those patients, identifying patients that are a fall risk. Identifying patients that have mobility issues and cognitive issues.
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So I think that’s the first part. And you’ll ha the nursing staff will have to look into the patient’s medical history and using the minimum data sheet to identify those patients as well. And then once you’ve identified that, and of course. Any patient can develop a skin tear. But using those biomechanics having patients wear long sleeves and pants using gait belts, using a draw sheet or some other glide underneath sheet to lift them up in the bed.
Moisturizing the skin keeping it so soft and supple so it isn’t getting dry. Those kinds of things now that we can, we know how to prevent it.
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Schenk:
What are some things that the nursing staff should be doing once they see one oh, we messed up. Like we, we, in our transfer, we cause a skin tear, whatever. What are the next steps for that nursing home?
Mitchell:
Depends on the type of skin tear. So believe it or not, there is an international skin tear advisory panel. And so a skin tear can be a type one where it’s a flap and the. Wound care nurse or the nurse can re approximate the edges. And then we’ll get into the dressing part in a second.
Or it could be a type two where there’s some skin loss. You can’t quite bring the edges together. And then there’s type three, which is complete skin loss. So it really depends on the degree of the skin tear as to the treatment. Most of the treatment is going to be a moist wound dressing and then.
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Absolutely no adhesives. Now I will say that some providers will, when they’re re approximating the skin edges, use Steri Strips. But, and if that’s the case, they should lead the Steri strips alone. Don’t take them off, let them come off on their own. And there are some tricks that we can teach staff how to help facilitate removing the stairs strip.
If it’s been on there for I don’t know, 15 days or whatever. But a moist dressing use of silicone dressings, which are very skin friendly. And don’t don’t tear at the skin when you lift it up to remove it or Vaseline gauze is an inexpensive solution, but absolutely no tape to affix the dressing to the skin.
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Schenk:
I would’ve never have thought of that in a million years. To not use like medical tape or, a bandaid.
Mitchell:
No. Yeah, no. Yeah. It’s the adhesive that will absolutely easily tear a older person’s thin skin.
What are the typical causes of burns in nursing homes?
Schenk:
Something that I’ve learned today for the first time that there is a skin tear advisory panel.
I’ve been doing this for a long time and obviously I think everybody that listens to this show knows that there’s a, an a pressure injury advisory panel, but not a skin tear advisory panel. That’s amazing. So let’s shift gears for a second. What about burns in nursing homes? So let’s start from the beginning as well. Like what would constitute a burn? To a nursing home resident.
Mitchell:
A burn in a nursing home resident is gonna be a burn in any other patient, in the general population. The American Burn Association has classified burns now as superficial, partial, and full thickness. We don’t go by the nomenclature of first degree, second degree, third degree, fourth degree any longer.
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It’s just easier for the rest of wound care and providers to understand. Partial thickness and full thickness. So much like in the general population, the most common type of burn or mechanism of burn injury is a skull, and that’s pretty much the same for patients that are in residential facilities, nursing homes, assisted living facilities, et cetera.
And that could be a skull injury from a hot liquid, hot soup, hot food to a skull injury during bathing or showering.
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Schenk:
Okay, so that, so if I understand correctly, most of the time the burns in long-term care, whether it’s assisted living, personal care, home, or nursing homes are happening in the shower.
Mitchell:
That or hot liquid being spilled. Hot coffee.
Schenk:
Hot coffee. Okay. I see hot coffee, hot.
Mitchell:
I don’t see too much in a nursing home setting or skilled nursing facility setting it being so much hot food. But yes, it is definitely hot, liquid and shower. Now the other type of burn injury that you can see is smoking related burn injuries.
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Patients or individuals that are in a nursing home it is their home and such so that if they decide that they wanna smoke, then we have to provide a safe space for them to smoke. And that’s usually an, in an area separate from their living quarters and separate from other exposure to other residents.
But they have to be supervised, but. They can still have their clothing catch fire if they’re not being supervised. And you definitely don’t wanna have an individual smoking that’s wearing oxygen. We see that a lot really a lot in the general population. If somebody comes in, if an elderly person comes in with a face burn, I can almost guarantee you they have a history of COPD and they’re smoking on oxygen.
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Schenk:
Oh my goodness. That’s so awful. Yes. Okay, so let’s set the smokers aside. We love the smokers, but I wanna talk about the other side. So how does the typical scalding burn present?
Mitchell:
It depends on the depth of the injury. As I had mentioned earlier, it is either gonna be a partial thickness or full thickness.
So a superficial burn is like a sunburn. So there’s redness, there’s erythema, but there’s no blister formation. So it’s like a bad sunburn. A partial thickness burn is gonna be any burn injury that develops into a blister. Sometimes the skin that epidermis can slough off, but it will initially blister.
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And then the look of the wound bed. Once that epidermis is removed, if it’s pink and red and wet and moist, it’s a partial thickness burn that should heal spontaneously with good local wound care within seven to 21 days. A full thickness burn injury is gonna look very different. It’s gonna look like.
Very pale, white, dry, usually not very painful. That doesn’t mean that full thickness burns don’t hurt in a deep way in the deeper tissues, but if you were to press on that pale white skin, it would not hurt the individual. So the treatment is gonna depend on the depth of the burn injury. Partial thickness burns.
Typically can heal within seven to 21 days. And there are some caveats to that. If there’s some comorbidities like diabetes or poor circulation, if it’s a burn on the leg or the foot, or if they smoke. That can definitely take a partial thickness burn and convert it over to a full thickness burn.
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So partial thickness burns, we typically would just treat with a moist dressing again depending on what the dressing is, will dictate how often it’s changed. But that’s the treatment for a partial thickness burn is a moist. Dressing and then full thickness burns typically require excision and skin grafting.
Why are these types of injuries often overlooked in elderly care?
Schenk:
Do you think that, let me say this. Does a non-clinician, like as a lay person, would they be able to tell the difference between a partial and a full thickness on a scalding burn?
Mitchell:
No. So it’s really important, nursing home staff, I don’t even know how much education they receive upon their first hire to, yearly updates.
I don’t know how much education they receive on wound care. I know they probably get zero on burn care because burn is a subspecialty and not all wound care providers. Know how to treat a burn and know what they’re looking at. So you can’t expect a nursing home staff to have that knowledge.
So it’s just best if, and they should be doing their skin checks every day with, if they see something where there’s a wound and there’s, they don’t know how they got the injury, go to the emergency room for treatment.
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What role does staffing and training play in preventing skin injuries?
Schenk:
But I guess then. I mean if I understand you correctly, like it’s not just a lay person problem, it’s a clinician problem as well.
’cause not, there’s not enough training on it to identify. Yeah.
Mitchell:
Yeah, I mean you can I mean if you are in a pretty big community hospital, I would think that the providers in the emergency room would be pretty well educated on burns. But in, in my area even even emergency room physicians that know that it’s a burn injury and know that it’s partial thickness, they will still refer them to our clinic ’cause we’re a burn. We’re a burn. Specialty. So that’s the right thing to do.
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Schenk:
I think that this presents a real challenge, Suzanne, because if it’s anything like a pressure injury, like whether it’s a stage two or a stage three or four is gonna determine how you treat it. So if the clinician doesn’t know if this is a partial thickness burn or a full thickness burn. They might be doing the wrong thing.
Mitchell:
Yeah, for sure.
How do nursing homes prevent skin tears and burns?
Schenk:
Wow. Okay. And then I guess from a broader standpoint, what are some of the policies or procedures that a long-term care facility can implement to reduce the likelihood of these type of scalding incidents? Like setting aside the smoking stuff?
Mitchell:
I think that, I don’t know what the policies are regarding the hot water heaters in a nursing home. Hot water heaters in your home or my home shouldn’t be any higher than 120 degrees Fahrenheit. But it’s also just not having residents left unattended, showering or bathing if they have any cognitive issues or other mobility issues.
So if they got any Alzheimer’s or some other Lewy body dementia or. Parkinson’s or history of a stroke, they shouldn’t be left unattended for obvious reasons. They can accidentally hit a person that has a seizure disorder, could have a seizure in the shower and inadvertently hit the hot water and then they’re, they’re gonna, they’re gonna have a pretty intense skull injury.
For a well-rounded look at prevention efforts, listen to Comprehensive Pressure Ulcer Prevention in Nursing Homes.
Schenk:
Suzanne, I really very much appreciate you coming on the show and sharing your knowledge with us.
Mitchell:
Thank you. I hope it was somewhat enlightening.
Schenk:
It was it was for me. I enjoyed it.
Thank you folks. I hope you found this episode Educational. If you have an idea for a topic that you would like for me to talk about, please let me know. If you have an idea or suggestion for someone that you want me to talk to, please let me know that as well. New episodes of the Nursing Home Abuse podcast come out every single Monday.
Please, for the love of all things, holy, let me know that you want one of these mugs so I can get rid of them and get them outta my house. So my wife leaves me along. And with that folks. We’ll see you next time.
Suzanne Mitchell’s Contact Information: