Simplifying the simple: pressure-based tissue injuries for dummies

Abstract

Journal of Wound CareVol. 27, No. Sup1 Supplement EditorialFree AccessSimplifying the simple: pressure-based tissue injuries for dummiesMichael MillerMichael MillerSearch for more papers by this authorMichael MillerPublished Online:15 Jan 2018https://doi.org/10.12968/jowc.2018.27.Sup1.S3AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail Like any other medical speciality, wound care has concepts that range from the ludicrously simple to the Einsteinian complex with the majority somewhere in between. The ‘self driving’ car is a complicated hardware and software ballet and yet, it is sold to the public simply as the ‘self-driving car.’ The trend from complicated to simple seems to be a universally requested progression, except for the concept of injuries occurring to the human body. Entities like the NPUAP have made attempts to universalise our understanding of not just how, what they now are calling ‘pressure injuries’ occur, but the many cousins that may or may not have a related or interrelated effect. The end result has been an increasingly complicated and poorly understood spectrum of what used to be called the humble ‘bedsore’.While I applaud their efforts to create the all-encompassing matrix that explains every nuance of these injuries, what they have done instead is created a pressure-based tissue injury (my preferred term) Tower of Babel. At its most basic, the issue is that the complexities of ‘mandatory’ staging across the spectrum of care entities has resulted only in universal disagreement of how to explain these injuries. However, staging is where the rubber truly slips from the road. Unless you have microscopic eyes that can identify the tissue type at the base of any wound that has been pressure, friction or shear tortured into submission, and then slathered in a healthy dose of IAD (incontinence associated dermatitis—another term under the auspices of numerous wound confounding bodies), the uniformity of staging of any given pressure-based tissue injury resembles a freshly twisted Rubik's Cube. So, how do we simplify this perpetually and increasingly perceived conundrum of desired simplicity and reproducibility in light of the zeal to keep the basic and simplest concepts obfuscatedIf we agree that the skin and its being intact is the most basic issue regarding pressure-based tissue injuries, then we need to keep the definition focused on that. Yes, what are called deep tissue injuries (DTI) unquestionably exist, but they go unrecognised unless skin loss exposes the damage. If these resolve, it is more often the luck of the draw and not due to any herculean interventions, the reality is that the single difference in treatment between what is called a category 1 and DTI is unquestionably ‘prayer’! Pressure reduction is the treatment, no dressings, ointments or unguents are used and so a simple prayer that the DTI does not progress is the only interventional difference.If the issue is the presence or absence of the skin then let us use that as the leading edge of our sword. Recognising that the entire scenario is in constant motion, getting better or worse, then trying to pick a single point in time on which to base a decision is akin to threading a needle while riding a skate board on a moving train. In the simplest terms, we go with the concepts based solely on the presence or absence of the protective skin. The complexity is now resolved and simplified into open or closed. If Zinc Oxide skin cream sticks to the area, despite evidence of DTI, it's still called closed. Since the ultimate goal is to mitigate the effects of pressure on the tissues, then the goal is to do so regardless of the means or manner in which they affect the tissues or other related factors.Trying to decide what tissue is at the base of an epithelial defect when the real issue is that offloading is needed is misdirection. The question of what to put into that skin defect is based on three simple questions: where is it located, how much drainage is there and, lastly, what are you trying to do (grow granulation tissue, epithelialise, remove slough, etc.) With this in mind, and the concept of open and closed for pressure-based tissue injuries, then the entire spectrum of issues to be considered becomes simple.Instead of trying to tease out every nuance of these all too common presentations of skin and tissue injury, the fundamentals are what remain the same and on which we must base the continuum of care. What occurs is pressure based and thus, simple. Attempting to simplify it any more is something that only Dummies need to buy books for. FiguresReferencesRelatedDetails 1 January 2018Volume 27Issue Sup1ISSN (print): 0969-0700ISSN (online): 2052-2916 Metrics History Published online 15 January 2018 Published in print 1 January 2018 Information© MA Healthcare LimitedPDF download