Skin Tears “STAR”
Project
Nursing Home………………………………………………………………………….
Name:
D.O.B:
Room No:
Date
Problem/ Need
Resident has sustained a skin tear to their_____________________________
(Use body map and no. on wound assessment chart)
Caring Goal
Promote healing and prevent infection.
Action Plan
Use aseptic technique, wash hands, wear
apron and gloves.
Clean/ irrigate wound (evidence suggests
warm tap water is acceptable).
Rationale
Ensure bleeding is under control first by
applying pressure as required.
Stop bleeding and prevention
of haematoma
Prevent Infection
Date
Signature
Try to lay the skin back over the wound as
soon after the injury with a dampened gloved
finger as possible, irrigate with tap water to
hydrate if needed the
If able re –approximate the skin edges
together.
Increase the chances of
the skin flap still being
viable.
Use Allevyn Adhesive or Allevyn Gentle as per
Flow Chart.
Clinical and cost effective
care.
Mark the dressing with an arrow so it can be
removed correctly as to not disturb the skin
flap.
These dressings promote
a moist wound
environment to accelerate
healing. They hold the skin
flap in place over the
wound and promote
healing.
Not to not disturb the skin
flap or peel it back the
wrong way.
DRESSING TO STAY IN PLACE
Dependant on STAR Grading (see poster):Grade 1a – 2a – leave on for 5days
Grade 2b and above leave on for 3days
However, if dressing needs changing
beforehand due to excessive
exudate/strikethrough (see Allevyn poster)
Or signs of infection.
REMOVAL
When removing Allevyn and Allevyn Gentle
Promote wound healing,
prevent infection and
prevent further skin
trauma.
To prevent further skin
trauma.
Border it may be appropriate to irrigate under
the dressing first to aid removal.
SUBSEQUENT DRESSING CHANGES
Reassess wound
Complete Skin Tears wound assessment
chart
Evaluate and monitor changes.
WOUND NOT HEALING
Please commence and complete Worcs PCT
Wound Assessment chart.
Avoid the use of steri/leuko strips and dry
dressings as these dry the wound out
causing the skin flap to die and cause an
area of skin loss which is prone to ulceration.
Assess
PCT Wound assessment
chart – suitable for nonhealing wounds
To reduce risk of skin flap
dying or further trauma.
Date Wound Healed ____________________ Signature _________________________________________ Date ____________