Week 6 | Skin Tears (16180-SP)

Photo of elderly hand with skin tear.

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Topics

Skin tear definition and prevalence.

Intrinsic factors associated with skin tear risk.

  • Very young (neonate) and very old (>75 y.o.).
  • Female.
  • Caucasian.
  • Cognitive impairment
  • Inadequate nutritional intake.
  • Long-term corticosteroid use.
  • History of previous skin tears.
  • Altered sensory status.
  • Cognitive impairment.
  • Limb stiffness and spasticity.
  • Polypharmacy.
  • Presence of ecchymosis, hematoma and/or edema.

Extrinsic factors associated with skin tear risk.

  • Assistance required for bathing, dressing, toileting and transferring.
  • Frequent bathing leading to dry skin.
  • Having blood drawn.
  • Using assistive devices.
  • Applying and removing stockings, tapes and dressings.

Skin tear prevention

Skin tear classification
Payne-Martin
Category I

  • Skin tear can fully approximate wound.
    • Linear skin tear. Full thickness wound; the epidermis and dermis are pulled apart as if an incision had been made exposing tissue below. No tissue loss.
    • Flap-type skin tears. Epidermal flap can be reapproximated so that no more than 1 mm. of dermis is exposed.

Category II

  • Skin tears with partial tissue loss.
    • Scant tissue loss. 25% or less of epidermal flap is lost.
    • Moderate to large tissue loss. More than 25% of the epidermal flap is lost.

Category III

  • Skin tears with complete tissue loss.
    • Epidermal flap is absent.
    • STAR classification system.

Skin tear management 

Objectives for Learning Outcomes

After completing this session, you will be able to:

  1. Describe the intrinsic and extrinsic factors associated with skin tear risk. 
  2. Discuss the two skin tear classification systems. 
  3. Describe the latest recommendations for skin tear management.
Course summary
Available: 
03/30/2016
Expires: 
06/30/2017

Renee Anderson, MSN, RN, CWON
Certified Wound Ostomy Nurse; Co-Director, Wound Management Education Program (WMEP) and Wound Management Fundamentals Course (WMFC), Continuing Nursing Education, University of Washington School of Nursing, Seattle; President, Rainier Clinical Consultants, Inc, Seattle, WA

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