Defining Pressure Ulcers and Skin tears A pressure ulcer according to the National Pressure Ulcer Advisory Panel (2009, no page) is "... localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure, or pressure in combination with shear. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors has yet to be elucidated.” Skin tears however are considered to be traumatic injuries, varying from minor to complex wounds, which can result in the development of partial or full thickness injuries, where the epidermis has separated from the dermis or both layers of skin have separated from the underlying structures (LeBlanc and Baranoski, 2012).
Management Simple steps to consider include: Control of any bleeding and cleaning of the wound according to local policy. If the wound is a skin tear and it is feasible and viable, to realign any skin flap or tear. Assessment of the patient, their wound and the peri wound area adhering to local policy documents, in order to assess the degree of tissue damage or loss. This may include the use of either a pressure ulcer or skin tear classification tool, depending on the diagnosis. Apply appropriate dressings according to local policy dressing formulary. Referral to appropriate healthcare practitioner for follow up dressings. Discussion with the patient regards to findings and health education and promotion. Completion of any clinical incident or safety thermometer report forms.
References Carville, K., Lewin, G., Newall, N., Haslehurst, P., Michael, R., Santamaria, N., and Roberts, P. (2007) STAR: a consensus for skin tear classification. Primary Intention. 15(1), pp:18-28 Fletcher, J. (2012) Device Related Pressure Ulcers Made Easy. Retrieved from http://www.woundsinternational.com/pdf/content_10472.pdf http://www.woundsinternational.com/pdf/content_10472.pdf LeBlanc, K., and Baranoski, S. (2011) Skin Tears: State Of The Science: Consensus Statements For The Prevention, Prediction, Assessment, And Treatment Of Skin Tears. Retrieved from http://www.skintears.org/pdf/SkinTearsConsensusStatements.pdf http://www.skintears.org/pdf/SkinTearsConsensusStatements.pdf National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory panel. (2009) NPUAP Pressure Ulcer Stages/Categories. Retrieved from http://www.npuap.org/resources/educational-and-clinical- resources/npuap-pressure-ulcer-stagescategories/ http://www.npuap.org/resources/educational-and-clinical- resources/npuap-pressure-ulcer-stagescategories/