Is it a Pressure Injury? Factors to Consider When Determining Wound Etiology

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Medical Device-Related Injury

by Holly M. Hovan MSN, APRN, ACNS-BC, CWOCN-AP

As specialists in wound, continence and ostomy care, we are forever in a role of wearing many hats. We are educators to patients, staff, and providers… we are patient advocates and supporters of our bedside nurses… we are liaisons in many aspects of care and help to coordinate care and services for our patient population. We are often referred to as the specialist and are called upon when there is a patient with a wound, skin, ostomy, or continence concern. Our peers trust us, and it is important that we possess the knowledge and skills to share with others when determining etiology and treatment of wounds and skin issues.

Determining Wound Etiology

An issue we are often faced with as skin specialists is determining the etiology of wounds and skin concerns. When determining the etiology of wounds, it is important to look at the entire picture…and, when doing so, understand that many variables can and do make wounds better or worse, but there is usually an isolated variable that caused the wound.

Medical Device-Related Pressure Injuries

Some things to keep in mind: Pressure injuries are usually round, can appear punched out, may be partial- or full-thickness, may have slough or necrotic tissue, and are usually over a bony prominence. In terms of shape, pressure injuries related to devices usually take the shape of that device (think of a linear, fluid-filled blister from Foley catheter tubing on the thigh… a stage 2 medical device-related pressure injury, or a purple or discolored, non-blanchable area on the lip from an endotracheal tube… a mucosal pressure injury). Other devices that may be responsible for pressure injuries are prosthetic devices (prosthetic limbs, shrinkers, hearing aids) and tubes (Foley catheters, endotracheal tubes, feeding tubes, nephrostomy tubes, fecal management system tubes)—always be sure that your tube is secured with an appropriate tube securement device to prevent pressure injuries! Other devices sometimes responsible for pressure injuries are foot pedals on chairs, bed pans, external catheters, shoes, and glasses. One of my mentors always said, "if your patient was not born with it, and they have it now, you need to check under or around it!" Device-related rounds are also helpful in areas that have a high incidence of medical device-related pressure injuries… this helps to bring awareness to the different types of devices we should be checking for and helps nurses to understand pressure injuries versus wounds or skin issues not related to pressure.

So, to reinforce: Always look back at what caused the wound, not what contributed to the wound happening. Conditions such as diabetes, peripheral vascular disease, incontinence, immobility, poor nutrition, and impaired sensory perception are all contributing factors to pressure injuries.

Always remember to look at the big picture, the main culprit of the skin injury, and consult your skin specialist with any questions! Take an interdisciplinary approach for prevention and healing, and be sure that everyone is on the same page. Frequent communication among the interdisciplinary team members and involving the patient or family in the plan of care definitely help with prevention.

End-of-Life Skin Failure

One more thing to mention briefly… skin failure. Skin failure occurs at the end of life (hours to days), and although it can be related to pressure, the real cause of it is just that… skin failure. When all prevention measures are in place and our patient still develops a wound at the end of life (hours to days), it is usually related to skin failure. The skin is our largest organ, and much like other organs, it can fail us, especially when near death. I will discuss this topic more in future blogs!

About the Author
Holly Hovan is a WOC nurse at the Cleveland Veterans Affairs Medical Center in long-term care/geriatrics. She has been practicing as a WOC nurse since 2013. Ms. Hovan has a passion for education, our veteran population, and empowering others to learn and succeed.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.

Comments

So is it ok to call it skin failure rather than stage the area? Is CMS ok with this definition?

Good information. Thank you

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