Pressure Ulcer, Suspected Deep Tissue Injury
Image and content excerpted from the VisualDx clinical decision support system.
VisualDx images show variation in age, skin color, and disease stage. VisualDx has 5 images of Pressure Ulcer, Suspected Deep Tissue Injury.
Full text and additional images for Pressure Ulcer, Suspected Deep Tissue Injury are available in the following VisualDx packages:
L89.95 – Pressure ulcer of unspecified site, unstageable
707.25 – Pressure ulcer, unstageable
707.00 – Chronic ulcer of skin, unspecified site
SynopsisDeep tissue injury is a newly created sub-category of pressure ulcer by the National Pressure Ulcer Advisory Panel. In deep tissue injury, there is a localized area of discolored skin that is purple or maroon-red in color. It is non-blanching, with the dermis intact. The area may be surrounded by redness, hardness, or swelling. The skin has a boggy feel to it. These changes may be preceded by skin that is painful, firm, or has a different temperature compared to the adjacent skin.
These changes indicate damage to the underlying deep tissue from pressure and shear. Typical sites of deep tissue injury are the sacrum and the heels. A primary cause of deep tissue injury is immobility in combination with the following factors: pressure, shear friction, and moisture.
Other risk factors that predispose to deep tissue injury include incontinence, nutritional deficits, old age, altered mental status, and malnutrition. Depending on these factors, a pressure ulcer may begin to develop in as little as 20 minutes.
When examining the ulcer, observe the following points:
- Location on the body
- Stage of the ulcer
- Size of the ulcer, which should include width and length in centimeters
- Wound edges – Look carefully at the edge of the ulcer for evidence of induration, maceration, rolling edges, and redness.
- Skin around the edges of the ulcer – The periwound skin should be assessed for color, texture, temperature, and integrity of the surrounding skin.
- Presence or absence of pain
- Odor, if present or absent