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Stage 3 Pressure Injury: Full-thickness skin loss in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. [6]

Stage 4 Pressure Injury: Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. [6]

Traumatic injuries occur when an external or foreign object strikes the body.  These injuries are commonly caused by motor vehicle crashes, bullets, natural disasters, explosive blasts, falls and industrial accidents.  Traumatic wounds may damage bone and/or internal organs, are not created surgically, and always are viewed as contaminated and at risk for infection. [18]

In-closed wounds, primary closure, the skin edges are re-approximated by stitches, staples, tissue adhesives or adhesive strips and left to heal by primary intention. [7]

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]

A burn is an injury to tissue that may be caused by dry heat, such as fire or contact with a hot surface, or moist heat, such as steam or hot liquids, chemicals, electricity, lightning, or radiation from either the sun or radiotherapy. Burns vary in severity depending on the extent of tissue damage: superficial, superficial -partial thickness, deep partial thickness, or full thickness. They are classified according to the total body surface area effected by the damage and sometimes classified by first, second, or third degree depending on the depth of the burn. Third degree burns are full thickness. Control of bacteria and reduction of pain associated with dressing changes is very important with burns and antimicrobial dressings can address these concerns. ConvaTec offers dressings that are helpful with burn care both for the burn, and the graft harvest area when skin grafts are required. [1,2]

A leg ulcer is the breakdown in tissue on a leg or foot resulting from alterations in either the arterial or venous vessels, or both, in the lower leg.   Venous leg ulcers are the most common type of leg ulcers and are the result of poor venous return to the heart resulting in sustained venous hypertension, causing swelling and tissue damage in the lower leg. [5]

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]

A diabetic foot ulcer is associated with a loss of sensation and/or peripheral arterial and/or structural changes in the lower limb as a result of diabetes.  It may be associated with pressure from ill-fitting footwear and these injuries are often on the tips of the toes or on the plantar surface of the head of the first metatarsal.  [3, 4]

Open surgical wounds are left to heal by secondary intention, which involves leaving wound to heal naturally, and relies on granulation tissue arising from the base of the wound to fill the tissue deficit created by surgery. [7]

Stage 1 Pressure Injury: Partial Thickness, intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Colour changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. [6]

Stage 2 Pressure Injury: Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink, or red, moist and may also present as an intact or ruptured serum-filled blister. Adipose (fat), is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. [6] The most important aspect of the plan of care is protection of at-risk areas; regular turning and repositioning and the use of pressure reducing support surfaces is important to the success of a protection program.

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.