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Stage 1 & 2 Pressure Injury
Closed Surgical Wounds
In-closed wounds, primary closure, the skin edges are re-approximated by stitches, staples, tissue adhesives or adhesive strips and left to heal by primary intention. [7]
- Doughty, D. & Sparks, B. (2016). Wound-healing physiology and factors that affect the repair process. In R.A. Bryant & D.P. Nix (Eds.), Acute & chronic wounds: current management concepts, 5th Ed. (pp. 63-81). St. Louis, MO: Elsevier.
Skin Tear
Traumatic wound occurring as a result of friction alone or in combination with shearing and friction forces. Most skin tears occur on the arms or legs, but may also occur on the trunk area due to trauma. Skin changes with aging make the elderly very vulnerable to these injuries. Every effort should be made to protect the skin in vulnerable areas. [10]
- Le Blanc, K., Baranoski, S., Christensen, D., et al. (2013). International Skin Tear Advisory Panel: A tool kit to aid in the prevention, assessment, and treatment of skin tears using a simplified classification system©. Adv in Skin & Wound Care. 26(10), 459-76.
Burns
A burn is an injury to tissue that may be caused by dry heat, such as fire or contact with a hot surface, or moist heat, such as steam or hot liquids, chemicals, electricity, lightning, or radiation from either the sun or radiotherapy. Burns vary in severity depending on the extent of tissue damage: superficial, superficial -partial thickness, deep partial thickness, or full thickness. They are classified according to the total body surface area effected by the damage and sometimes classified by first, second, or third degree depending on the depth of the burn. Third degree burns are full thickness. Control of bacteria and reduction of pain associated with dressing changes is very important with burns and antimicrobial dressings can address these concerns. ConvaTec offers dressings that are helpful with burn care both for the burn, and the graft harvest area when skin grafts are required. [1,2]
- Edwards, V. (2013). Key aspects of burn wound management. Wounds UK. 9(Supp 3), 1-9.
- International Best Practice Guidelines (2014). Effective skin and wound management of noncomplex burns. Wounds International. Retrieved from http://www.woundsinternational.com/best-practices/view/best-practice-guidelines-effective-skin-and-wound-management-in-non-complex-burns.
Unstageable Pressure Injury
Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) on an ischemic limb or the heel(s) should not be removed. [6]
- Edsberg, L.E., Black, J.M., Goldberg, M., et al. (2016). Revised National Pressure Ulcer Advisory Panel pressure injury staging sytem. J Wound Ostomy Continence Nursing. 43(6), 1-13.
Leg Ulcers
A leg ulcer is the breakdown in tissue on a leg or foot resulting from alterations in either the arterial or venous vessels, or both, in the lower leg. Venous leg ulcers are the most common type of leg ulcers and are the result of poor venous return to the heart resulting in sustained venous hypertension, causing swelling and tissue damage in the lower leg. [5]
- Principles of compression in venous disease: a practitioner’s guide to treatment and prevention of venous leg ulcers. (2013). Wounds International. Retrieved from http://www.woundsinternational.com/best-practices/view/principles-of-compression-in-venous-disease-a-practitioners-guide-to-treatment-and-prevention-of-venous-leg-ulcers.
Moisture Associated Skin Damage
Moisture from many sources causes skin irritation that can result in skin loss. Excess wound fluid, drainage around tubes or fistulae, and moisture between folds of skin are examples. [8]
- Dowsett, C. and Allen, L. (2013). Moisture-associated skin damage made easy. Wounds UK 9(4), 1-4. Retrieved from http://www.wounds-uk.com/pdf/content_10961.pdf.
Diabetic Foot Ulcers
A diabetic foot ulcer is associated with a loss of sensation and/or peripheral arterial and/or structural changes in the lower limb as a result of diabetes. It may be associated with pressure from ill-fitting footwear and these injuries are often on the tips of the toes or on the plantar surface of the head of the first metatarsal. [3, 4]
- Young, M. (2014). The diabetic foot: an overview for diabetes nurses. J of Diabetes Nursing 18(6), 218–26.
- International Best Practice Guidelines (2013). Wound management in diabetic foot ulcers. Wounds International. Retrieved from http://www.woundsinternational.com/best-practices/view/best-practice-guidelines-wound-management-in-diabetic-foot-ulcers.
Stage 1 & 2 Pressure Injury
Stage 1 Pressure Injury: Partial Thickness, intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Colour changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. [6]
Stage 2 Pressure Injury: Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink, or red, moist and may also present as an intact or ruptured serum-filled blister. Adipose (fat), is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. [6] The most important aspect of the plan of care is protection of at-risk areas; regular turning and repositioning and the use of pressure reducing support surfaces is important to the success of a protection program.
Stage 2 Pressure Injury: Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink, or red, moist and may also present as an intact or ruptured serum-filled blister. Adipose (fat), is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. [6] The most important aspect of the plan of care is protection of at-risk areas; regular turning and repositioning and the use of pressure reducing support surfaces is important to the success of a protection program.
Incontinence associated dermatitis
Incontinence associated dermatitis, (IAD) is Inflammation of the skin that occurs when urine or stool comes into contact with skin from prolonged exposure to urine and/or stool. [9]
- Beeckman, D. and Global IAD Expert Panel. (2015). Incontinence associated dermatitis: moving prevention forward. Wounds International. Retrieved from http://www.woundsinternational.com/consensus-documents/view/incontinence-associated-dermatitis-moving-prevention-forward.