Document Category: Pathways

Venous Leg Ulcer (VLU): Characterized by edema of the legs with shallow irregular shaped wound(s) typically occurring on the medial or lateral distal lower leg. The ulcer is usually red but can also contain slough, yellow film or fibrin. Etiology of VLU is chronic venous hypertension. The failure of valves in the veins and/or ineffective calf muscle pump results in inadequate venous return from the legs

Traumatic Wound: Includes lacerations, abrasions and penetrating injuries, and usually involves skin/tissue being ripped or torn. These wounds often involve foreign bodies (gravel, glass, etc.) and are prone to infections

Surgical Site Complication: Any surgical wound that is not healing by primary intention and/or within an expected timeframe due to one or more complications i.e. infection, dehiscence, etc.
Note: Surgical wounds deemed “non-healable” should follow the Chronic Maintenance/Non Healing Wound ICP.

Pressure Injury: Localized damage to the skin and underlying tissue occurring as a result of intense and/or prolonged pressure with or without shear.
PRESSURE INJURY CLASSIFICATION:
– STAGE I – Patients identified as being at risk for the development of a pressure injury or intact skin with reddened area non-blanchable-
STAGE II – partial thickness loss of dermis presenting as shallow open injury with a pink red wound bed without slough, may also present as an intactor
open/ruptured serum filled blister
– STAGE III – full thickness skin loss, subcutaneous fat may be visible; but bone, tendon, or muscle are not; slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling
– STAGE IV – full thickness skin loss, with exposed muscle, tendon, or bone. Slough or eschar may be present, often includes undermining or tunneling.
– UNSTAGEABLE – Full thickness tissue loss in which the base of the injury is covered by slough and/or eschar in the wound bed
– DEEP TISSUE INJURY (DTI) – purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or sheer

Partial Thickness Burns (PTB): PTB can involve the epidermis and dermis and are characterized by pain, redness, edema &blistering. PTB can be life-threatening depending on age, comorbidities and the extent of the body surface involved. These burns can often be managed safely in the community or out-patient setting and may require hospitalization from time to time.
Full Thickness Burns: Destroy the epidermis, dermis and capillary network. Skin grafting may be required. They are typically managed in an acute care burn unit setting

Ostomy: An ostomy refers to a surgical opening in the abdomen, known as a stoma. The purpose of the ostomy is to divert waste out of the body through the stoma. The four most commonly encountered ostomies are as follows:
1. Colostomy – stoma is created when a section of the large intestine is brought to the surface of the abdomen. Output can vary from liquid or past-like stool to formed stool, with or without the presence of gas, depending on the type of colostomy.
2. Ileostomy – stoma is created when a section of the small intestine is brought to the surface of the abdomen. Output is dark green and will range in consistency from liquid to mushy, with gas.
3. Urostomy or ileal conduit – urine is diverted away from the bladder and expelled from the body through the stoma. Output is urine for a urostomy, and urine with mucous for an ileal conduit.
4. Mucous Fistula – stoma is created when two ends of the bowel are brought to the surface of the abdomen. Mucous created by the disconnected end of the bowel is released through one stoma, the mucous fistula.

Diabetic Foot Ulcer (DFU): DFU is a complication of diabetes mellitus characterized by a partial or full-thickness open wound with or without discharge. Cracks, fissures, or ulcers form as a result of acute trauma, callous formation, or repeated/persistent trauma. DFU may be complicated by pain and/or neuropathy.
Neuropathic Foot Ulcer: Neuropathic foot ulcers can occur in the absence of diabetes.

Acute Surgical Wound: Acute surgical wounds heal within an expected timeframe and without complications

Abscess: Collection of pus within inflamed tissue frequently caused by bacterial infection. The infection often damages the surrounding tissue creating a cavity.
Incision & Drainage: Common treatment for cysts or abscesses (including pilonidal sinus wounds) may include incision and drainage, where the abscess is incised and the debris is drained.
Pilonidal Sinus Wound: A pilonidal sinus wound is a cyst or abscess located near or at the natal cleft of the buttocks and often contains hair and skin debris.