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Deep Tissue Injury
Added to Pressure Ulcer Staging System
By Jeri Lundgren, RN, CWS, CWCN
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New Definitions |
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Winter 2007
 In its update of the Pressure Ulcer Staging System, the National Pressure Ulcer Advisory Panel added deep tissue injury (DTI), formally recognized “unstageable” as a stage and up-dated stages I and ll. This staging system is meant for pressure ulcers only and should not be used for dermatitis, maceration, lower extremity ulcers, surgical wounds or any other wound that is not a pressure ulcer.
In the past, many facilities would admit a wound that had no break in the skin, but showed signs that the damage was deeper than skin level (deep purple in discoloration, mushy or boggy to palpation, etc.). The old staging system required such a wound to be designated a stage I, implying the damage was only at the skin level. However, very often these types of wounds would digress to stage III or stage IV ulcers, despite diligent care. Because of this, it would appear in the records that staff admitted a stage I and it digressed to a stage III or IV, when in reality the wound on admission was actually a stage III or IV. Now you can stage these pressure ulcers as a DTI indicating it is suspected that there is already deep tissue injury even though the skin is intact. It is imperative nursing staff is trained on the new definitions. The admitting nurses, in particular, must be able to identify wounds with deep tissue damage immediately upon admission.
See new definitions in grid to right.
If you would like more information, education or consultation please contact:
Jeri Lundgren, RN, CWS, CWCN
Director of Wound & Continence Management
Pathway Health Service
612-805-9703
consult@pathwayhealth.com
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Suspected 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 shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. |
Further description: Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment. |
| Stage I: |
| Intact skin with non-blanchable redness of a localized area, usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. |
Further description: The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Stage I may be difficult to detect in individuals with dark skin tones. May indicate "at risk" persons (a heralding sign of risk). |
| Stage II: |
| Partial thickness, loss of dermis presenting as a shallow open ulcer with a red/pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. |
Further description: Presents as a shiny or dry shallow ulcer without slough or bruising.* This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. *Bruising indicates suspected deep tissue injury |
| Stage III: |
| Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. |
Further description: The depth of a stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep stage III pressure ulcers. Bone/tendon is not visible or directly palpable. |
| Stage IV: |
| Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. |
Further description: The depth of a stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable. |
| Unstageable: |
| Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. |
Further description: Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as "the body's natural (biological) cover" and should not be removed. |
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