Classifying 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.

1. Department of Health, Preventing and Managing Pressure Injuries, 2014, Sector Performance, Quality and Rural Health, Victorian Governement, Department of Health.

2. Australian Wound Management Association, Pan Pacific Clinical Practice Guideline for the Prevention and Management of Pressure Injury, 2012: Cambridge Media Osborne Park, WA.

3. Ferrell, B.A., B.M. Artinian, and D. Sessing, The Sessing scale for assessment of pressure ulcer healing. J Am Geriatr Soc, 1995. 43(1): p. 37-40.

4. Stephen-Haynes, J. and K. Carville, Skin tears made easy. Wounds International, 2011. 2(4): p. 1-6.

Reviewed 05 October 2015

Classifying pressure injuries and skin tears