Myth # 5-An area of discolored intact skin is most likely a Stage 1 pressure ulcer or a bruise
A deep tissue injury (DTI) is commonly mistaken for a stage 1 pressure ulcer or a bruise. This is a serious error and can have a profound impact on patient outcomes, liability, and reimbursement.
What is a deep tissue injury (DTI)?
Deeper, full-thickness damage to underlying tissue which may appear as purple areas or dark necrotic tissue should not be confused with Stage 1 pressure ulcers.
The National Pressure Ulcer Advisory Panel (NPUAP) has defined wounds such as these as “A pressure-related injury to subcutaneous tissue under intact skin. Initially, these lesions have the appearance of a deep bruise”(NPUAP, 2002). DTI’s require rapid identification, as they may quickly progress to Stage 3 and 4 pressure ulcers despite aggressive and optimal treatment.
How do DTI’s form?
Fleck (2007) explains that DTI’s form over areas of bony prominence and occur from the inside out. Superficial damage is not seen until later, when tissue undergoes necrosis, reaching the outer layer of skin and resulting in the formation of an external wound. She further stresses that DTI’s can be differentiated from Stage 1 ulcers by their rapid deterioration despite proper care.
What are the legal implications of DTI’s?
DTI’s that are not recognized for what they are can have legal implications due to their ability to deteriorate despite stringent wound management practices. They result in increased costs and hospitalization, not to mention pain and suffering for the patient who develops one of these wounds, putting the health care practitioner and the facility at risk for litigation.
Salcido (2008) discusses the current Medicare changes that are scheduled to take effect October 1, 2008. These changes will have a huge impact on how hospitals are reimbursed. In regards to wound care, pressure ulcers will be considered hospital acquired (and therefore not reimbursed) unless these wounds are documented within 48 hours of admission. The onus is now on us, as healthcare professionals, to ensure that these wounds never develop, and if they do, they should be well documented and aggressively treated. This new policy is forcing us to examine our wound care management practices.
Documentation of DTI’s
Wounds that are suspected as being a DTI should be afforded a full description and the word “DTI” should be mentioned. For those practitioners who work in long-term care with the Minimum Data Set (MDS) documentation system, the word “unstageable” should be used to describe those wounds that are suspicious for DTI. Thorough and ongoing documentation is crucial in respect to DTI’s, as their rapid deterioration may make these wounds particularly tempting targets for litigation.
Education is the key to recognition and management of DTI’s
Understanding the etiology of DTI’s and learning how to differentiate these wounds from bruises, hematomas, and other closed wounds that may have a similar appearance is the key to prevention and treatment of these wounds, which have the potential for significant morbidity for patients, as well as being potentially litigious.
Woundeducators.com strives to provide you, the healthcare professional, with the information you need to recognize and treat DTI’s and other wounds. Our online wound care certification course can give you the tools you need to protect your patient, yourself, and your agency. If you are interested in becoming wound care certified contact us today, and you can be on your way to an exciting new career.
{ 6 comments… read them below or add one }
It is so important to understand deep tissue injury. One of our nurses was documenting a heel ulcer as a bruise, and a week later it became a huge ulcer. The patient and family thought our agency was responsible. I guess they are right, Had this nurse assessed and documented correctly, even though it may not have been prevented, at least our agency wouldn’t be blamed.
On an OASIS what do you choose for suspected deep tissue injury?
The new pressure ulcer stage of “Suspected Deep Tissue Injury” is not represented in the current OASSIS pressure ulcer items. If the physical wound characteristics of the suspected DTI meet the descriptions included in the staging definitions for pressure ulcers currently listed in M0450, then the DTI should be reported. If the suspected DTI does not meet the descriptions included in the staging definitions currently listed in M0450, it should not be reported in any of the OASIS pressure ulcer items (M0445-M0464) but would be reported in the clinical documentation.
CMS OCCB Q&As – October 2007
I received a gun shot wound to the hand, only going through the meaty portion just below the pinky and out the side, with a lot of gun powder residue. I went to emergancy care and they flushed the entire wound wrapped it and said it has to heal from the inside out gave me prescription for antibiotics. What do I do Know for treatment? How often do I change bandages I know what the bad signs are do I use peroxide or just betadine…. I am a reited army sergeant been blown-up but never shot had to become a civilian to do that…. LOL
I am so lucky it wwas a small caliber and missed every thing though my picky does kind of point the wrong way. feel everything and can cletch a fist. But hay its only day two… So any way I would aprecieate any input as to what care I need now……
Thanks
Tim
Hi Tim,
I am sorry to hear about your wound. There are many things that need to considered when determining the optimal course of treatment for a wound. I recommend that you contact a certified wound specialist. Practitioners who have earned certification in wound care have a good understanding of the physiology of wound healing and current treatment modalities. You can search for wound specialist at the AAWM website. http://www.aawm.org. Good luck!
my son stumbled on the floor four weeks ago, he fell on his face and acquired a large bruise..i was afraid that he had a fracture of the cheek bone so i had him x-rayed that day…x-ray results revealed no fracture…i just did cold compression on his face for 24 hours…and after 24 hours i did heat compress up until now…it’s been almost 4 weeks now, the bruise is gone but there is a hardened part on his cheek that was left…it’s color is blackish and it appears as if it was dimpling or should i say there is a depression on his face…i really dont know what or how to call or term that…Im really bothered by my son’s facial problem…any comments or inputs would be highly appreciated…thank you so much…
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