Wounds and Ulcers: Know the Types and Causes

Pressure ulcer or tissue damage? A Crucial Difference

In the care and nursing sector, we have succeeded in implementing a great common awareness of wounds, and across professional groups, we are good at spotting even the smallest changes in the client's / resident's skin.

But through almost 7 years of teaching within the healthcare industry, I have become aware that many do not distinguish between pressure ulcers and other tissue damages. One of the reasons may be recent years' emphasis on reduction of pressure ulcers leading to the word 'wound' becoming synonymous with 'pressure ulcers'. 

Another reason, however, may also be a lack of knowledge about the different types of wounds and how they occur.

An incorrect categorization of the wound may mean that treatment and preventative measures are aimed at reducing pressure. However, if the tissue damage has occurred for other reasons, it is not certain that the wound heals using the same efforts as a pressure ulcer would.

Therefore, when the slightest redness or other visible change in the skin is observed, investigative work to identify the cause of the tissue damage and thus the type of wound in question should be initiated.

Pressure ulcer: Direct pressure on the skin

Most people are aware that direct pressure on the skin can cause pressure ulcers, bedsores, or decubitus.

Pressure ulcers are due to ischaemic necrosis and ulceration in the tissue, that has been exposed to prolonged pressure. The pressure might be caused by the bed, wheelchair, a cast, or from lying on an operating table.

Pressure ulcers can also occur if the client sits on a shower/toilet chair with an oversized hole, and therefore rests on the hip bone. It can also occur if the client accidentally lies on top of a catheter or a large crease in the sheet.

If pressure is suspected as the root cause of a wound or redness, it is necessary to review the client's everyday life to see if there are times during the day when the area is exposed to pressure. Eliminating or altering the situation where pressure occurs, is the first step in allowing the pressure ulcer to heal.

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Shear: Shear forces in the skin

Shear is a lateral shift of the layers of the skin, which is especially dangerous when the tissue is already exposed to pressure, because even with relatively modest shifts of the tissue, twisting the vessel can cause them to close.

Often, the cause of tissue damage can be found in a combination of both pressure and shear. When the skin is subjected to pressure and shear forces between the surface and bone, the circulation in the area is closed off, after which the tissue dies due to necrosis (cell or tissue death) after a short time.

Shear damage often occurs in the area around the coccyx and buttocks. Typical reasons for shearing are incorrect sitting position or forces from the bed's profiling properties e.g., by elevating the headboard or by tilting from side to side. Shear can also occur during patient transfer when we move the client by pulling and/or pushing on the client's shoulder/hip.

Shear is also seen when we hoist the client in and out of bed (if no friction-reducing aids are used), and when the client “walk” their wheelchair forward while sitting in it. These are just some of the places where the investigative work can begin.

Friction: Damage to the Epidermis

If we do not find that the tissue damage is caused by pressure or shearing, we must relentlessly continue our search for the cause.

Friction can be confused with both pressure and shear wounds. Where shear and pressure create damage in the tissue layers, friction creates damages to the epidermis. 

However, there is no evidence that friction can cause wounds, but experience from practice shows that if the epidermis is continually exposed to friction, the skin will be negatively affected over time.

The client can expose themselves to friction with involuntary movements e.g., due to motor disturbances or restlessness in the body.

Maceration: The moist skin

Maceration is a softening of the tissue when the skin is exposed to moisture and heat. This can occur when body fluids in the form of sweat and urine are in prolonged contact with the skin. If the skin is exposed to a constantly moist environment in this way, it becomes dissolved and very sensitive.

Clients who are incontinent and clients who use diapers are, of course, at risk of being exposed to maceration. However, also clients that are positioned using non-breathable material such as duvets and cushions are at risk of maceration injuries.

Duvets and cushions absorb the bodily fluids and create a moist and warm bed environment, causing increased sweating and moisture.

This means that if you discover tissue damage on a client who is very sweaty or wet due to incontinence, then replacing some of their duvets and cushions with breathable positioning cushions can be a good place to start besides using incontinence sheets with a high absorbency.

However, it is important to note that tissue damage due to moisture is not a pressure ulcer, but the risk of developing a pressure ulcer is increased as the tissue is already sensitive.

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Need for Interdisciplinary Efforts

It is far from an easy task to get a handle on tissue damages and wounds.

Often it is not enough to simply call in a nurse to treat the wound and establish a positioning regimen or implement an alternating air mattress. 

Instead, there is a need for interdisciplinary collaboration that also includes caregivers and therapists who have their daily contact with the client.

This is just a small part of the complex work that needs to start when redness or a wound is found on the client’s skin.