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 / Rationale / Date / Signature
Use aseptic technique, wash hands, wear apron and gloves.
Clean/ irrigate wound (evidence suggests warm tap water is acceptable). / Prevent Infection
Ensure bleeding is under control first by applying pressure as required. / Stop bleeding and prevention of haematoma
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.
These dressings promote a moist wound environment to accelerate healing. They hold the skin flap in place over the wound and promote healing.
Mark the dressing with an arrow so it can be removed correctly as to not disturb the skin flap. / 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. / Promote wound healing, prevent infection and prevent further skin trauma.
REMOVAL
When removing Allevyn and AllevynGentle Border it may be appropriate to irrigate under the dressing first to aid removal. / To prevent further skin trauma.
SUBSEQUENT DRESSING CHANGES
Reassess wound
Complete Skin Tears wound assessment chart
Evaluate and monitor changes. / Assess
WOUND NOT HEALING
Please commence and complete Worcs PCT Wound Assessment chart. / PCT Wound assessment chart – suitable for non-healing wounds
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. / To reduce risk of skin flap dying or further trauma.

Date Wound Healed ______Signature ______Date ______