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.
Best practice recommendations for the prevention and management of skin tears in aged skin. Best Practice, Wounds International. Carville K, Lewin G, Newall N, et al. STAR: a consensus for skin tear classification. Primary Intent 2007;15(1):18-28. Stephen-Haynes J, Carville K. Skin tears made easy. Wounds International. 2011;2(4):1-6.
Skin tears with partial tissue loss 2 A - Scant Category II Skin T ear: 25% or less of the epidermal flap is lost 2B - Moderate Category II Skin T ear: More than 25% of the epidermal flap is lost Category 3 : Skin tears with complete tissue loss Epidermal flap is absent + Category 1 and 2 photographs are courtesy of Kim LeBlanc, Dawn ...
International Skin Tear Advisory Panel: Skin Tear Definition "A skin tear is a traumatic wound caused by mechanical forces, including removal of adhesives. Severity may vary by depth (not extending through the subcutaneous layer)" LeBlanc et al, 2018 UPDATED: Definition of a "flap": "A flap in skin tears is defined as a portion of the skin
• Assess surrounding skin • Categorise using STAR. 1,2. classification • Select appropriate dressing • In the direction of the skin flap, draw an arrow on top of the dressing. A. Category 1a and 1b - Skin flap can be realigned Category 2a and 2b - Skin flap . cannot be realigned Category 3 - No skin flap. Product solution ALLEVYN GENTLE ...
The classification defines a skin tear as a traumatic wound occurring primarily on the extremities of older adults because of friction alone, or because of shearing and friction forces that separate the epidermis from the dermis, or that separate both the …
• Mature skin is vulnerable to skin tears as aging epidermis thins and there is a flattening of the epidermal-dermal junction. • onsider Hydrogel Ag, alcium Alginate Ag or order Foam Ag if infection or critical colonization is suspected or present. • …
Advisory Panel: A Tool Kit to Aid in the Prevention, Assessment, and Treatment of Skin Tears Using a Simplified Classification System. Adv Skin Wound Care, 26(10), 459-476.
Procedure NOTE: The use of the “Payne-Martin Classification System for Skin Tears” is but one part of the holistic assessment of an individual admitted/presenting with a skin tear. Assessment 1. Review the person’s medical chart for: a. Any previous skin tear classification documentation b. Current wound care orders Planning 1.
Support the prevention of skin tears through skin hygiene and hydration, responsible bathing, good nutrition, appropriate clothing, the removal of environmental risk factors and correct turning, positioning and transferring.