Skin Tear
Also Consider: Abrasion, Bite Wound, Laceration, Puncture Wound, Rash
Embedded Files
Definition
Skin Tear: a wound in which the epidermis is separated from the dermis, commonly occurring in those with fragile skin.
1. Take Vital Signs
Temperature:
Blood Pressure:
Heart Rate:
Respiratory Rate:
Oxygen Saturation:
2. Evaluate Symptoms and Signs
Location and size of skin tear
Unrelieved pain
Bleeding
Patient description of what caused the skin tear
3. Take Action using SBAR Report:
Presence of other, significant symptoms or signs of illness
Refer to appropriate Situation-Specific Evaluation for the identified symptoms and signs.
Immediately notify the medical staff & resident representative
Accompanied by significant pain or uncontrolled bleeding
Notify medical staff & resident representative within the next 16 hours.
Symptoms or signs of infection
Notify medical staff at the next regular rounds
Skin tear without complication treated using the facility protocol
SBAR Report
Situation: laceration size) "Skin tear of" (abrasion location) “association with” (pain) (bleeding) (infection)
Background:
Reason the patient is in the nursing home (rehab for___, long term care for __).
When the skin tear occurred, what treatments have been used.
Wound caused by a dirty or rusted object
Abnormal vital signs
Unrelieved pain
Abnormal findings on skin observations
Patient receiving anticoagulant or antiplatelet medication
Date of last tetanus vaccination if greater than 5 years in the past
Assessment: I am concerned about: __________
Recommendations/Requests:
Dressing
Tetanus vaccination (Tdap) for dirty wound or if last vaccination more than 10 years in the past
Pain medication
Systemic antibiotic
Other:
Clarify expectations for care, interventions, and illness course/prognosis. Repeat any telephone orders back to the provider to ensure that they are correct and complete
4. Implement Management Plan
Cleanse the skin tear and apply treatment per the facility protocol
Irrigate wound with saline solution
Approximate the skin flap using gloved fingers or a moist cotton swab
Apply transparent dressing
Place on 24-hour report for 2-3 days
Investigate the cause of the wound
Determine if abuse or neglect occurred
Update care plan regarding fall risk, skin protection, pressure ulcer prevention, assistance needed with ADLs, supervision for safety.
Review status and plan of care with designated representative
Monitor wound each shift until healed
2025-04-27
Page updated
Google Sites
Report abuse