Skin Tears and the STAR Classification System

Skin tears are acute, traumatic injuries caused by shearing, friction or blunt force wherein the layers of skin are separated. This may be a separation of the epidermis from the dermis (known as partial thickness) or a separation of both the epidermis and dermis from underlying structures (full thickness).

To distinguish between different types of skin tears, Australia uses the Skin Tear Audit Research (STAR) classification system.

The STAR system comprises of five categories:
• 1A - Edges can be realigned to their normal anatomical position (without excessive stretching). Not pale, dusky or darkened.
• 1B - Edges can be realigned to their normal anatomical position (without excessive stretching). Pale, dusky or darkened.
• 2A - Edges can not be realigned to their normal anatomical position (without excessive stretching). Not pale, dusky or darkened.
• 2B - Edges can not be realigned to their normal anatomical position (without excessive stretching). Pale, dusky or darkened.
• 3 - The skin flap is completely absent.

Managing skin tears

Prompt and appropriate treatment of skin tears improves patient outcomes. The goals of treatment are primarily to:
• Preserve the skin flap;
• Protect the surrounding tissue;
• Re-approximate the edges of the wound (without excessive stretching); and
• Reduce the risk of further infection or injury.

Skin Tear Treatment Process:

1. Control any bleeding.
• Apply pressure to the wound.
• Elevate the affected limb if possible.

2. Cleanse the wound.
• Remove residual debris or clotted blood with a non-woven swab.
• Cleanse the wound with warm, sterile isotonic saline or water.
• Gently pat the surrounding skin dry; the wound itself should be left to air dry.

3. Approximate the skin flap.
• If the skin flap is viable (category 1 or 2), gently ease it back into place to use as a dressing (using a gloved finger, dampened cotton tip, forceps or silicone strip).
• If this is difficult, rehydrate the flap using a moistened non-woven swab for 5-10 minutes.
• Do not excessively stretch the flap during approximation.
• If the skin flap is non-viable or necrotic it should be debrided.
• Note: Ensure this is performed by an experienced trained nurse.

4. Dress the wound.
• Choose an appropriate non-adherent dressing based on the wound characteristics and classification.
• Films and tapes should not be used on fragile skin.

The chosen dressing should:
• Maintain a moist healing environment;
• Protect the wound and surrounding skin from further trauma and dressing removal;
• Manage any exudate and/or infection;
• Be easy to apply;
• Be cost-effective.

Apply the dressing, securing it with a non-adhesive silicone-interfaced dressing material (e.g. arm/leg protector, flexible netting). Mark the dressing with an intended removal date and an arrow indicating the removal direction, away from the skin flap opening.

5. Monitoring and Reassessment
• Leave the initial dressing in place for no longer than five days.
• Reassess within 24 to 48 hours if the skin flap is pale, dusky or darkened.
• The wound should be monitored for any infections or changes.
• Dressings should be changed more frequently if an infection or exudate is present.

If there is no sign of infection or deterioration after the initial dressing, subsequent dressings should be left in place for about five days. If there is no improvement after four reassessments, refer the patient to a specialist.

Complications
• If Skin Tears are not properly treated, complications such as pain, delayed healing, infection, Cellulitis and even Sepsis may arise.
• If a skin tear does not heal within four weeks, it is considered chronic.

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