Classifying and responding to pressure injuries and skin tears

Pressure injuries and skin tears can be classified using a staging system. This staging system provides a consistent method of assessing, documenting and communicating the extent of the injury.

Effective management and treatment of pressure injuries and skin tears depends on their stage or classification.

Classifying pressure injuries

For pressure injuries, examine the:

• location, size and depth of pressure injury
• appearance of wound bed
• condition of wound edges and surrounding skin
• odour, amount and types of exudate
• level of pain and discomfort¹.

Pressure injuries can be classified using a staging system:

• Stage 1 – non-blanchable erythema
• Stage 2 – partial thickness skin loss
• Stage 3 – full thickness skin loss
• Stage 4 – full thickness tissue loss
• Unstageable – depth unknown
• Suspected deep tissue injury – depth unknown².

Use a validated pressure injury healing assessment scale to evaluate the healing progress of the pressure injury:

• Pressure Ulcer Scale for Healing (PUSH)
• Bates-Jensen Wound Assessment Tool (BWAT)
• Sessing Scale³.

Classifying skin tears

For skin tears, examine the:

• location and duration of skin tear
• size and depth
• wound bed characteristics and percentage of viable and non-viable tissue
• type and amount of exudate
• presence of bleeding or haematoma
• degree of flap necrosis
• integrity of surrounding skin
• signs and symptoms of infection
• associated pain⁴.

Skin tears can be classified according to the Skin Tear Audit Research (STAR) classification system:

• Category 1a – a skin tear where the edges can be realigned to the normal anatomical position (without undue stretching) and the skin or flap colour is not pale, dusky or darkened
• Category 1b – a skin tear where the edges can be realigned to the normal anatomical position (without undue stretching) and the skin or flap colour is pale, dusky or darkened
• Category 2a – a skin tear where the edges cannot be realigned to the normal anatomical position and the skin or flap colour is not pale, dusky or darkened
• Category 2b – a skin tear where the edges cannot be realigned to the normal anatomical position and the skin or flap colour is pale, dusky or darkened
• Category 3 – a skin tear where the skin flap is completely absent

If a patient has a pressure injury or skin tear, consider whether you should refer the patient to a wound specialist.

Responding to pressure injuries and skin tears

Pressure injuries and skin tears are considered an adverse event, and if they occur we need to manage them. This means being aware of the factors that can promote and prevent healing and taking steps to manage and address injuries and tears. There are several things we can do to promote injury and wound healing and prevention in hospital.

Develop a management plan

A combination of physical, social and environmental factors can have a major impact on a person’s ability to heal from a wound. When developing a management plan for someone with a pressure injury or skin tear, we need to consider and ask the following:

How long have they had the skin problem for? Is this the first episode or have there been episodes of recurrence?

What caused the skin problem? For example:

• Was a skin tear due to being knocked on an environmental hazard at home?
• Was a pressure injury due to their mattress prior to coming to hospital?
• Do they have a diabetes-related foot ulcer because they have suboptimal glycaemic levels for long periods?

Are the dressings and skin care products acceptable to the patient?

• Will the availability of the dressings and skin care products while in hospital and after discharge affect the patient’s ability to manage the care plan?
• Will the cost of the dressings and skin care products affect the patient’s ability to manage the care plan?

Who will care for the skin problem, particularly after discharge?

• Does the patient or family and carer understand what they need to do and what others will do?
• Will the patient or family and carer be able to remember what they need to do and what others will do?
• Does the patient have adequate social support and contact to provide emotional support and help with skin care if needed?
• Have they been provided with precise written instructions, including measurements if appropriate?
• Will they be able to change the dressings and apply the skin care products themselves?
• How often will the dressing need to be changed?
• How often will the skin care products need to be changed?

What is the goal for the skin problem?

• Can it heal, or is that not possible? If it is not possible, what will that mean for the patient?
• Does discharge from the skin problem need to be contained and odours managed to improve the person’s comfort level?

Dress wounds

When choosing an appropriate wound dressing, we should consider:

• cause (aetiology) of the wound
• type of wound
• characteristics of the wound
  • location
  • extent of tissue damage
  • size
  • phase of healing
  • pain
  • odour
  • infection
• cost and availability of dressing
• comfort to the patient, especially overnight
• patient preference
• pain management.¹

Manage pain

When someone tells you that their foot is hurting, take a bit of notice.
- Patient who experienced a hospital acquired pressure injury

Pain can indicate that the patient has a skin problem.

Assess for the presence of pain in people who have a pressure injury or skin tear:

• Use a validated pain assessment tool².
• Develop an individualised pain management plan in partnership with the patient, family and carer and interdisciplinary healthcare team.

Ask the following questions to help develop a pain management plan and monitor wound healing:

• What makes the pain better or worse?
• What kind or pain are you experiencing?
• Would you describe it as sore, aching, deep, cramping, burning, shooting or sensitive?
• Where is the pain?
• Does it radiate? If so, where to?
• Would you describe your pain as none, mild, moderate, severe or excruciating?
• How would you rate the pain on a scale of 0 to 10, with 0 being no pain and 10 being worst pain possible?
• What is the pain intensity at its worst, best and now?
• Is the pain better or worse at any particular time of the day or night?
• When does the pain start and stop?
• Is it intermittent or constant? Or does it only occur when you are moving?

Manage nutrition

Optimise good nutrition and hydration, to reduce risk and optimsie healing, for under-nourished people who do not have sufficient nutrients available to maintain and repair tissues³.

Nutritional interventions, such as vitamin or protein supplements, could be implemented to assist healing of pressure injuries and skin tears if the individual’s diet is deficient. Consider referral to a dietitian.

Support wellbeing

Although the most important concern in relation to the management of skin tears and pressure injuries is healing the actual wound, it is also important to consider the overall wellbeing of the person and how this may impact on the management and healing process.

A wound can have a big impact on a person’s life, and if not treated or managed properly can affect their wellbeing, including their physical, mental, social, spiritual and cultural wellbeing.

Having a wound is often associated with increased anxiety and depression and poor quality of life. Anxiety and depression are also associated with delayed wound healing.

Having a wound can contribute to social isolation and loneliness. Encourage the person to engage with others and return to previous activities wherever possible, and to seek support.

Document interventions and outcomes

Health professionals are required by law to have written evidence of all communication, assessments and outcomes or interventions. This documentation aims to facilitate communication between healthcare staff, patients and family and carers both within and across healthcare settings.

The following information, including date and time completed, should be documented in the patient’s clinical record or notes:

• risk status
• skin assessment
• interventions to prevent skin damage
• interventions to manage pressure injuries or skin tears
• evaluation of the interventions.

Involve and inform the patient, their family and carers

Evidence shows that when patients are involved in their care, their outcomes improve.

We can include the patient in all treatment and management options following pressure injuries, skin tears or any other wounds.

We can educate patients, their family and carers about maintaining healthy skin and reducing the risk of pressure injuries and skin tears by:

• providing relevant, easy to understand information
• offering information in languages other than English if necessary
• checking the person’s understanding of the information you have provided
• asking the patient and their family and carers to assist with the prevention strategies
• displaying pressure injury and skin tear prevention posters in ward areas commonly used by patients, their family and carers⁴.

Patient information should include, but not be limited to:

• risk factors for developing pressure injuries and skin tears, and what can be done to reduce those risks
• how to inspect skin and recognise skin changes and be aware of body sites that are at greatest risk of damage
• how to care for skin, including correct hygiene and moisturising procedures
• use of support surfaces and protective devices
• methods for pressure redistribution including movement and positioning
• treatment schedule and what they need to do
• who and when to ask for further advice or assistance⁵.

There are many things a patient can do to maintain their own skin integrity both in hospital and at home. These include:

• using only unscented, soap free, pH balanced body wash
• performing a daily skin inspection to pick up any problems
• discussing skin problems with their GP or other health professional
• using the right moisturiser type twice a day to protect dry skin
• using skin tear protection strategies, such as taking care when moving (either by self or with the help of a carer), using padding on furniture edges, and removing unnecessary furniture or equipment to reduce clutter
• moving regularly by following a pressure relieving regime to avoid pressure on an area for a long time
• using pressure relieving equipment
• maintaining appropriate and adequate nutrition and hydration
• maintaining good balance and mobility
• avoiding falls.