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