skin tear stings, decubitus does not?

mariebailey, MSN, RN · Sep 9, 2012

I can't say with certainty that it is true, but I do know that there are many terminal nerve endings and pain receptors in the layers of the skin, especially the basal layers, that are not found in deeper layers. When I give IM injections, I almost never hear a patient complain that it stings. An intradermal PPD, I can say from personal experience, does sting. With a decubitus, those layers that contain most of the pain receptors may be gone. I'm not saying this means that is the accurate criteria for classifying a wound; I'm just suggesting some rationale behind their statements.

CapeCodMermaid, RN · Sep 9, 2012

I've never heard of such a thing. A healed/resolved pressure ulcer will always be more prone to breaking down again.

mariebailey, MSN, RN · Sep 10, 2012

I just read your post for a 2^nd time. Please disregard my 1^st response; I don't think I grasped your concerns initially. I totally agree that it shouldn't be reverse-staged. I do like the "stings or not stings" classification system though, and I think it should be part of the NDNQI pressure ulcer training . Not really.

redfoxglove · Sep 10, 2012

Thanks for your comments, ladies. I've been thinking about it, and I am going to seek more clarification tomorrow.

I am sure that certain decubiti have extensive damage to the nerves and are not painful. However, when the skin over a Stage II (closed) looks like small blisters and is opening again, I don't think it's accurate to say it is a skin tear. I think it is a Stage II (formerly closed) that is reactivated.

The skin, in that case, may sting when cleansing agents are applied. That does not make this lesion a skin tear. It is a reactivating Stage II.

If there is no history of a Stage II there, open skin over the ischial tuberosities may be a skin tear, simply. Or, it might be the first sign of a decubitus over the tuberosity.

I think the preceptor may have hastily interpreted some information that had been passed to her by the team leader. It's worth more clarification.

All this to say, I noticed on this website a certification course for RNs who are not BSNs. I think I will look into it.

Thanks again.

PalmHarborMom · Sep 10, 2012

I would be careful with the "stings or doesn't sting" theory. My husband had a pressure ulcer on his foot which was then infected with MRSA. It had to be extensively surgically debrided, to the point that about 1/3 of his foot was down to bone & tendon. So one can assume that most of the nerves were gone that had been close to the skin. About a week after surgery, a nurse tried using an spray to clean the wound. Not only did it sting, it sent him reaching for the ceiling to get away from her. Nerve damage is not an absolute when it comes to decibitus ulcers. It may happen but do not assume that it is always the case.

mindlor · Sep 10, 2012

While doing field orientation for home health, my preceptor quoted our team leader as follows: When the skin opens over an old, formerly closed, Stage II decubitus, the defining factor as to whether it is defined as a skin tear is if it stings when cleansing solution is applied. According to the preceptor, a skin tear will sting and a decubitus will not.
I am only out of school for a year, but to me, this sounds arbitrary and inaccurate. To my recall, the most current evaluation criteria of decubiti is, they are never reverse staged. Once a lesion, always a lesion, and it is either closed or open.
I have never heard of the "stings or not stings" discriminator.
Comments?

First,

Decub etc is an antiquated term. Modern literature uses the phrase "pressure ulcer"....

Second, pain is what it is for each patient and each patient and each situation must be assessed on an individualized basis....

Third,

My teaching says that pressure ulcers are never reverse staged.......

redfoxglove · Sep 14, 2012

First,
Decub etc is an antiquated term. Modern literature uses the phrase "pressure ulcer"....
Second, pain is what it is for each patient and each patient and each situation must be assessed on an individualized basis....
Third,
My teaching says that pressure ulcers are never reverse staged.......

Laughing out loud! Of course, pressure ulcer, not decubitus. I must not have been fully awake!

followyourbliss · Sep 15, 2012

Hi Everyone,

In regard to staging pressure ulcers; once it is staged it is always referred to as a Stage 2,3,4 etc. If it is healing it is a healing stage 2, 3 or 4. It can take years for the re-modelling of tissue, and even then it may only achieve 60-80% of it's previous tensile strength. This of course exposes that area to re injury of any kind due to the fragility of the tissues.

Pertaining to the issue of the "skin tear" and the skin prep/alcohol test ...this is murky to use as a clinical tool as there are so many mitigating factors that contribute to this being perhaps a less than solid practice. Many people have LOPS- Loss of Protective Sensation, Neuropathies, scar tissue, impaired sensation, and impaired cognition. Many etiologies blunt sensation.

In addition pressure ulcers often have/are different stages all at once - when healing as well as deteriorating. In regard to "pain" again depending on location and etiology there many be no pain, intense pain, or new pain with presentation of infection.

Great to see Wound chats happening!

Regards,

Follow Your Bliss

followyourbliss · Sep 15, 2012

Hi,

I meant to say that a skin tear, pressure ulcer, excoriation, incontinent associated dermatitis etc all have different causes and often accidentally interchanged and mis- labelled.

:)

mommy.19, MSN, RN, APRN · Sep 19, 2012

Wounds are diagnosed/"labeled" based on their etiologies, as the previous poster said--not the amount, presence or absence of pain in said wound. The instructor's statement is absurd! Shear/friction/trauma causes skin tears and pressure causes pressure ulcers.