Wound Care Plan

Skin Tear (Stage 2b – >25% skin flap loss) – Shepparton Retirement Village

Last Updated
22 May 2025
Back

Quick Overview

Reference ID Number: SRV-WCP-04

Categories

Skin Tears

Scope of Practice (ScOP) Designation

Medical Officer,Registered Nurse (RN),Enrolled Nurse (EN)

Treatment Goals

Provide a stable environment for that the large skin flap can survive to minimise any secondary intention healing needed

Aim of Dressing

Removing all adhesives on the skin and provide a stable, secure moist wound bed for the attachment of the large skin flap

Frequency of Dressing Change

3 Days(s) Min - 3 Days (Max)

References

Shopping List

Dressing Pack Basic – Shepparton Retirement Village,Normal Saline,Algisite M Dressing (10cm x 10cm) – Shepparton Retirement Village,Zetuvit Plus (20cm x 20cm) – Shepparton Retirement Village,Softban Natural Padding (15cm x 2.7m) – Shepparton Retirement Village,Crepe Bandage (15cm x 1.6m) – Shepparton Retirement Village
Page Table of Contents

    Product Selection Disclaimer:

    The wound care products being currently used are a suggestion ONLY. They do not take into account your patient's individual needs which you must assess. No funding from medical companies has been provided and wound care products are chosen on their merit and what is available on the NSW Health State Wound Care Contract. Where an exact brand name product is not available we suggest you review the alternative tab or use another wound care product from its category eg. Hydrofibre

    Photo Gallery

    Care Plans

    Immediately after trauma has occured

    Your resident has sustained a skin tear and it is actively bleeding and there is >25% skin loss.

     Swipe 
    Step 1

    Clean the wound and reposition skin flap

    Clean the wound using normal saline and gauze and as you are cleaning and using normal saline as lubricant realign the skin flap. This will aid in its salvage and ultimately its viability
    Products Used
    Step 2

    Seek medical advice

    If you have a medical staff that can be onsite in the next 20 -30min call them immediately. If possible ask them to anchor the skin flap with minimal sutures if the skin edges are stable enough. If medical staff are not on hand continue and secure dressing very well. *DO NOT USE STERI-STRIPS**
    Products Used
    Step 3

    Apply Primary dressing

    Apply the alginate dressing
    Products Used
    Step 4

    Secure the dressing

    Use a highly absorbent non-adhesive dressing. This is because it will absorb any exudate that occurs and you wont need to change it. This lessens the chances of the skin flap being disturbed and dying. It also adds protection to the area through adding bulk to the dressing
    Products Used
    Step 5

    Apply Compression

    Using a cotton bandage and crepe combination apply a small amount of pressure to aid the skin flap being pushed onto the skin bed. The dressing does not need to be 'tight'. NO tapes should be used on the patient's skin
    Products Used
    Step 6

    Monitor

    Monitor the dressing to make sure there is no active bleeding. Do NOT remove the dressing as this could dislodge the fragile clot that is forming and the skin flap
    Products Used

    Once bleeding has stopped

    Bleeding has stopped and the wound requires a moist wound environment to epithelise. AFTER THE INITIAL DRESSING HAVE BEEN LEFT FOR 3 DAYS. ** Assess if the skin flap has survived. If it has not it has progressed to a Category 3)

     Swipe 
    Step 1

    Clean the wound

    Clean the wound using normal saline and gauze. Do not scrub the area but 'dab' softly. If blood or crusting does not come off easily leave it. The viability of the skin flap is more important.
    Products Used
    Step 2

    Assess skin flap

    Assess the skin flap. If there is a pungent smell, purulent exudate or if it is bunched up it is best to remove it at this stage. This sharp debridement will need to be done by someone qualified to do it.
    Products Used
    Step 3

    Apply Primary dressing

    Apply a double layer of jelonet
    Products Used
    Step 4

    Secure the dressing

    Use a highly absorbent non-adhesive dressing. This is because it will absorb any exudate that occurs and you wont need to change it. This lessens the chances of the skin flap being disturbed and dying. It also adds protection to the area through adding bulk to the dressing
    Products Used
    Step 5

    Secure the dressing

    Use a highly absorbent non-adhesive dressing. This is because it will absorb any exudate that occurs and you wont need to change it. This lessens the chances of the skin flap being disturbed and dying. It also adds protection to the area through adding bulk to the dressing
    Products Used
    Step 6

    Monitor

    Recheck in 2-3 days
    Products Used