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Skin Tears
Prevention, assessment
and management
Workbook to record your training and
personal development in prevention,
assessment and management of skin tears
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Version 2
Skin Tears | Prevention, Assessment and Management
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© NHS Education for Scotland 2015. You can copy
or reproduce the information in this document for
use within NHSScotland and for non-commercial
education purposes. Use of this document for
commercial purposes is permitted only with the
written permission of NES.
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Skin Tears | Prevention, Assessment and Management
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Table of contents
Introduction .................................................................................................................................................................................. 4
Assessment ................................................................................................................................................................................... 23
Learning outcomes ............................................................................................................................................................. 5
Assessment Part 1: Multiple choice ....................................................................................................... 24
Section 1 Skin tears: prevention, assessment and management ............. 7
Assessment Part 2: Case study to demonstrate clinical reasoning ........ 26
Section 2 What are skin tears? ...................................................................................................................... 8
Assessment Part 1: Multiple choice answers ........................................................................... 28
Section 3 Prevalence of skin tears ............................................................................................................ 9
Assessment Part 2: Case study answers .......................................................................................... 30
Section 4 Age-related skin changes associated with skin tears ............... 10
Acknowledgements ....................................................................................................................................................... 33
Section 5 At-risk groups ...................................................................................................................................... 11
References .................................................................................................................................................................................... 34
Section 6 Prevention of skin tears ........................................................................................................ 12
Learning Activity 2 ....................................................................................................................... 13
Learning Activity 3 ....................................................................................................................... 14
Section 7 Classification of skin tears ................................................................................................. 15
Section 8 Principles for management of skin tears .................................................... 16
Learning Activity 4 ....................................................................................................................... 17
Learning Activity 5 ....................................................................................................................... 18
Learning Activity 6 ....................................................................................................................... 19
Section 9 When to seek help ....................................................................................................................... 20
Learning Activity 7 ....................................................................................................................... 21
In summary ................................................................................................................................................................................ 21
Questions and answers to Learning Activities ....................................................................... 22
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Skin Tears | Prevention, Assessment and Management
Introduction
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Introduction
Target audience
How to use the Workbook
This workbook is suitable for any practitioners
and carers working in Scotland to learn about
skin tears and their prevention, assessment
and management.
The purpose of this workbook is to support your learning around skin
tears and their prevention, assessment and management. It is a resource
where you and your Line Manager/Mentor can assess your current level of
knowledge of skin tears and agree your developmental needs. These should
be recorded on the Statement of Completion at the end of the workbook.
Accompanying this workbook is a video
which supports the workbook and offers more
in depth information including a case study
on effective management of skin tears. The
video can be accessed at
https://vimeo.com/107907101
Completing the Workbook
It is recommended that you watch the video
before completing the workbook.
There are learning activities within the workbook which include:
• multiple choice questions
• questions where you can reflect on your current practice and compare
it to the new recommendations for practice
• a case study to demonstrate clinical reasoning.
The answers to the multiple choice questions can be found under
“Assessment Part 1: Multiple Choice Answers”. You will self-mark these
questions.
Once you have successfully completed the learning activities your Line
Manager/Mentor will review your activities and assessment answers and sign
your workbook as completed, using the Statement of Completion at the end
of the workbook to record your achievement. You can use the Statement of
Completion to evidence achievement of the learning outcomes.
NHS staff can scan and upload a copy of the Statement of Completion into
e-KSF or in their own evidence of learning folder. Non NHS staff can record
it in their Practice Training and Learning Record or in their own evidence
of learning folder.
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It is estimated that it will take about 4 hours to complete the workbook.
Skin Tears | Prevention, Assessment and Management
Learning Outcomes
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Learning outcomes
Before we move on, please take time to read the learning outcomes
for this workbook. These will give you clear direction on what it
covers and the learning we hope will result from it.
By the end of this workbook, you will be able to:
1. Identify patient/client groups who are at risk of developing
skin tears.
2. Relate age-associated skin changes to skin tears.
3. Demonstrate an understanding of skin tear prevention.
4. Categorise skin tears using the recommended assessment
tool.
5. Demonstrate an understanding of best practice in
assessment and management of skin tears.
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Skin Tears | Prevention, Assessment and Management
Your details
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Your details
Name:.........................................................................................................................................................................
Job title: ...................................................................................................................................................................
Line Manager/Mentor: .............................................................................................................................
Organisation: .....................................................................................................................................................
Department: .......................................................................................................................................................
Date workbook commenced: ...........................................................................................................
Date workbook completed: ................................................................................................................
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Skin Tears | Prevention, Assessment and Management
Section 1
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Section 1 –
Skin tears: prevention, assessment
and management
Skin tears are viewed as an increasing problem by healthcare
workers and if appropriate treatment is not given, these injuries may
become chronic wounds with prolonged healing - subsequently
causing unnecessary pain and distress.
Traditional management of skin tears can cause new damage and
slow down the healing process. This type of injury usually happens
in pre-term infants, newborns (infants in the first 28 days after birth)
and in older people.
As our population changes and the number of older people
increases, whether we are caring for people in their own home,
a care home or hospital, we need to be aware of best practice in
prevention, assessment and management of skin tears.
The image has been provided for inclusion with kind permission from the SilverChain Group
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Skin Tears | Prevention, Assessment and Management
Section 2
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Section 2 –
What are skin tears?
An international consensus panel has defined skin tears as:
They occur most commonly:
“A wound caused by shear, friction and/or blunt force resulting
in separation of skin layers. A skin tear can be partial-thickness
(separation of the epidermis from the dermis) or full thickness
(separation of both the epidermis and dermis from underlying
structures)”
• at the extremes of age
(LeBlanc et al 2011).
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• in critically ill or medically compromised individuals
• in those who require assistance with personal care
Prevention of skin tears, where possible, should be our priority. When
skin tears occur, accurate assessment and appropriate management will
minimise further trauma and preserve viable tissue.
Skin Tears | Prevention, Assessment and Management
Section 3
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Section 3 –
Prevalence of skin tears
Studies often try to determine how common a condition is in a
population. This is referred to as prevalence. The studies which
have been conducted to identify the prevalence of skin tears
indicate that in elderly care settings, skin tears commonly occur.
The evidence on prevalence and incidence of skin tears is limited
and generally dated.
• An Australian study conducted in a long term care facility
indicated that 41.5% of known wounds were found to be skin
tears (Everett & Powel 1994).
• In 1991 an incidence of 0.92% was reported in an elderly care
facility in the USA (Malone et al, 1991).
• A more recent survey found prevalence of between 8-11% in
public hospitals in Western Australia (Government of Western
Australia Department of Health, 2009).
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The work carried out in Australia led Carville et al (2007) to state that skin
tears are perceived to be common wounds and occur more frequently
than pressure ulcers. To date, there are no prevalence data available for the
UK, therefore the true extent of patients requiring hospital attendance, or
the resource impact or cost to the patient or the NHS due to skin tears, is
still not fully known.
Skin Tears | Prevention, Assessment and Management
Section 4
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Section 4 –
Age-related skin changes
associated with skin tears
Changes to the skin due to the ageing process make the skin more
vulnerable. These changes include:
• Thinning of the epidermis (top layer of the skin) and dermis
(middle layer of the skin)
• Shrinkage of subcutaneous/fatty tissue (bottom layer of skin)
• Small blood vessel walls widen, shrink and become disorganised
• Decrease in collagen (natural protein component of the skin)
amount and quality
• Reduced sebum (natural lubricant) production
Pre-term and newborn infants have immature skin and are also
vulnerable to skin tears.
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Skin Tears | Prevention, Assessment and Management
Section 5
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Section 5 –
At-risk groups
Both internal and external factors make the skin more vulnerable.
The following groups have a heightened risk of skin tears:
Older people
Please select the one correct answer
• The epidermis gets thinner and takes longer to repair itself
Skin tears occur most commonly:
• The dermis gets thinner
A. As a result of sport injuries
• The fatty layer of the skin becomes thinner to certain areas of the
body such as the face, neck, hands, arms and lower legs
B. As a result of surgery
Pre-term infants and newborns
• Pre-term infants and newborns have underdeveloped skin.
Furthermore, although full term infants are born with a
competent skin barrier, their skin is still developing through the
first year of life
Those suffering from lowered immune system,
malnutrition, circulation problems and poor oxygen intake
• People with advanced kidney disease
• Overweight or undernourished people
• People with who have had a stroke or have poor circulation in the
lower legs
• People with heart failure
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Learning Activity 1
C.In critically ill and medically compromised individuals
D.In school age children
Answer =
Skin Tears | Prevention, Assessment and Management
Section 6
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Section 6 –
Prevention of skin tears
Prevention of skin tears starts with early identification of individuals
who are at risk. Based on available evidence the consensus
statement of an international panel, suggests certain strategies
should be part of prevention.
The following strategies should be considered for skin tear prevention.
1. Assess for risk upon admission to care setting and whenever the
individual’s condition changes and document in person centred care
plan.
2. Implement a systematic prevention protocol including a person
centred care plan (covered in points 3-10).
3. Have individuals at risk wear long sleeves, long trousers or knee high
socks.
4. Provide limb protectors for those individuals who experience repeat
skin tears.
5. Ensure safe patient handling techniques and equipment/environment.
6. Involve individuals and families in prevention strategies.
7. Educate practitioners and carers to ensure proper techniques for
providing care without causing skin tears.
8. Consult dietician to ensure adequate nutrition and hydration.
9. Keep skin well lubricated by applying hypoallergenic moisturiser at
least 2 times per day. Encourage the patient or their carers to apply
emollient.
10.Protect individuals at high risk of trauma during routine care from
self-injury, e.g. keep nails short to avoid scratching.
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Skin Tears | Prevention, Assessment and Management
Section 6
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Learning Activity 2
Think of an individual/person in your care with high risk of
developing a skin tear. In the space provided list the strategies
taken to reduce the risk to that individual and compare it to the
recommendations for prevention of skin tears.
Practical advice on maintaining a safe environment to minimise the risk
of skin tears is also available. Where relevant, these techniques should be
noted on the patient’s care plan. The following should be considered to
prevent skin tears.
• Ensure adequate lighting and position small furniture (night tables,
chairs) to avoid bumps or knocks. Remove rugs and excessive
furniture.
• Upholster or pad sharp borders of furniture or bed surroundings
with padding and soft material.
• Use appropriate aids when transferring patients and safe patient
handling techniques according to local manual handling policy.
• Never use bed sheets to move patients as this can contribute to
damage by causing dragging effect on the skin. Always use lifting
device or slide sheet.
• Where possible reduce, or eliminate pressure, shear and
friction using pressure relieving devices and positioning techniques.
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Skin Tears | Prevention, Assessment and Management
Section 6
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Learning Activity 3
Please select the one correct answer
Which of the following intervention should
be part of skin tear prevention?
A. Have individuals at risk wear shorts sleeves, short trousers/
skirts or short socks to let the skin breathe
B. Assessment of the risk of skin tears if admission is greater than
one month
C.Keep skin well lubricated by applying skin moisturiser at least
twice a day
D.Use limb protectors for individuals considered at risk of skin
tears
Answer =
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Skin Tears | Prevention, Assessment and Management
Section 7
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Section 7 –
Classification of skin tears
The most important aspect of
assessment and management is
to minimise further trauma and
preserve viable tissue.
It is important to classify the type
of skin tear as this will determine
the severity and aid in planning
appropriate treatment. The Skin
Tears Audit Research (STAR)
Classification System is a validated
classification tool recommended by
the National Association of Tissue
Viability Nurse Specialists (Scotland)
for use throughout Scotland.
The STAR skin tear assessment tool is
outlined on the right.
STAR Skin Tear Classification System
STAR Skin Tear Classification System Guidelines
1
2
3
4
5
6
Control bleeding and clean the wound according to protocol.
Realign (if possible) any skin or flap.
Assess degree of tissue loss and skin or flap colour using the STAR Classification System.
Assess the surrounding skin condition for fragility, swelling, discolouration or bruising.
Assess the person, their wound and their healing environment as per protocol.
If skin or flap colour is pale, dusky or darkened reassess in 24-48 hours or at the first dressing change.
STAR Classification System
Category 1a
A skin tear where the
edges can be realigned
to the normal anatomical
position (without undue
stretching) and the skin
or flap colour is not pale,
dusky or darkened.
Category 1b
A skin tear where the
edges can be realigned
to the normal
anatomical position
(without undue
stretching) and the skin
or flap colour is pale,
dusky or darkened.
Category 2a
A skin tear where the
edges cannot be
realigned to the normal
anatomical position
and the skin or flap
colour is not pale,
dusky or darkened.
Category 2b
A skin tear where the
edges cannot be
realigned to the normal
anatomical position and
the skin or flap colour is
pale, dusky or
darkened.
The image has
provided
inclusion
withNursing
kind Association
permission
SilverChain
Group
Skin been
Tear Audit
Research for
(STAR).
Silver Chain
and from
School the
of Nursing
and Midwifery,
Curtin University of Technology.
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Category 3
A skin tear where the
skin flap is completely
absent.
Revised 4/2/2010. Reprinted August 2012.
Skin Tears | Prevention, Assessment and Management
Section 8
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Section 8 –
Principles for management
of skin tears
The same principles used to manage other wounds should be
employed when treating skin tears. These principles include:
• Approximate the skin flap by gently easing the flap back into
place using dampened cotton bud or gloved finger
• applying an aseptic technique
• If the skin flap is difficult to align, consider applying using a
sterile moistened non-woven swab for 5-10 minutes first to
rehydrate the skin flap
• controlling bleeding
• cleaning with sterile normal saline at body temperature
• applying an appropriate dressing
A skin tears/first aid trauma box containing an appropriate dressing
should be available in the care setting.
The following are the additional recommendations for management
of skin tears.
• Apply aseptic technique
• Assess the wound and the skin flap to determine the category
of skin tear using a validated documentation system (e.g. STAR
classification system)
• Cleanse the skin tear following assessment using sterile saline or
water at body temperature to remove debris and any residual
haematoma
• Depending on healthcare setting, a tetanus immunoglobulin may
be administered
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• Encourage moist wound healing by applying a dressing such as soft
silicone-based mesh or foam dressing, lipido-colloidal based mesh and
foam dressing, calcium alginate, adsorbent clear acrylic and skin glue
• Avoid the use of adhesive strips. Sutures or staples are generally not
recommended; however they may be required in the treatment of
deep, full thickness skin tears
• If possible, dressing should be left in place for several days to avoid
disturbing the flap
• If an opaque dressing is used, mark an arrow to indicate the preferred
direction of removal and record in notes
• Dressings should be held in place with stocking-like products
(e.g. tubular viscose retention bandage)
• Pain assessment should be carried out and appropriate analgesia
should be provided
• Complete formal wound assessment form
• Document in care plan, complete accident/incident documentation
and where relevant discuss with family or next of kin
Skin Tears | Prevention, Assessment and Management
Section 8
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Learning Activity 4
Think of a patient/client in your care who has developed a skin
tear. In the space provided describe the care which was given
and compare it to the recommendations for management.
For ongoing management of skin tears, at each dressing change the
dressing should be gently removed. If it does not remove easily, consider
the use of saline soaks or silicone-based adhesive removers. The wound
flap may be friable (fragile and bleed easily) so care should be taken to
prevent disturbing it. The wound should be observed for signs of infection
and any changes in the colour of the tissue of the flap that may indicate
that it is becoming non-viable tissue.
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Skin Tears | Prevention, Assessment and Management
Section 8
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Learning Activity 5
Look at the photographs from the STAR skin tear assessment tool
on the right. From the list of categories below, write the category
number of the skin tear next to each photograph.
Category 1a
Edges can be realigned without undue stretching. Skin flap not pale
dusky or darkened.
Category 1b
Edges can be realigned colour is pale, dusky or darkened.
Category 2a
Edges cannot be realigned, colour is not pale, dusky or darkened.
Category 2b
Edges cannot be realigned skin is pale, darkened or dusky.
Category 3
Skin flap is completely absent.
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The images have been provided for inclusion with kind permission from the SilverChain Group
Skin Tears | Prevention, Assessment and Management
Section 8
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Learning Activity 6
Please select the one correct answer
When dressing a skin tear:
A. Use adhesive strips
B. Leave dressing in place for several days
C.Hold dressing in place with tape
D.Use products to encourage dry wound healing
Answer =
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Skin Tears | Prevention, Assessment and Management
Section 9
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Section 9 –
When to seek help
If any of the following occur, you should seek help from other
services.
• If the skin tear is extensive or associated with a full thickness injury
and/or
• If there is uncontrolled bleeding or large haematoma formation
Action: a referral to the General Practitioner if you are in the
community or to surgical/plastic surgery in the hospital setting
may be required.
• If the skin tear is on the lower leg and fails to progress over a two
week period
Action: consider referral to local leg ulcer clinic or vascular nurse
specialist for leg ulcer assessment.
• If the wound fails to progress towards healing over a two week
period
Action: consider referral to tissue viability specialists.
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Skin Tears | Prevention, Assessment and Management
Section 9 • In summary
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Learning Activity 7
From the information you have read in this workbook how
will this change the prevention and management of skin
tears in your workplace?
In summary
Skin tears are common wounds, particularly at the extremes of age.
We should be aware of the risk factors associated with skin tears
and where ever possible minimise risk to patients/clients. When a
patient/client develops a skin tear, the use of a skin tear classification
system will aid our decision-making, and ensure we are all using the
same language to describe skin tears.
You have now completed the workbook.
Please review your answers to the learning activities
on the following page.
Once you have done this please complete the
workbook assessment.
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Skin Tears | Prevention, Assessment and Management
Questions and answers to Learning Activities
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Questions and answers to
Learning Activities
Learning Activity 1
Learning Activity 5
Please select the one correct answer
Skin tears occur most commonly:
The order the images is as follows:
A. As a result of sport injuries
2b
B. As a result of surgery
C.In critically ill and medically compromised individuals
D.In school age children
Correct answer = C
Learning Activity 3
Please select the one correct answer
Which of the following intervention should be part of skin
tear prevention?
A. Have individuals at risk wear shorts sleeves, short trousers/
skirts or short socks to let the skin breathe
B. Assessment of the risk of skin tears if admission is greater than
one month
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2a
1b
1a
3
Learning Activity 6
Please select the one correct answer
When dressing a skin tear:
A. Use adhesive strips
B. Leave dressing in place for several days
C.Hold dressing in place with tape
C. Keep skin well lubricated by applying skin moisturiser at least
twice a day
D.Use products to encourage dry wound healing
D.Use limb protectors for individuals considered at risk of skin tears
Correct answer = B
Correct answer = C
Skin Tears | Prevention, Assessment and Management
Assessment
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Assessment
On successful completion of this assessment, learners will have
demonstrated achievement of the following learning outcomes:
1. Identify patient groups who are at risk of developing skin tears.
2. Relate age-associated skin changes to skin tears.
3. Demonstrate an understanding of skin tear prevention.
4. Categorise skin tears using the recommended assessment tool.
5. Demonstrate an understanding of best practice in assessment
and management of skin tear.
There are 2 parts to the assessment below:
Part 1:
10 multiple choice questions. 10 marks
Part 2:
Case study to demonstrate
clinical reasoning. 10 marks
The pass mark is 50% which is 10 marks in total.
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Skin Tears | Prevention, Assessment and Management
Assessment
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Assessment Part 1:
Multiple choice questions
Choose the correct response to all the questions below
by selecting the ONE correct answer.
Read each question, instructions and all possible answers
carefully BEFORE you choose the correct answer.
There are 10 questions.
A. Make sure legs are shaved to decrease the risk of infection
B. Provide limb protectors
C.Advise to wear short socks
D.Apply moisturiser once a day
1. Which of the following groups are not considered at risk
of suffering from skin tears?
A. Only use bed sheets to move patients
B. Elderly patients/clients
B. Advise patients not to change position too much
C.Children
C.Encourage the use of rugs on the floor
Answer =
2. Which of the following factors may impact on fragility of
the skin?
Answer =
4. Which of the following practical advice can be given on
maintaining a safe environment to minimise the risk of skin tears?
A. Overweight patients/clients
D.Pre-term babies
D.Ensure adequate lighting
Answer =
5. According to the STAR skin tears classification tool, a category 1a
skin tear is when the:
A. Edges cannot be realigned
A.Malnutrition
B. Taking antibiotics
B. Edges can be realigned and the skin or flap is pale, dusky or
darkened
C.Clothing worn
C.Edges can be realigned and the skin or flap is not discoloured
D.Mobility
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3. If individuals experience repeat skin tears on shins:
Answer =
D.Skin flap is completely absent
Answer =
Skin Tears | Prevention, Assessment and Management
Assessment Part 1
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6. According to the STAR skin tears classification tool, a
category 3 skin tear is when the:
8. A General Practitioner, surgical/plastic surgery referral may be
required when a skin tear is:
A. Edges cannot be realigned
A. Associated with a superficial injury
B. Edges can be realigned and the skin or flap is pale, dusky
or darkened
B. Associated with a full thickness injury
C.Edges can be realigned and the skin or flap is not discoloured
D.Superficial and no more than 2cms in length
C.Occasionally has light bleeding
Answer =
D.Skin flap is completely absent
Answer =
7. Which of the following describes the recommended
management of skin tears:
A. Encourage bleeding, assess the wound, cleanse the skin,
approximate the skin flap using a clean finger, apply dressing
and leave for several days
B. Control bleeding, assess the wound, cleanse the skin,
approximate the skin flap using a gloved finger, apply dressing
and leave for several days
C.Encourage bleeding, assess the wound, cleanse the skin,
approximate the skin flap using a dry cotton bud, apply
dressing and leave for several days
D.Control bleeding, assess the wound, cleanse the skin,
approximate the skin flap using a dry cotton bud, apply
dressing and leave for several days
Answer =
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9. When removing dressings for skin tears:
A. Remove in the preferred direction
B. Remove quickly to prevent prolonged pain
C.Bleeding is a good sign that the circulation to the
area is good
D.Keep the area dry, even when the dressing
is sticking
Answer =
10. Dressings for skin tears should:
A. Encourage moist wound healing
B. Be held firmly with adhesive tape
C.Be changed every day
D.Always be clear so that you can see the wound
Mark =
/10
Answer =
Skin Tears | Prevention, Assessment and Management
Assessment Part 2
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Assessment Part 2:
Case study to demonstrate
clinical reasoning
Relevant factors:
1.
2.
Read the case study below and then list 10 factors that would
be important for you, the nurse or carer, to consider when
assessing this situation involving a skin tear and deciding upon
appropriate management.
Case study
3.
4.
5.
Mrs Cook is a patient/client in your care home. She has
cut her leg after bumping into a coffee table. Mrs Cook is
6.
75 years old, has rheumatoid arthritis and needs help with
mobility. Mrs Cook doesn’t eat well and her daughter, who
visits twice a week, is worried about this.
7.
8.
If, after working on the answer to this question for at least 10
minutes, you cannot list 10 relevant factors; you may consult with
peers or receive prompts from your line manager/mentor until you
have identified at least 10 relevant factors.
9.
10.
Mark =
26
/10
Total mark combining multiple choice questions mark
and case study mark =
/20
Skin Tears | Prevention, Assessment and Management
Assessment Part 2
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You have now completed the assessment. Please check
your answers against those provided on the following
page and mark your assessment.
Following this, meet with your Line Manager/Mentor
and discuss your current level of knowledge and any
development needs you may have.
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Skin Tears | Prevention, Assessment and Management
Assessment Part 1 – answers
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Assessment Part 1:
Multiple choice answers
Check your answers against the answers below. Allocate one
mark for each correct answer.
If your answer is incorrect, revisit the section of the
workbook indicated below the correct answer.
1. Which of the following groups are not considered at risk of
suffering from skin tears?
A. Overweight patients/clients
B. Elderly patients/clients
3. If individuals experience repeat skin tears on shins:
A. Make sure legs are shaved to decrease the risk of infection
B. Provide limb protectors
C.Advise to wear short socks
D.Apply moisturiser once a day
Correct answer = B
Workbook Section 6
4. Which of the following practical advice can be given to maintain a
safe environment to minimise the risk of skin tears?
C.Children
A. Only use bed sheets to move patient
D.Pre-term babies
B. Advise patients not to change position too much
Correct answer = CWorkbook Section 5
C.Encourage the use of rugs on the floor
D.Ensure adequate lighting
2. Which of the following groups are not considered at risk of
suffering from skin tears?
B. Taking antibiotics
A. Edges cannot be realigned
C.Clothing worn
B. Edges can be realigned and the skin or flap is pale, dusky or darkened
D.Mobility
Workbook Section 6
C.Edges can be realigned and the skin or flap is not discoloured
D.Skin flap is completely absent
Correct answer = C
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Workbook Section 6
5. According to the STAR skin tears classification tool, a category 1a
skin tear is when the:
A.Malnutrition
Correct answer = B
Correct answer = D
Workbook Section 7
Skin Tears | Prevention, Assessment and Management
Assessment Part 1 – answers
home
6. According to the STAR skin tears classification tool, a
category 3 skin tear is when the:
A. Edges cannot be realigned
A. Associated with a superficial injury
B. Edges can be realigned and the skin or flap is pale, dusky or
darkened
B. Associated with a full thickness injury
C.Edges can be realigned and the skin or flap is not
discoloured
D.Superficial and no more than 2cms in length
D.Skin flap is completely absent
Correct answer = D
Workbook Section 7
7. Which of the following describes the recommended
management of skin tears:
A. Encourage bleeding, assess the wound, cleanse the skin,
approximate the skin flap using a clean finger, apply dressing
and leave for several days
B. Control bleeding, assess the wound, cleanse the skin,
approximate the skin flap using a gloved finger, apply dressing
and leave for several days
C.Encourage bleeding, assess the wound, cleanse the skin,
approximate the skin flap using a dry cotton bud, apply
dressing and leave for several days
D.Control bleeding, assess the wound, cleanse the skin,
approximate the skin flap using a dry cotton bud, apply
dressing and leave for several days
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8. A General Practitioner, surgical/plastic surgery referral may be
required when a skin tear is:
Correct answer = B
Workbook Section 8
C.Occasionally has light bleeding
Correct answer = B
Workbook Section 9
9. When removing dressings for skin tears:
A. Remove in the preferred direction
B. Remove quickly to prevent prolonged pain
C.Bleeding is a good sign that the circulation to the area is good
D.Keep the area dry, even when the dressing is sticking
Correct answer = A
Workbook Section 8
10. Dressings for skin tears should:
A. Encourage moist wound healing
B. Be held firmly with adhesive tape
C.Be changed every day
D.Always be clear so that you can see the wound
Correct answer = A
Workbook Section 8
Skin Tears | Prevention, Assessment and Management
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Assessment Part 2:
Case study answers
Read the case study below and then list 10 factors that would
be important for you, the nurse or carer, to consider when
assessing this situation involving a skin tear and deciding upon
appropriate management.
Correct answer: 10 factors to be identified
1.
Role of family/carers
2.
Type of clothes worn
3.
Nutrition
4.
Age
5.
Circulation
6.
Cause of the skin tear
7.
Pain level
8.
Eyesight
9.
Other medical conditions
10.
Ability to self care
Case study
Mrs Cook is a patient/client in your care home. She has
cut her leg after bumping into a coffee table. Mrs Cook is
75 years old, has rheumatoid arthritis and needs help with
mobility. Mrs Cook doesn’t eat well and her daughter, who
visits twice a week, is worried about this.
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If you were unable to identify any of the factors please review the table on
page 31 which identifies the reasons why these factors are relevant and
revisit Sections 5, 6 and 8 of your workbook.
Skin Tears | Prevention, Assessment and Management
Assessment Part 2 – answers
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Guideline answer:
Relevant factors
Reasons for relevance
Role of family/carers
Carers may need to be educated about the importance of good skin care
Carers may need information about risk factors
Carers may need information about the management plan
Nutrition
Impact on condition of the skin
Impact on healing
Impact on energy levels/ability to self-care
Circulation
Impact on condition of the skin
Impact on skin sensation/awareness
Pain level
May give an indication of the depth of the tear
May give an indication of sensory levels
Pain must be managed
Other medical conditions
Impact on mobility
Impact on circulation, skin condition
Possible impact on communication
Type of clothes worn
Skin may not be covered during moving and handling procedures
Age
Skin more prone to tearing due to age-related changes
Other age-related changes may increase risk (for example hearing loss may have an impact on communication
with carers)
Cause of the skin tear
Has to be identified to prevent further occurrence
Has to be identified to inform management (e.g. safe moving and handling as part of the management plan)
Eyesight
May affect ability to transfer safely
May affect ability to read any written instructions about a dressing etc.
Ability to self-care
Moving and handling may be a risk that needs to be managed
May not be moving safely in bed
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May affect ability to keep dressing clean
Skin Tears | Prevention, Assessment and Management
Statement of Completion
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Statement of completion of the Skin Tears prevention, assessment and
management workbook
Name of Organisation:
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Pass mark of .............................. % obtained:
Name of person who completed the learning outcomes and 4 hours learning time:
Agreed development needs:
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Job title:
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Ward/Unit/Department:
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Date of completion:
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Signature of Line Manager/Mentor:
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Skin Tears | Prevention, Assessment and Management
Acknowledgements
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Acknowledgements
NHS Education for Scotland would like to acknowledge the support
they received from the National Association of Tissue Viability Nurse
Specialists (Scotland) and the Wound Care Advisory Group in the
development of this workbook. Thanks are also given to Dr Sabine
Nolte, Educational Projects Manager, NHS Education for Scotland for
her invaluable advice and contribution to the resource development.
Membership of the Wound Care Advisory Group
Sarah Freeman
Educational Projects Manager (Chair), NHS Education for Scotland
Janice Bianchi
JB Medical Ed Ltd, Honorary Lecturer Glasgow University
Alison Edwardson
Senior Infection Control Nurse, NHS Greater Glasgow & Clyde
Mary Hutchinson
Staff Nurse, NHS Ayrshire & Arran
Liz McMath
Tissue Viability Nurse, NHS Ayrshire & Arran
Joyce O’Hare
Professional Adviser Tissue Viability, Care Inspectorate
Linda Primmer
Tissue Viability Nurse, NHS Lothian and Chair of National Association of
Specialist Tissue Viability Nurses (Scotland)
Anne Wilson
Tissue Viability Nurse, NHS Greater Glasgow & Clyde
Adam Wood
Senior Infection Control Nurse, NHS Borders
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Skin Tears | Prevention, Assessment and Management
References
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References
Carville K, Lewin G, Newall N et al (2007) STAR: a consensus for skin
tear classification. Primary Intention 15:1:18-28
Everett S, Powel T (1994) Skin tears – the underestimated wound. Prim Intent 2; 8:8-30
LeBlanc K, Baranoski (2011) Skin Tears: State of Science – Consensus
statement of the prevention, prediction, assessment and treatment
of skin tears. Advances in Skin and Wound Care 24; 9:2-15
Malone ML, Rozario N, Gavinski M, Goodwin J (1991) The
epidemiology of skin tears in the institutionalised elderly. Journal of
American Geriatric Society 39; 6:591-595
National Association of Tissue Viability Nurses Scotland (2009),
Prevention and Management of Pressure Ulcers Best Practice Statement
WoundsWest wound survey 2009: Key results at a glance. Government of Western Australia Department of Health
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and community languages.
Please contact us on
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Published September 2015