The Wound Care Pathway: Your 5 step guide to wound healing
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Take a shorter way to wound healing
By following the steps in this pathway, you can provide an optimal healing environment for skin tears and reduce the risk of complications that could lead to delayed healing or worse.
Any advice included here needs to work in conjunction with your local protocols and your individual scope of practice.
This article is based on the book A pathway for treating a person with a: Skin tear.
What is a skin tear?
A skin tear is a wound caused by shear, friction and/or blunt force resulting in separation of skin layers. A skin tear can include partial thickness or the full thickness of the skin.1
Skin tears are traditionally categorised as acute but without the appropriate treatment they can become chronic.
What does it look like?
Type 1 skin tear
Type 2 skin tear on the lower leg
Interested in a step-by-step guide for managing chronic wounds?
The guidance provided in this Wound Type Specific Pathway, is best understood in combination with the detailed guidance available to you in The Wound Care Pathway.
How to assess a skin tear
➔ Begin your holistic patient and wound assessment, to determine skin integrity. Several factors need to be taken into account:
- Age
- Dryness
- Fragility
- Medications that make the skin thinner such as steroids, bruising or discoloration, hygiene
➔ Explore the cause of the skin tear:
- Was it caused by a trauma (external factor)
- Was it caused by an intrinsic factor such as a breakdown of skin?
If it was caused by an external factor then screen for safety factors.
➔ Assess and administer first aid if necessary, and determine if Tetanus vaccination is required (recommended for patients who have not received Tetanus during the last 10 years).
➔ Assess blood loss and determine if the patient is on anti-coagulants.
➔ Screen for associated fractures, especially if the patient fell, etc.
Keep skin tones in mind
In all wound types and skin conditions, it is important to be aware of how signs and symptoms may present in a range of skin tones.2
How to diagnose a skin tear
➔ In order to diagnose a skin tear, you first have to classify the wound based on ISTAP classification system: 3,4
Type 1: No skin loss where flap can be repositioned to cover the wound bed
Type 2: Partial flap loss where flap can be repositioned to cover the wound bed
Type 3: Total flap loss exposing the entire wound bed
➔ Proceed by making an assessment about the duration of the skin tear:
- Is the wound new/fresh?
- Is the skin flap still viable?
➔ You also need to measure and document the wound size
- Width
- Length
- Depth
➔ Next, assess the wound bed characteristics
- Percentage of viable and non-viable tissue
- Type and amount of exudate
- Look for signs of infection
➔ Finally, consider the location of wound and assess its implications:
- If the tear is located in the leg area, assess vascular status and look for ischemia and chronic oedema.
For more information, view the ISTAP best practice recommendations.
How to develop a treatment and care plan
➔ Develop your treatment plan taking the age of the wound into consideration – as well as several other factors.
➔ Consider pain control.
➔ Consider skin integrity, and the need for nutrition and hydration – moisturizing twice daily is recommended.5
➔ Develop prevention protocols to manage risks – environmental hazards and infection risk
Keep haematomas in mind
Associated large haematomas / deep dissecting haematomas should be evacuated or referred. You can determine the depth and extent of a haematoma by palpating the area, assessing the range of motion, assessing distal circulation and identifying severity of pain.
Large haematoma with suspected extension
Large haematoma restricting blood flow, cousing local oedema and inflammation
Large haematoma requiring evacuation
Looking for more in-depth knowledge about skin integrity?
Discover our free online medical education programme supporting clinicians who are managing wounds and skin care complications.
How to manage a skin tear
In case you are dealing with a new skin tear (at the time of injury):
➔ Administer first aid.
➔ Stop bleeding with gentle pressure.
➔ Clean wound with non-irritating cleansers, potable water or saline.
➔ Re-approximate the skin flap by gently rolling the flap back into place using dampened sterile cotton tip applicators, gloved fingers or sterile tweezers/forceps.7
➔ Check flap after 24 hours for type 1 and 2.
Be aware
Suturing of skin tears is not generally recommended.8 And the maximum length to width ratio of a skin flap on the extremities should be 1:1, flaps beyond this have a higher risk of failure.9
Remember
If you are using adhesive strips, then position the strips apart and allow them to fall off. Do not remove them!
Positioning of adhesive strips
In case you are dealing with an older skin tear:
➔ Clean wound with saline.
➔ Debride non-viable tissue.
➔ Watch/observe for signs of infection.
➔ Use topical antimicrobials in case of local infection and systemic antibiotics in case of spreading infection.
➔ Implement prevention protocols
How to choose dressing and additional therapy
➔ Always use a dressing that is appropriate for the level of exudate, the size of the skin tear and the skin type.
➔ Select a dressing that will be atraumatic upon removal, and will not cause any further damage to the wound bed and/or any remaining skin flap or the periwound skin.4
Remember!
Avoid iodine-based dressings (drying affect) and film/hydrocolloid dressings (strong adhesives).
➔ Make sure the dressing facilitates moisture balance and protects periwound skin. Generally, skin tears are not heavily exudating wounds; however, in some cases, depending on the location and co-morbidities such as peripheral oedema, skin tears may be heavily exudating. Choose a dressing accordingly.
➔ Always draw an arrow on dressings to indicate correct direction of removal and write either the date for review or the date dressed.Minimize trauma by slowly removing dressing in the direction of the arrow, adhesive removers can also be used.
Keep in mind!
Compression therapy should be considered as an additional therapy if the wound is on an extremity. (Before applying compression on a lower leg, a full leg assessment including vascular assessment should be carried out.10 Light compression or support can be considered for an arm.)
How to monitor progression
➔ Conduct regular reassessments at time intervals that are appropriate for the severity of wound. A skin tear should not take more that 4 weeks to heal.
Healed skin tear
➔ Assess risk factors, including screening for co-morbidities which can increase the risk of chronicity (i.e. peripheral arterial disease, venous insufficiency, etc.)
➔ Discuss prevention strategies with patients based on risk factors.11
- Encourage them to consider protective sleeves and pads for injury prone areas (i.e. elbows and shins)
- Discuss need for hydration and nutrition
- Suggest application of pH neutral, perfume-free moisturiser applied twice daily, that can substantially reduce skin tears among aged care residents5
- All patients may benefit from moisturising twice a day to manage the risk of skin damage. However it has been found that the physiological properties of skin differ depending on skin tone and dry skin can be more problematic for those with dark skin tones.
Remember!
Extra care should be taken to avoid Medical Adhesive Related Skin Injuries (MARSI), as they can affect skin integrity, cause pain, increase risk of infection and potentially increase wound size and delay healing.(12) MARSI can be hard to identify when it occurs in patients, especially those with dark skin tones.(2)
When to refer or contact a specialist
- Refer if a skin tear has not healed after 4 weeks, and has become chronic.
- Refer large haematomas / deep dissecting haematomas for evacuation if they are outside your scope of practice.
Glossary of skin tear terms
Haematoma
– is an abnormal collection of blood outside of a blood vessel, causing swelling. A bruise is bleeding under the skin without swelling. The skin over a haematoma often feels spongy, rubbery and lumpy. Severity of haematoma depends on the size and depth. Refer patients if the haematoma is large, tense, painful, infected, over a joint or airway or is expanding.
Peripheral arterial disease (PAD)
- is a narrowing or blockage of the vessels that carry blood from the heart to the legs.
Venous insufficiency
– is a condition in which the veins fail to return blood efficiently to the heart. Symptoms include swelling of the legs and pain in the extremities.
MARSI
– stands for Medical Adhesive Related Skin Injury. It occurs when superficial layers of skin are removed by medical adhesive, resulting in skin trauma such as formation of vesicles, bulla, skin erosion, and skin tears, that persist longer than 30 minutes after removal of the adhesive.
For a glossary of general wound care terms consult The Wound Care Pathway: