Maureen’s Healing Journey in Pictures: A Case Study in Managing a Complex Skin Tear
Provided by Lenora Fitzgerald, RANP Tissue Viability Service, RNP, MSc (Hons), Waterford Older Person Services, Republic of Ireland
Consent to use the details of this case and images was provided by the patient
Introduction to the Case
Patient History:
- 85-year-old female with fragile skin
- Known to have atrial fibrillation with pacemaker in situ
- On anticoagulant medication
- Mechanism of injury: fall at home lead to a skin tear on her knee, plus a sternal fracture.
- Extensive bruising and haematoma to the knee
Week 1: Initial Wound (15 May 2024)
(15 May 2024 – On presentation at the Emergency Department)
Maureen’s Voice:
- “There was a rolled‑up runner [mat]… I tripped over it… my two knees hit that, and my chest hit a chair.”
- “Older skin is much more fragile… very, very fragile.”
Emotional Context:
- Shock at severity; fear of looking at the wound.
Key Points:
- Partial flap loss was evident
- Presence of fragile surrounding skin
- Initial Emergency Department management for the skin tear was the use of wound closure strips
- Use of wound closure strips contributed to deterioration
Maureen’s Voice:
“I was frightened… if they pulled the plaster off, I could see a big thing of skin coming off.”
Week 2 – Week 3: Maureen remained in hospital
Key Points:
- Steri‑strips remained in place (Figure 3a)
- Bruising and haematoma continued to evolve (Figure 3a)
- Week 3 Maureen was referred to the Tissue Viability Nurse but there was no mention of a wound.
Maureen’s Voice:
- “I felt like there should have been more being done with it.”
- “I’m glad I didn’t look at it… I would have panicked.”
Week 4: First Tissue Viability In-Patient Assessment
Key Points:
- Wound size 6cm × 5 cm
- 40% slough / 60% eschar
- High purulent malodorous exudate
- Erythema + mild pain → local infection
Week 5: Progress & Reassessment
Key Points:
- Maureen remains in hospital
- Wound area reducing
- Eschar debrided → 80% slough / 20% granulation
- Moderate purulent exudate
- Infection improving (no erythema, no pain)
Week 6: Improvement and Discharge Home
Key Points:
- 65% slough / 20% hypergranulation / 15% epithelialising
- Exudate reducing
- Non-painful, infection resolving
Week 7: Visit to out-patient clinic
out-patient clinic
Key Points:
- Wound size reducing overall but ‘pockets’ of depth were noted in the wound bed (up to 0.8cm)
- Hypergranulation tissue evident
Week 8 – Week 9: Continued Improvement
Week 8:
- 10% Slough / 40% healthy granulation tissue / 50% epithelising tissue
- Exudate low, no odour
- Depth almost resolved
- There was a significant improvement after only one week of single use NPWT
Week 9:
- Majority of the wound was epithelialising
Week 10 – Week 11: Wound continued to improve
Key Points:
- No deterioration
- Consistency of community care maintained
Week 12 – Week 13: Wound continues to improve
Key Points:
- Different depths & tissue types
- One deeper wound (0.8 cm) → further debridement
Maureen’s Voice:
- “It took an awful lot out of me.”
- “I live in fear… but it doesn’t stop me doing things.”
Week 14: Near Resolution
Key Points:
- Wound size <0.6 cm
- Minimal exudate
Refer to the ISTAP Best Practice Recommendations for prevention strategies
Case Study Learning Points
- Never use wound closure strips on skin tears
- Early identification of skin fragility is essential
- Importance of clear communication and documentation
- Person-centred care improves outcomes
Strengths That Supported Healing
- Highly motivated patient + supportive family
- Excellent adherence to treatment
- Strong collaboration between the Tissue Viability Nurse and Community Nurse
- Regular reviews & rapid response to changes
Final Outcome (14 August 2025)
Key Points:
- Skin fully intact, but remains fragile
- Maureen carries out a daily moisturising routine
- Awareness of risk factors maintained
- A positive long-term outcome through partnership care
Maureen’s Voice:
- “I have to be very, very careful… door handles, dogs, little ones’ legs flying.”
- “Absolutely frightened of my life to move.”
- “I have never in my life used moisturising cream… now I put on lots.”
- “If you don’t moisturise… it’s dryer and easier to break.”
- “I put on lots of cream… moisturising is very important.”
- “Drink plenty of water.”
Key themes from Maureen’s narrative:
- Extremely fragile, thin, “tissue-paper” skin
- Severe emotional impact (shock, panic, fear of bleeding, fear of movement)
- Describes wound as “horrific… dreadful… unbelievable”
- Fear regarding wound closure strip removal and inappropriate adhesive use
- Long-term lifestyle changes to prevent further trauma
Emphasis on moisturising, hydration, risk reduction, environmental modification
Conclusion
Key Points:
- This case demonstrates value of structured wound management
- Highlights role of advanced practice & community collaboration
- Reinforces importance of assessment, reassessment, and adaptability