Week 6 | Skin Tears (16180-SP)
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Skin tear definition and prevalence.
Intrinsic factors associated with skin tear risk.
- Very young (neonate) and very old (>75 y.o.).
- Cognitive impairment
- Inadequate nutritional intake.
- Long-term corticosteroid use.
- History of previous skin tears.
- Altered sensory status.
- Cognitive impairment.
- Limb stiffness and spasticity.
- 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
- 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.
- 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.
- 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:
- Describe the intrinsic and extrinsic factors associated with skin tear risk.
- Discuss the two skin tear classification systems.
- Describe the latest recommendations for skin tear management.
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