Long-Term Care

Skin tears

LTC Nursing Assistant Trainer, December 15, 2011

A skin tear is a traumatic wound occurring principally on the extremities. It is the result of friction alone or shearing and friction forces which separate the epidermis from the dermis (partial thickness wound), or separates both the epidermis and the dermis from the underlying structures (full thickness wound).
The Payne-Martin classification system categorizes skin tears in the following way:

  • Category I: Edges of the skin tear can be approximated (within 1 mm) with no tissue loss. Type A: Linear. Type B: Flap.
  • Category II: Varying amounts of tissue loss. Type A: Scant tissue loss < 25%. Type B: Moderate to large tissue loss > 25%.    
  • Category III: Complete tissue loss; epidermal flap is absent.

More than 1.5 million skin tears occur every year in healthcare facilities. Research has shown that dependent residents are at greatest risk of skin tears. Injuries to these residents occur during dressing, bathing, positioning, and transferring. Independent, ambulatory residents sustain the second highest number of skin tears, commonly occurring on the lower extremities.

This is an excerpt from the HCPro book, The Long-Term Care Nursing Desk Reference, Second Edition, by Barbara Acello, MS, RN.

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