Wound Care Management

Skin Tear

skin tear

What is a Skin Tear?

  • An acute traumatic wound resulting from external friction and/or shearing forces that separate the epidermis from the dermis
  • Usually present on hands and upper extremities

What are the Risk Factors Involved?

  • Occurs in individuals with fragile skin
  • Older adults at high risk
  • Previous skin tears
  • Ecchymoses
  • Compromised nutrition
  • Cognitive impairment
  • Multiple medications
  • Impaired mobility
  • Dry skin/Dehydration
  • Presence of pressure or shear
  • Impaired sensory perception
  • Disease processes such as congestive heart failure, renal failure, and stroke (CVA)
  • Prolonged use of corticosteroids

Clinical Pearls:

  • LIFT do not drag patients
  • Avoid tape or adhesives
  • Exercise caution during bathing, dressing, and transferring
  • Pad bed rails, wheelchair arm and leg supports
  • Maximize nutrition and hydration