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South West Regional Wound Care Toolkit: F.4.3 Skin Tears Classification & Risk Assessment Tool ClientName: Address: AssessmentDate: SkinTearClassification ActualSkinTearClassification Category1Skintearswithouttissueloss.

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ISTAP has also developed a ISTAP Skin Tear Risk Assessment Pathway, which identifies those at risk and link the patients at risk to a prevention programme (Figure 1.) Education of the patient and caregivers is important as is management of the environment to enhance patient safety (Stephen-Haynes and Carville, 2011).

Perform a physical assessment This includes assessment of skin color, moisture, temperature, texture, mobility and turgor, and skin lesions. Inspect and palpate the fingernails and toenails, noting their color and shape and whether any lesions are present.

Classification 1 Type 1 Skin Tear: No skin loss. Linear or flap tear where the skin flap can be repositioned to cover the wound bed. Type 2 Skin Tear: Partial flap loss. The skin flap cannot be repositioned to cover the whole wound bed. Type 3 Skin Tear: Total flap loss. Total skin flap loss that exposes the entire wound bed.

Risk Factors Dry, fragile skin. History of previous skin tears. Medications that affect the thickness of the skin (e.g. steroids, immune-suppressives, anti-inflammatories, anticoagulants) Impaired mobility or vision. Cognitive or sensory impairment.

Although skin tears can occur at any age, those 65 years old and older are at high risk and those 80 years old and above at greatest risk because of more pronounced physiological changes in the skin.

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.

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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232