INTRODUCTION

I believe that we, as a society of WOC nurses, must address the issue of how to accurately describe pressure injuries occurring in the naris. Inconsistencies will affect not only our facility data but also national data used for benchmarking.

Using a free online survey tool, I showed a convenience sample of 42 WOC nurses 4 photographs of pressure injuries to the skin at the edge of the naris opening caused by nasogastric or nasoenteric tubes. One wound was covered by eschar, 2 were erosions with red tissue in the base, and 1 showed purple discoloration to the skin. I asked them to reply anonymously and classify the skin injury using the choices: mucosal, unstageable, stage 2, stage 3, stage 4, or deep tissue pressure injury. Depending on the photograph, 33% to 69% of respondents classified the injuries to skin as mucosal pressure injuries. These data lead me to believe we may have serious inconsistencies in our collective pressure injury incidence and prevalence data when applied to the nares.

When evaluating the nose, it is important that WOC nurses understand where the skin ends and the mucous membrane starts. The key area in this conversation is the nasal vestibule. Figure 1 shows a cross section of a human cadaver with the nasal vestibule delineated.1 Notice how far up the naris that the vestibule extends. The nasal vestibule is a pear-shaped opening that comprises the entrance to the nasal cavity. It is bordered by the nasal septum and columella medially, the lower lateral nasal cartilage laterally, and the premaxilla cartilage inferiorly. The vestibule terminates at the limen nasi posteriorly. It also comprises the junction of the lower and upper lateral cartilages and demarcates the transition from skin to mucosa. The vestibule is lined by skin that contains hair follicles, sebaceous glands, and sweat glands.2Figure 2 shows the borders of these landmarks exteriorly. By applying pressure on the tip of the nose and using a penlight, the clinician can get a partial view into the nasal vestibule. It requires the use of an otoscope and the largest ear speculum to see the inside of the nose to the depth of the nasal mucosal tissue.3

Figure 1. This cross section through the midline of a human cadaver head allows us to see how far the skin of the nasal vestibule extends up the naris.

Figure 2. This photograph outlines the borders of the nasal vestibule: nasal septum/columella, the junction of the lower and upper lateral nasal cartilages, and the alar cartilages.

I searched the Journal of Wound Ostomy and Continence Nursing (the WOCN Society's official publication) to improve my understanding of this issue. I found no article dealing specifically with pressure injuries to the naris from feeding/sump tubes and how to classify them. Edsberg and colleagues4 define medical device-related pressure injury (MDRPI) and mucosal membrane pressure injury in their revised staging system. They note that the mucosal tissues are at increased risk for pressure injury from medical devices such as oxygen tubing and orogastric and nasogastric tubes.4 The revised staging system defines a pressure injury as localized damage to the skin and underlying soft tissue; in contrast, a musical pressure injury occurs on a mucous membrane occurring in the context of a medical device in use at the location of the injury. Because of difference in the histology of mucosal tissues, these injuries cannot be staged. Edsberg and colleagues4 further clarify that MRDPIs are caused by devices designed and applied for diagnostic or therapeutic purposes. The resultant pressure injury generally conforms to the pattern or shape of the device, and these injuries should be staged using the current staging system.5

Pressure-related damage to the lips, tongue, and mouth are examples of mucosal membrane pressure injuries. However, I submit that pressure-related damage to the nasal vestibule is not. Given what we know about nasal anatomy and in keeping with the revised staging system promulgated by the National Pressure Ulcer Advisory Panel,4,5 I propose that damage to the opening of the naris (the nasal vestibule) be categorized as a stage 1-4 pressure injury, unstageable pressure injury, or deep tissue pressure injury. I also encourage readers to critically explore the topic of pressure injury associated with nasogastric or nasoenteric tubes. I urge you to carefully consider the following question: "In addition to the visible damage to the skin of the nasal vestibule and exterior nose, is there also damage to the nasal mucosa?" Grab your otoscopes and let's go.

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