Evolution of Deep Tissue Injury

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 Clinicians need to determine whether the first appearance of skin injury is a stage I or II pressure ulcer or if it is a deep tissue injury (DTI).  A nurse might think a pressure ulcer is getting worse instead of the change being the progression of a DTI pressure ulcer.

There is evidence that demonstrates the layers of the skin are more resilient to pressure than muscle tissue, so many pressure ulcers start in the muscle.  Pressure ulcers can present within 24 hours of insult or can take as long as 5 days to appear. When there has been damage to the muscle tissue it may take days before there is any indication of a pressure ulcer on the surface of the skin.

A DTI initially presents as an area of intact skin with dark discoloration, such as purple, maroon, a bruise like appearance, or a blood-filled blister.  The tissue round the DTI area may be painful, firm, mushy, boggy, warmer or cooler than the adjacent tissue.

A stage I pressure ulcer will have light discoloration, light pink or light red on intact skin.  If the pressure ulcer initially presents with a fluid-filled blister versus a blood-filled blister, it is considered a stage II pressure ulcer.

Nurses may see a thin blister over a dark wound bed on the skin as the DTI evolves. The skin may open up which causes many clinicians to erroneously stage the DTI as a stage II pressure ulcer. You should continue to stage the wound as a DTI, and describe the characteristics of how the skin is blistering or has superficial open areas. The DTI may further evolve and become covered by eschar, further evolution may be rapid, exposing additional layers of tissue, even with optimal treatment. Once fully opened and exposing the level of tissue damage, the DTI can be accurately staged as a III or IV pressure ulcer.

Accuracy of the stage is important to assess the progress of the wound, also to determine appropriate interventions. The staging classifications system should be used for pressure ulcers to describe the level and type of tissue involvement. Accurate staging of a pressure ulcer can help residents receive appropriate treatment to achieve the best possible outcomes.

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