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What is a Deep Tissue Injury?

August 6, 2013 17 Comments

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Deep Tissue Injury ExampleA deep tissue injury is a unique form of pressure ulcer. The National Pressure Ulcer Advisory Panel defines a deep tissue injury as “A pressure-related injury to subcutaneous tissues under intact skin. Initially, these lesions have the appearance of a deep bruise. These lesions may herald the subsequent development of a Stage III-IV pressure ulcer even with optimal treatment.”(NPAUP, 2005). Why is it important to have yet another stage for pressure ulcers? The answer lies in the fact that, even with proper treatment, deep tissue injuries can deteriorate quickly into your worst nightmare.

The Problem With Deep Tissue Injuries

The problem with deep tissue injuries is that they are not readily apparent. A patient who has fallen at home and lain on the floor for a day may be admitted to the hospital and have every inch of skin examined upon admission, and then develop the tell-tale area of purplish discoloration several days after admission. In many cases, hospitals and other care facilities are being blamed (and payment is being withheld) when patients end up with a gaping hole in their sacrum that takes several months (and several trips to the OR) to heal, if they don’t succumb to their injury.

How to Recognize a Deep Tissue Injury (DTI)

You should be alert to the development of deep tissue injuries. Here’s how NPUAP describes these ulcers:

  • localized area of maroon or purplish discoloration of intact skin OR a blood-filled blister that forms due to shear and/or pressure
  • prior to the identification of the discolored area, the skin may feel boggy, firm, mushy, painful, cooler or warmer than the surrounding skin
  • the wound may progress to a thin blister overlaying a dark wound bed, which may eventually be covered by eschar
  • additional tissue layers may become rapidly exposed even with optimal treatment

Notice the last words (italicized). These wounds may become extremely large and may form very large pockets that expose the bone, despite your best efforts and the use of every wound care adjunct we have in our arsenals. Also remember that these ulcers may be even more difficult to detect in dark-skinned individuals.

The point is not to scare you, but to make you very aware of the danger that these types of ulcers present. It is important to be on your guard and watch for the development of these ulcers. Early identification, proper and accurate documentation and aggressive treatment are extremely important should you come in contact with a patient with a DTI.

Sources

Ankrom, M., Bennett, R., Sprigle, S., Langemo, D., Black, J., Berlowicz, D., Lyder, C., and the National Pressure Ulcer Advisory Panel (2005). Pressure-related deep tissue injury under intact skin and the current pressure ulcer staging systems. Advances in Skin and Wound Care 18, (in press).

NPUAP Pressure Ulcer Stages/Categories. http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/

Categories: Pressure ulcers

About the Author

Laurie Swezey's avatar

Laurie Swezey, founder and president of WoundEducators.com, has been a Registered Nurse for more than a quarter century, with most of those years dedicated to wound treatment. Ms. Swezey is a Certified Wound Care Nurse and a Certified Wound Specialist.

Reader Interactions

Comments

  1. Anthony T. Tuccio, DPM says

    August 13, 2013 at 6:35 am

    Thank you. I have seen this several times in my wound healing practice. The DTI appeared so benign that I would pay little attention to the area in question. I would then be amazed at the depth of the subsequent lesion. Many times the only reason that you initially pay attention to the area is a cellulitis is present.

    Reply
  2. Sara says

    September 24, 2013 at 7:38 pm

    Mike had major surgery 17 months ago. He had the Ivor Lewis procedure done. His stomach incision has occasionally developed a bread through wound about the size of a dime. Off and on it develops a blister that has a thin skin over it. It is painful to the touch, drains bloody liquid. Doctor put him on antibiotics which did not change anything. He now has an opening the looks like a beebee hit him. No one knows what to do with it. Could this be an like ulcer you talked about in the article? If so, how can we get a doctor to treat it as such?

    Reply
  3. Sara says

    September 24, 2013 at 7:46 pm

    He did go 6 months with the incision totally closed, then blistered up again in same spot and has lasted about 6 weeks.

    Reply
  4. Isabel Marant Sneakers says

    October 17, 2013 at 6:57 pm

    I like what you guys tend to be up too. Such clever work and
    reporting! Keep up the superb works guys I’ve incorporated
    you guys to my blogroll.

    Reply
    • Laurie Swezey says

      October 29, 2013 at 8:25 am

      Thanks Isabel. I am happy that you enjoy our articles.

      Reply
  5. Wanda Leaman says

    June 4, 2016 at 2:57 pm

    I have a resident that has developed DTI on L bunion, L outer Gr toe, L outer ankle, L outer foot near 5th toe, L outer 5th toe and L Achilles, this was after applying foam heel boot. Boot is always on except for dressing and hygiene. Should this be considered pressure. This is the resident stroke side.

    Reply
    • Tracy Forker says

      April 29, 2019 at 3:05 pm

      We have had several patients develop pressure injury from the heel protective boot! DeRoyal boot can be fastened too tightly and cause pressure especially in patients with ischemic disease. We stopped using them and are looking for an alternative.

      Reply
      • WoundEducators says

        May 21, 2019 at 12:29 pm

        Wanda – try searching here – https://www.woundsource.com/product-category/positioners-protectors/protectors

        Reply
  6. Getty Cruz says

    February 9, 2017 at 5:20 pm

    We have a patient that is thrombocytopenia . He was so sick that it’s hemodynamically unstable , (on septic shock )to turn for the first 8-12 hours shift. His arm , knees has purplish discoloration and bruises already. Because of multiple pressors his fingers and toes are cold and clamped and purplish dark colored too. When we are able to turn him, his butt cheek is mottled, is it consider DTI? Because it’s around the butt area but not the coccyx or sacrum.

    Reply
    • Laurie Swezey says

      July 22, 2017 at 8:36 am

      Deep tissue injury is a term proposed by NPAUP to describe a unique form of pressure ulcers. Since this is not a pressure ulcer, it is incorrect to call it a DTI.

      Reply
  7. DR Cream Review says

    February 17, 2017 at 12:03 am

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  8. rehoboth massage says

    February 23, 2017 at 2:41 am

    I loved your post ! I read your blog fairly often and you always come up with gret stuff !
    I shared this on my Facebook and my followers loved it !
    Keep up the good work !

    Reply
  9. Marla says

    January 7, 2018 at 1:11 am

    What is a treatment method for a DTI?

    Reply
    • Laurie Swezey says

      January 8, 2018 at 6:02 pm

      Please refer to NPUAP for information about treatment of DTI.

      Reply
  10. Elizabeth M Bueno says

    September 30, 2019 at 6:46 pm

    So what’s the difference between deep tissue injury and eccyhmosis.

    Reply
    • WoundEducators says

      October 14, 2019 at 10:41 am

      Hi Elizabeth, thanks for your interest in wound care! DTI is a pressure related injury
      https://woundeducators.com/what-is-a-deep-tissue-injury/, whereas eccyhmosis is bruising that can occur anywhere on the skin. Read more about eccyhmosis here – https://www.medicalnewstoday.com/articles/321943.php

      Reply
  11. Jaime says

    October 17, 2019 at 12:46 pm

    Bed bound patient with healing ischial pressure injuries. Granulation tissue present as well as epithelial tissue growth.
    Randomly develops hematoma within the wound bed that comes and goes within 2-3 weeks.
    Categorized as a sDTI however I’m not convinced.
    Suggestion?

    Reply

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