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Deep Tissue Pressure Injury
Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. These areas may resolve with pressure relief, or may evolve into full thickness tissue injury even with pressure relief. [6]
Note: Major intervention is pressure relief/reduction, monitoring the skin and keeping it clean.
Note: Major intervention is pressure relief/reduction, monitoring the skin and keeping it clean.
- 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.
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.
Medical Device Related Pressure Injuries
(MDRPI) result from the use of devices designed and applied for diagnostic or therapeutic purposes. The resultant pressure injury generally conforms to the shape of the device. [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.
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.