Is it a Pressure Injury?

     Factors to Consider When Determining Wound Etiology


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 … read more