Skin Tear assessment and management guidelines

[Pages:1]SKIN TEAR ASSESSMENT & MANAGEMENT GUIDELINES `STAR' CLASSIFICATION

GENERAL GUIDELINES:

? Control bleeding by applying firm pressure initially. If bleeding persists, apply Melgisorb? as directed in the guideline

? Gently realign skin flap if possible without undue stretching of the flap ? Assess the skin tear and surrounding skin ? Assess the person and their wound along with any factors that may delay healing ? The length of time the dressing can be left on will depend on the level of exudate

ENSURE A HOLISTIC ASSESSMENT OF THE PERSON WITH THE SKIN TEAR IS CONDUCTED

CONSIDER THE FOLLOWING; ? Visually assess the skin each shift and perform a skin assessment at least daily ? Ensure a soap free wash is used to cleanse the skin and emollients applied at least daily as required for high risk patients ? Protect the limbs with retention stockings (eg; tubular plus) in high risk patients ? Ensure the patients fluid and nutritional intake is adequate

CATEGORY 1A

CATEGORY 1B

CATEGORY 2A

CATEGORY 2B

CATEGORY 3

A SKIN TEAR WHERE THE EDGES CAN BE

A SKIN TEAR WHERE THE EDGES CAN BE

A SKIN TEAR WHERE THE

A SKIN TEAR WHERE THE EDGES CANNOT BE

A SKIN TEAR WHERE THE SKIN FLAP IS

REALIGNED TO THE NORMAL ANATOMICAL REALIGNED TO THE NORMAL ANATOMICAL EDGES CANNOT BE REALIGNED TO THE POSITION (WITHOUT UNDUE STRETCHING) POSITION (WITHOUT UNDUE STRETCHING) NORMAL ANATOMICAL POSITION AND

REALIGNED TO THE NORMAL ANATOMICAL POSITION AND THE SKIN OR FLAP COLOUR IS

COMPLETELY ABSENT.

AND THE SKIN OR FLAP COLOUR IS NOT

AND THE SKIN OR FLAP COLOUR IS PALE,

THE SKIN OR FLAP COLOUR IS NOT PALE, PALE, DUSKY OR DARKENED.

PALE, DUSKY OR DARKENED.

DUSKY OR DARKENED.

DUSKY OR DARKENED.

? Cleanse with normal saline, using ? Cleanse with normal saline, using ? Cleanse with normal saline, using ? Cleanse with normal saline, using

? Cleanse with normal saline, using

aseptic technique

aseptic technique

aseptic technique

aseptic technique

aseptic technique

? Approximate edges with a

? Approximate edges with a

? Approximate edges (as much as ? Approximate edges (as much as

? Debride any non-viable tissue

moistened saline cotton bud

moistened saline cotton bud

possible) with a moistened saline

possible) with a moistened saline

? If wound is bleeding, apply

? Apply a Mepilex? Border dressing ? If wound is bleeding, apply

cotton bud

cotton bud

Melgisorb? as a primary dressing

? Leave intact for approx. 3-5 days,

Melgisorb? as a primary dressing ? Apply a Mepilex? Border

? If wound is bleeding, apply Melgisorb? ? Then, apply Mepilex? Border as a

or change if the dressing is 75%

? Then, apply Mepilex? Border as a

dressing

as a primary dressing

secondary dressing

saturated

secondary dressing

? Leave intact for 3-5 days,

? Then, apply Mepilex? Border as a

? After48 hours - remove dressing

? Once it is ready to be changed,

? After 48 hours - remove dressing

depending on level of exudate

secondary dressing

and review the wound

remove the dressing and cleanse

and review skin tear

? After this time, remove the

? After 48 hours - remove dressing and ? If the wound is superficial or

the wound. If wound has not

? Cleanse wound as above and apply

dressing and cleanse the wound

review skin tear

partial thickness, apply a

healed, apply a new Mepilex?

a Mepilex? Border dressing

as above. If wound has not

? Cleanse wound as above and apply a

Mepilex? Border dressing

Border dressing and leave for up to ? Leave intact for approx. 3- 5 days,

healed, apply a new Mepilex?

Mepilex? Border dressing

? Leave intact for up to 3-5 days,

7 days -depending on exudate level

depending on level of exudate

Border dressing and leave for up ? Leave intact for up to 3-5 days

depending on level of exudate

? Draw an arrow in the direction of ? Draw an arrow in the direction of

to 7 days

? Draw an arrow in the direction of the ? Document in wound chart

the skin flap on top of the dressing

the skin flap on top of the dressing ? Draw an arrow in the direction of

skin flap on top of the dressing

? Consider applying Mepitel? as the

to avoid further trauma at next

? Document in wound chart

the skin on top of the dressing

? Document in wound chart

primary dressing once bleeding

dressing change

? Document in wound chart

? Consider applying Mepitel as a primary

has ceased

? Document in wound chart

dressing once bleeding has ceased

References: Photographs courtesy of the Skin Tear Audit Research (STAR) photographic library, Silver Chain Nursing Association and School of Nursing and Midwifery, Curtin University of Technology. 3 Carville, K., Lewin,

G., Newall, N., Haslehurst, P., Michael, R., Santamaria, N., & Roberts, P. (2007). STAR: A consensus for skin tear classification. Primary Intention, 15(1), 18-28

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