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Other Wound Types and Skin Injuries

Terms in this set (41)

Wound types and skin injuries often misclassified as pressure ulcers include:
Skin Tears
Venous Ulcers
Arterial Ulcers
Diabetic Foot Ulcers
Incontinence-Associated Dermatitis
Skin Tears
A wound caused by shear, friction, and/or blunt force resulting in separation of skin layers.

A skin tear can be:

Partial Thickness
(separation of the epidermis from the dermis)

OR

Full Thickness
(separation of both epidermis and dermis from underlying structures)
Skin Tear Causes
Causes

Blunt trauma from accidently bumping into objects
Friction/shear injury or mechanical trauma during provision of ADLs
Transfers and falls
Equipment related injury
Tape removal/adhesive dressing removal
Skin Tear Risk Factors
Intrinsic

Older age
Altered mobility
Dependence in ADLs
Compromised nutrition or hydration status
Cognitive impairment and decreased sensation
History of skin tears

Extrinsic

Corticosteroid and anti-inflammatory medication use
Chronic disease polypharmacy
Dry skin from frequent bathing and/or use of skin cleansers that reduce natural skin oils
Corticosteroid
Decrease the production of body chemicals that trigger inflammation. Inhaled, they can prevent inflammation in the respiratory tract and reduce inflammation that has already started. DRUGS: beclomethasone (QVAR), budesonide (Pulmicort), flunisolide (AeroBid), fluticasone (Flovent), triamcinolone (Azmacort).
polypharmacy
The use of many different drugs concurrently in treating a patient, who often has several health problems.
Skin Tear Location & Skin Assessment
Location

-Most commonly - upper and lower extremities
-Other body areas

Associated Skin Assessment

-Thin skin appearance due to changes associated with aging
-Epidermal thinning
-Decreased dermal thickness
-Subcutaneous tissue loss
-Decreased skin elasticity and tensile strength
-Surrounding purpura or ecchymosis
purpura
A condition characterized by multiple pinpoint hemorrhages and accumulation of blood under the skin, producing purplish discoloration of the skin; merging ecchymoses and petechiae over any part of the body
ecchymosis
Black and blue skin discoloration caused by hemorrhage. Bruise.
International Skin Tear Advisory Panel (ISTAP) Skin Tear Classification
Type 1 - No skin loss: linear tear or flap tear that can be repositioned to cover the wound bed

Type 2 - Partial flap loss: partial flap loss that cannot be repositioned to cover the wound bed

Type 3 - Total flap loss: total flap loss exposing entire wound bed
Payne-Martin Classification System for Skin Tears
Category I - Skin tears without skin loss

Category II - Skin tears with partial-thickness skin loss

Category III - Skin tears with complete tissue loss
STAR Skin Tear Classification System
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Skin (Epidermal) Stripping - Neonates
A type of wound found in neonates that results in the separation of skin layers is epidermal stripping.

-Causes

Tape removal/adhesive dressing removal

-Risk Factors

Neonatal prematurity
At 24 weeks, the epidermis is thin with poorly formed stratum corneum

At 30 weeks, the stratum corneum in only 2 to 3 cells thick

At 36 weeks to term, the epidermis and dermis are only about 60% as thick as an adult

Cohesion between the dermis and epidermis are diminished

-Associated Skin Assessment

Thin skin if the subcutaneous fat layer is not fully developed

-Wound Characteristics

Partial thickness tissue loss
May result in full thickness tissue loss if the neonate lacks subcutaneous tissue
Arterial Ulcers
A wound caused by impaired arterial blood flow to the lower leg and foot.

The impairment in blood flow results in tissue ischemia, necrosis, and loss.
Arterial Ulcer Causes
Causes

Most commonly - Atherosclerosis
Arteriosclerosis
Atherosclerosis
A disorder in which cholesterol and calcium build up inside the walls of the blood vessels, forming plaque, which eventually leads to partial or complete blockage of blood flow.
Arteriosclerosis
A disease of the arterial vessels marked by thickening, hardening, and loss of elasticity in the arterial walls.
Risk Factors for Atherosclerosis/Arteriosclerosis
Age
Smoking
Diabetes Mellitus
Hypertension
Dyslipidemia
Obesity
Family history of cardiovascular disease
Dyslipidemia
Disorder in serum lipid levels, which is an important factor in development of the artherosclerosis. Includes hyperlipidemia (high lipids), hypercholesterolemia (high cholesterol), and hypertriglyceridemia (high triglycerides)
Arterial Ulcer Location
Toes, dorsum of the foot, lateral malleolus, distal lower leg
Alterial Ulcer Assessment
Associated Skin Assessment

Cooler skin temperature
Thin, shiny skin
Decreased or absent skin hair
Decreased pulse strength in affected extremity
Skin pallor on foot elevation; dusky rubor on dependency
Dystrophic toenails

Characteristics

Round and regular in shape
Pale wound bed
Can be shallow in depth or relatively deep
Smooth wound edges
Gangrenous/necrotic tissue may cover the wound
Minimal drainage
Severe pain

Classification System

Arterial ulcers are usually classified as partial thickness or full thickness wounds
Venous Ulcers
A wound caused by venous system dysfunction that leads to poor blood outflow from the lower extremities and venous hypertension.

Prolonged venous hypertension results in vessel injury/damage. This increases capillary permeability and allows the extravasation of micromolecules and macromolecules into the surrounding tissue. Damage to these tissues leads to venous ulcer development.
Venous Ulcer Risk Factors
Older age
Obesity
History of venous disease or thromboembolism
Trauma to the legs
Female
Pregnancy
Occupation that involves standing for a long period
Smoking
Venous Ulcer Location
Between the knee and the ankle
Often seen between the lower calf and ankle (the gaitor area)
Location on the medial lower leg is more common than the lateral lower leg
Venous Ulcer Assessment/Characteristics
Associated Skin Assessment

Hyperpigmentation of lower calf and ankle skin from hemosiderin staining (leakage of red blood cells into the tissue)
Lipodermatosclerosis (hardened skin) from thickening and fibrosis of normal adipose tissue
Edema that may worsen with prolonged standing
Dry scaly skin that may be itchy
Weepy skin
Evidence of healed venous ulcers

Wound Characteristics

Typically shallow in depth
Irregular in shape
Defined wound edge
Moderate to large amount of drainage is common
Variable pain (mild to severe)

Classification System

Usually classified as partial thickness or full thickness wounds
malleolus
Ankle
Diabetic Foot Ulcers
A wound on the foot of a person with diabetes.
DFU Causes
Causes

-Peripheral neuropathy
-Sensory neuropathy leads to loss of protective sensation
-Motor neuropathy causes an imbalance between flexor and extensor muscles leading to foot deformities that create abnormal bony prominences -Autonomic neuropathy alters blood flow in the foot and sweat and oil gland function leaving skin dry
-Peripheral vascular disease with poor microvascular circulation
-Leads to tissue ischemia
-Repetitive mechanical stress or excessive pressure
-Less well noticed or not noticed because of sensory neuropathy
-Poorly controlled blood glucose levels
It accelerates the development of arterial disease
neuropathy
Any abnormal condition characterized by inflammation and degeneration of the peripheral nerves.
DFU Additional Risk Factors
Smoking
Visual impairment or retinopathy
Obesity
Poor foot care preventive practices
Previous foot ulcerations
DFU Locations
Common sites - toe interphalangeal joint, metatarsal head, plantar surface of the foot, under heel
DFU Assessment & Characteristics
Associated Skin Assesssment

-Decreased sensation in the foot
-Warm skin, may be dry
-Plantar fat pad atrophy
-Foot deformities such as hammer toe, claw toe, and Charcot's foot

Wound Characteristics

-Depth varies from partial thickness to full thickness with bone involvement
-Regular wound margins
-Often surrounded by a rim of calloused tissue
-Low to moderate amount of drainage
DFU Classification Systems
Meggit-Wagner Classification System
Grade 1 - Superficial diabetic ulcer
Grade 2 - Ulcer extends to ligament, tendon, or joint without abscess or osteomyelitis
Grade 3 - Deep ulcer with abscess or osteomyelitis
Grade 4 - Gangrene to portion of forefoot
Grade 5 - Extensive gangrene of foot

University of Texas Diabetic Wound Classification System
Stage A to D based on infection and ischemia
Grade 0 to 3 based on ulcer depth
Charcot's Foot
Neuropathic osteoarthopathy involving both sensory and motor loss creating a convex foot with a rocker-bottom appearance; usually associated with diabetes
Moisture-Associated Skin Damage
A term used to describe skin conditions that are the result of exposure to moisture.

Defined as inflammation of the skin and erosion from prolonged exposure to moisture and its contents.

Common sources of moisture include urine and stool, perspiration, wound exudate, and effluent from an ostomy.
effluent
A liquid, solid, or gaseous discharge from the ostomy. Usually composed of fecal material.
ostomy
SURGICALLY CREATE AN OPENING
Incontinence-Associated Dermatitis (IAD)
A form of moisture-associated skin damage.

Caused by prolonged exposure to urine, stool, or both that irritates the skin leading to erosion.

-Urine overhydrates exposed skin increasing the risk for friction injury
-Ammonia in urine elevates skin pH impairing its barrier function
-Fecal enzymes weaken epidermal integrity. Liquid stool is particularly irritating to the skin.

Other names for Incontinence-Associated Dermatitis have included Perineal Dermatitis and Diaper Dermatitis.
IAD Risk Factors & Assessment
Risk Factors

-Use of absorptive products that cover the skin (diapers, incontinence brief, incontinence pad)
-Diminished tissue tolerance
-Influenced by patient age, health status, nutritional status, oxygenation, body temperature
Impaired toileting ability

Location

-Buttocks, perineum, perianal area - may extend to inner and posterior thighs

Associated Skin Assessment

-Diffuse erythema of the skin surface
-Erythema is brighter red in persons with lighter skin tones
-Erythema is subtle red in persons with darker skin tones
-Edema may be present
-Areas of skin maceration may be observed
-Secondary cutaneous infection
-Irritated/impaired skin is more easily invaded by microorganisms
-A secondary fungal infection (from Candida Albicans) is seen as a maculopapular rash with satellite lesions
maceration
In its broadest sense, refers to the moistening, and softening, of any tissue decomposing in a liquid medium.
IAD Wound Characteristics & Classification
Wound Characteristics

-Usually partial thickness skin loss
Ranges from one or more islands of erosion to extensive denudation of the epidermis and dermis
-Irregular and indistinct borders/edges
-No exudate or clear, serous exudate which can cause the skin to glisten
No slough or eschar
Burning pain, itching

Classification System

-Incontinence-Associated Dermatitis Intervention Tool
-Incontinence-Associated Dermatitis Severity (IADS) Instrument
-Body location of incontinence-associated dermatitis
Magnitude of erythema
Presence or absence of skin erosion
Presence or absence of skin rash
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