Wound Care

Wound Management, Products, and Support Surface Selection 287
• Underestimation of the total problem
• Underestimation of the total length of healing time and the
appropriate treatment
Muscle and subcutaneous tissues are highly susceptible to
pressure injury from either direct or shearing forces on segmental
and perforator arteries while cutaneous vessels often benefit
from nearby anastomozing vessels.
Individuals with neurologic, vascular abnormalities as in
diabetes mellitus and spinal cord injury have increased susceptibility
to pressure injury.
Definition: generally pressure ulcers are local areas of tissue
trauma over soft tissue that has been compressed between a
bony prominence and any external surface for a prolonged time
period. These ulcers are the result of mechanical injury to the
skin and underlying tissues.
The National Pressure Ulcer Advisory Panel (NPUAP) has
developed the following staging system for determining
amount and type of tissue involved in the ulcer:
• Stage I: an observable pressure related alteration in intact
skin whose indicators as compared to the adjacent or opposite
area on the body may include changes in one or more of
the following: skin temperature (warmth or coolness), tissue
consistency (firm or boggy feel), and/or sensation (pain, itching).
The ulcer appears as a defined area of persistent redness in
lightly pigmented skin, whereas in darker skin tones, the
ulcer may appear with persistent red, blue, or purple hues
(see Figure 3–2.).
• Stage II: partial-thickness skin loss involving epidermis or
dermis, or both. The ulcer is superficial and presents clinically
as an abrasion, blister, or shallow crater (see Figure 3-3).
• Stage III: full-thickness skin loss involving damage or
necrosis of subcutaneous tissue, which may extend down to
but not through underlying fascia. The ulcer presents clinically
as a deep crater with or without undermining of adjacent
tissue (see Figure 3–4).