When the Wound Isn't Pressure-Related

Hospital-acquired pressure injuries (HAPI) are quality indicators/measures that negatively impact patients and health-care facilities. Pressure is often documented as the etiology of skin damage although trauma, shear/friction, and moisture-associated skin damage are also responsible. Inaccurate documentation can be attributed to unknown events occurring prior to hospitalization, lack of patient history, and brief length of stay. This can lead to erroneous reporting of HAPI.

Determining the etiology of skin breakdown can be problematic. An atypical location/presentation of skin breakdown can impede diagnosis and delay care. Reviewing first-responder and ED notes may reveal significant physical findings such as the patient’s position when found (right/left side, run over/drug by vehicle, immobile for days, or helmet on when engulfed in flames). This information may determine wound etiology and, when present, “wound evolution”, a term used by military physicians to describe progression of traumatic injuries over time.

Examples of “wound evolution”:

• Adult male patient with right frontal skull deformity was documented as HAPI by nursing/physician staff. ED records revealed the patient was intoxicated, developed syncope and fell. CT scan confirmed a subdural hematoma. The scalp deformity was fall-related, not HAPI.
• Adult male patient was pedestrian versus car and sustained multiple pelvis factures. Sacral wounds were documented as HAPI by nursing/physician staff. Medical records/images revealed pelvic fractures correlated to location of sacral wounds. Trauma-related wounds, not HAPI.
• Teen-aged female jumped out of a moving vehicle, was run over then drug by another vehicle. Right frontal scalp wound was documented as HAPI by nursing/physician staff. ED records/images revealed right parietal scalp hematoma and laceration on admission. Trauma-related wounds, not HAPI.

Experience, knowledge and analysis of patient assessment and records are necessary to determine the etiology of skin breakdown. Wound, Ostomy, Continence Nurses have an opportunity to improve patient outcomes with research of trauma-related skin damage.