Multi Service Pages  |  Woundcare Pathway - Skin Tears




PATHWAYS


Multi Service Pages

Woundcare Pathway - Skin Tears

  1. Assess whether partial thickness (separation of epidermis from dermis) or full thickness (separation of epidermis and dermis from underlying tissue). Classify according to STAR system, or skin tear decision algorthim.

  2. Control bleeding with pressure, elevation.

    Clean wound – Clean or irrigate with warm water or saline until debris is removed (5-10 mins). Potable tap water is safe to use directly on wounds. Cold saline slows the healing process for several hours. Pat the wound dry, dress with an appropriate product. Mark with an arrow the direction in which dressings should be removed.

  3. Assess for risk factors - patient:

    • Age/gender
    • Previous skin tears
    • Dry fragile skin
    • Medications – especially steroids
    • Ecchymosis
    • Impaired mobility/vision
    • Poor nutrition/hydration
    • Cognitive/sensory impairment
    • Co-morbities Smoking status, peripheral vascular disease, diabetes, vascular insufficiency, oedema, cardiac failure, malnutrition, immunosuppressants, corticosteroids. These are red flags for       potential delayed wound healing.
    • Dependency – esp showering, dressing, transfers


Lacerations below the knee:

Simple, linear wounds involving skin and sub-cut only – suture. Involvement of deeper structures may need referral to ED.
Proximally based flaps – if the blood supply is good, replace to cover as much of the defect as possible without any tension. Hold the flap in place with the dressing. If the blood supply is poor, manage as for a distally based flap.

Distally based flaps - carefully remove all underlying fat until and replace the skin over defect to provide as much cover as possible. No sutures or steri-strips. Make small vertically orientated perforations in flap (this is effectively a full thickness graft). Hold the flap in place with the dressing. Elevation is crucial.

 



Last updated : Friday, August 21, 2015
Next review date : Saturday, August 20,2016


Disclaimer: This site is intended to be flexible and frequently updated. While every effort has been made to ensure accuracy, all information should be verified.