WOUND WISE

Best nursing practices from the Hospital of the University of Pennsylvania

Deep Tissue Pressure Injury: A Clinical Review

Evidence-based interventions can reduce the incidence of these serious,
complex wounds.
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ABSTRACT
A deep tissue pressure injury (DTPI) is a serious type of pressure injury that begins in the muscle closest to the
bone and may not be visible in its early stages. Its hallmark is rapid deterioration despite the use of appropriate
preventive interventions. In 2007, the National Pressure Ulcer Advisory Panel added suspected deep tissue in-
juries to the traditional classification system, and by 2010 DTPIs had accounted for about 9% of all pressure in-
juries and were for the first time more prevalent than stage 3 or 4 pressure injuries. On average, patients who
develop these injuries are older and have a lower body mass index than patients who develop other pressure
injuries. Most commonly, DTPIs appear on the skin over the coccyx or sacrum, the buttocks, and the heels. This
article discusses the pathophysiology; risk factors; and assessment, prevention, and treatment of DTPIs, using
a composite case to illustrate the progression of this serious type of pressure injury.

Keywords: assessment, deep tissue pressure injury, pressure injury, pressure ulcer, treatment

M
r. A., a 62-year-old man with an extensive
cardiac history, was admitted to the car-
diothoracic ICU after undergoing coronary
artery bypass graft surgery. (This case is a compos-
ite based on our experience.) On admission, Mr. A.’s
height and weight were 5 ft 11 in and 164 lb; his
body mass index (BMI) was normal (22.9 kg/m2).
His ejection fraction before surgery was 60% (50%
to 75% is considered normal). Mr. A.’s surgical
procedure lasted a total of 604 minutes, which in-
cluded a cardiopulmonary bypass time of 139 min-
utes and an aortic cross-clamp time of 104 minutes.
On arrival in the ICU following surgery, Mr. A. re-
mained intubated and was acutely ill. His ejection
fraction was 55%, with normal left ventricular func-
tion and moderate right ventricular dysfunction. His
temperature was 96.7°F, and he was very unstable
hemodynamically, requiring multiple vasopressors
and blood transfusions to support his blood pres-
sure.
During the immediate postoperative period, Mr. A.’s
pressure injury risk, as measured using the Braden
Scale for Predicting Pressure Sore Risk, a validated risk
assessment tool, was 11 out of a possible 23 points
(lower scores indicate greater risk).1 This score reflected
a high risk of pressure injury development as the result
of immobility, inactivity, and nutritional status.
Based on Mr. A.’s high risk of developing a pres-
sure injury, we initiated preventive treatment using the
SKINCARE Pressure Injury Prevention Bundle, a col-
lection of interventions developed by a nursing team
of wound care nurses, clinical nurse specialists (CNSs),
and skin care champions at our hospital that has been
shown to help prevent pressure injury (see Table 1).2
Nursing staff placed Mr. A. on a low-air-loss support
surface, applied air-fluidized heel suspension boots,
and maintained the head-of-bed elevation at 30°. Un-
fortunately, in the first 24 hours after surgery (postop-
erative day 1), when Mr. A.’s nurses attempted to turn
him to assess the skin over his sacrum, his arterial ox-
ygen saturation level dropped into the mid-70% range
(94% to 99% is considered normal); therefore, he
could not be turned safely, which prevented his nurses
from performing a thorough skin assessment and tak-
ing pressure off the sacrum. The nursing staff used a
repositioning wedge to provide small weight shifts ev-
ery two hours. On postoperative day 2, when Mr. A.
could safely be turned and assessed, his nurse noted
that his sacrum and right buttock had an area 3 cm
in length × 5 cm in width of intact deep purple skin
that was boggy and nonblanchable when palpated.
This wound was classified as a deep tissue pressure
injury (DTPI).
DTPI DEFINITION AND EPIDEMIOLOGY
A DTPI is a serious type of pressure injury that be-
gins in the muscle closest to the bone. In the early
stages of the injury, damage may not be visible on

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Robyn Strauss, MSN, RN, ACNS-BC, WCC, Rebecca Stamm, MSN, RN, CCRN, CCNS, WCC, and
the skin’s surface.3 The hallmark of a DTPI is rapid
deterioration despite the use of appropriate preven-
tive interventions.3 In 2007, the National Pressure
Ulcer Advisory Panel (NPUAP) added suspected deep
tissue injuries and unstageable categories to the tra-
ditional pressure ulcer classification system (stages 1
through 4).4 In 2016, the NPUAP announced a change
in terminology, from pressure ulcers to pressure in-
juries, updated the staging definitions, and added
two new pressure injury definitions: medical device–
related and mucosal membrane pressure injuries
(the former describes the etiology of the injury; the
latter cannot be staged because of the anatomy of
the tissue). This 2016 update defined a DTPI as fol-
lows5:
Intact or non-intact skin with localized area
of persistent non-blanchable deep red, maroon,
purple discoloration or epidermal separation
revealing a dark wound bed or blood filled
blister. Pain and temperature change often pre-
cede skin color changes. Discoloration may ap-
pear differently in darkly pigmented skin. This
injury results from intense and/or prolonged
pressure and shear forces at the bone-muscle
interface. The wound may evolve rapidly to
reveal the actual extent of tissue injury, or
may resolve without tissue loss. If necrotic
tissue, subcutaneous tissue, granulation tis-
sue, fascia, muscle or other underlying struc-
tures are visible, this indicates a full thickness
pressure injury (Unstageable, Stage 3 or Stage
4). Do not use DTPI to describe vascular,
traumatic, neuropathic, or dermatologic
conditions.
After the introduction of the DTPI classification
in 2007, a 2010 study reported that DTPIs accounted
for about 9% of all pressure injuries, three times
the prevalence in 2006 (presumably, most of this in-
crease was a result of the updated classifications, but
precisely how much is unknown).6 By this measure,
DTPIs were for the first time more prevalent than
stage 3 or 4 pressure injuries. On average, the pa-
tients who developed these injuries were older and
had a lower BMI than patients who developed other
pressure injuries.6 Most commonly, DTPIs appeared
on the skin over the coccyx or sacrum, the buttocks,
and the heels.6-8
PATHOPHYSIOLOGY
The pathophysiology of DTPIs is not yet fully under-
stood and continues to be debated among experts. A
prevailing theory suggests that DTPIs are caused by
pressure or shear stresses or both, which leads to
ajn@wolterskluwer.com
By Ave Preston, MSN, RN, ACNS-BC, CWOCN, Aditi Rao, PhD, RN,
Demetra Zalman, MSN, RN, CRNP, CSC, WCC
deformation of cells and, finally, to cell death. DTPIs
are uniquely complicated by the combination of ische­
mia along with these stresses, which accelerates the
resulting injury.3, 9
DTPIs arise in tissues that sustain the highest
pressures—typically, muscle layers adjacent to bony
prominences. Muscle tissue is extremely vulnerable to
ischemia; cells in the muscle layer closest to the bone
die first when a DTPI occurs.9, 10 The tissue that sur-
rounds the muscle layer is also damaged by the re-
duced blood flow and is prone to further injury by
inflammatory cytokines when reperfusion occurs
(that is, when blood flow resumes).9, 11 Unless the
ischemic and injured muscle tissues surrounding the
deepest injury can be rescued, the DTPI advances
toward the skin.8, 9, 11
Both pressure and ischemia could have precipitated
Mr. A.’s injury. Despite the surgical team’s precaution
of using a pressure-redistributing gel mattress on the
operating room table, Mr. A. experienced pressure on
his sacrum due to the duration of the surgery and the
thinness of his frame. Because of the interruption of
circulation during surgery (as the body redirected
blood flow to vital organs) and the inflammatory ac-
tion of cytokines when circulation was restored, the
surgical procedure itself exposed Mr. A. to ischemia
and reperfusion injury.
In recent years, experts have come to a consensus
on the circumstances in which patients are likely to
develop pressure injuries because of their individual
risk profiles.12 The appearance of the DTPI so soon
after Mr. A.’s surgery suggests that the initial insult
may have been an unavoidable consequence of the
procedure. In Mr. A.’s case, lower tissue tolerance
to pressure and the ischemia and reperfusion injury
that resulted from surgery apparently caused the
DTPI, despite the nurses’ implementation of stan-
dard evidence-based preventive measures.
Table 1. SKINCARE Pressure Injury Prevention
Bundle
S upport surfaces
K eep repositioning
I ncontinence care
N utrition and hydration
C heck medical devices
A ssess risk and skin daily
R educe head of bed < 30° (unless contraindicated)
E levate heels
AJN ▼ May 2017 ▼ Vol. 117, No. 5 51
 WOUND WISE
Figure 1. The Development of a Deep Tissue Pressure Injury
A B
As shown on the sacrum of this patient, a deep tissue pressure injury presents suddenly as discolored intact skin (A), progresses to thin
blisters over a dark wound bed (B), then becomes black eschar (C). Identifying patient information is covered by the white bar.
RISK FACTORS
The precipitating events and comorbid conditions
that contribute to DTPIs are complex and multifacto-
rial; among them are altered tissue perfusion (with as
few as one to three hypotensive events),13 surgery,7, 8, 13
altered mobility,7, 13, 14 falls,7, 13 and recent transfers (for
various diagnostics or procedures).13 The patient’s
baseline health status and physiological and meta-
bolic state are also important considerations.13 In two
studies, anemia was the most common condition
noted among patients who developed DTPIs.7, 13 Ad-
ditional comorbidities and physiological variables in-
clude diabetes mellitus,7, 8 anticoagulation therapy,13
vascular disease (peripheral vascular disease and cor-
onary artery disease, for example),7, 8, 14 respiratory
disease (respiratory failure, chronic obstructive pul-
monary disease, and pneumonia, for example),7, 14
and end-stage renal disease.7, 14 Another recent study
noted that DTPI development was associated with
variables including cardiac arrest, mechanical venti-
lation longer than 72 hours, and the use of vasopres-
sors.15 Mr. A. had many of these comorbid conditions
and contributing factors, including cardiovascular
disease and anemia; in addition, he underwent a long
surgery and required the administration of multiple
vasopressors to correct hypotensive events and main-
tain his blood pressure.16
Additional factors during hospitalization that may
contribute to DTPI development include exposure to
intense or prolonged periods of pressure (the result of
lying on an operating room or diagnostic table, sitting
in a bedside chair, the presence of medical devices, or
a combination of these, for example) and exposure to
shear (as a result of raising the head of the bed, for ex-
ample).3 Patients whose tolerance for pressure is com-
promised are more likely to develop a DTPI. Further,
in the metabolically unstable patient, pressure and
52 AJN ▼ May 2017 ▼ Vol. 117, No. 5 ajnonline.com
C
shear injuries may result in greater vulnerability to a
reperfusion injury, despite appropriate preventive in-
terventions.11
Evolution. DTPIs evolve in a relatively predict-
able pattern. Typically, they present suddenly as dis-
colored (purple or hyperpigmented) intact skin (see
Figure 1A).3 They progress to thin blisters over a dark
wound bed (see Figure 1B) before becoming black es-
char (see Figure 1C). Eventually, the DTPI opens, re-
vealing a full-thickness (stage 3 or 4) pressure injury.17
As this process unfolds, the DTPI is not necessarily
“getting worse,” as one might assume from its ap-
pearance, but is instead following the usual pattern
of dead tissue decay, changing from purple to black to
wet, grayish-yellow slough.9 A 2013 study reported
that these wounds may resolve without tissue loss;
however, careful attention to the possibility of further
deterioration is critical.8
Underlying tissue damage may be present several
days before a DTPI becomes visible on the skin’s sur-
face. Early investigation suggests that the event that
causes a DTPI may precede its cutaneous manifesta-
tion by one to five days.13 Blistering or epidermal
sloughing (also referred to as skin slippage) usually
follows a few days after the intact purple skin devel-
ops. By the time black eschar forms, the underlying
tissues have been nonviable for approximately two
weeks.3, 18 Mr. A.’s wound progressed quickly accord-
ing to this anticipated pattern.
PROGRESSION OF MR. A.’S INJURY
On postoperative day 2, Mr. A. was extubated, and
as noted above, a nurse discovered the pressure in-
jury on his buttock and over his sacrum. A wound
care nurse assessed, photographed, and documented
the extent of Mr. A.’s injury. In the consult note, the
nurse described the wound as “intact deep purple
skin” (see Figure 2A). When palpated, the area felt
boggy and was nonblanchable. Mr. A.’s overall pain
was assessed as 7 on a 0-to-10-point numeric pain
rating scale. In response to these findings, the nurs-
ing staff initiated a plan of care that included topical
treatment—a silicone-based foam dressing applied
over the DTPI to minimize friction and shear—and
daily wound assessment and changes of dressing, as
needed. To address Mr. A.’s pain level, his provider
prescribed patient-controlled analgesic therapy to
maintain a target pain threshold of 3 or less. To eval-
uate his nutritional status, nursing staff consulted
clinical nutrition support services.
On postoperative day 3, Mr. A. was weaned from
vasopressors, and his provider ordered a physical ther-
apy consult. Additionally, nutrition support services
conducted a Nutrition Risk in Critically Ill (NUTRIC)
risk assessment. The NUTRIC is a validated tool for
use in critically ill patients to quantify the risk of mal-
nutrition that might be mitigated with aggressive nu-
tritional therapy.19 Mr. A.’s NUTRIC score was 1 (on
a 0 to 10 scale), indicating a low malnutrition risk.
Based on this score, the dietician developed an individ-
ualized nutrition care plan that included high-protein,
high-calorie oral supplements with Mr. A.’s diet and
recommended monitoring his daily calorie intake and
weight. Concurrently, Mr. A.’s nurses began encour-
aging oral intake while closely monitoring his hydra-
tion status via fluid intake and output measurements.
A nurse reassessed his wound and noted a thin blister
over a dark wound bed, measuring 4 cm in length ×
5.5 cm in width with minimal drainage, and reap-
plied the silicone-based foam dressing. The nurse
also transferred Mr. A. to a reclining chair with a
pressure-redistributing cushion in place. When Mr. A.
began tolerating oral intake, his pain regimen was ad-
justed to oxycodone 5 mg–acetaminophen 325 mg
by mouth, one tablet every four hours as needed
for mild to moderate pain and two tablets every
four hours as needed for severe pain, to maintain
his target pain threshold of 3 or less.
On postoperative day 4, a physical therapist as-
sessed Mr. A. and recommended a mobility plan:
ambulate 100 to 200 feet twice daily and progress
to an anticipated goal at discharge of a minimum of
1,000 feet three times daily. During interprofessional
rounds, the team determined that Mr. A. should be
transitioned to the intermediate care unit. Nurses
continued to assess his wound, noting that the blister
had deroofed (that is, ruptured), resulting in partial-
thickness skin loss (see Figure 2B); the wound’s size
remained the same. In response, the nurse applied
medical-grade honey and covered the wound with a
foam dressing.17 That afternoon, Mr. A. transitioned
to the intermediate care unit, where the nurses contin-
ued his plan of care, maintaining the SKINCARE bun-
dle, wound assessment, and daily dressing changes.
On postoperative days 5 and 6, the wound’s ap-
pearance was unchanged, and nurses maintained the
medical-grade honey treatment. On postoperative day
7, the nurse who assessed the wound noted that es-
char was present (see Figure 2C). Given this change,
a wound care nurse reassessed, rephotographed, and
completed an updated consult note in the electronic
health record. She noted the wound’s appearance
as full-thickness skin and tissue loss with eschar ob-
scuring the base and accordingly reclassified it as an
unstageable pressure injury.5, 8 The wound measured

Figure 2. The Progression of Mr. A.’s Pressure Injury

A B C

The deep tissue pressure injury on Mr. A.’s sacrum and right buttock on postoperative day 2 appeared as an area of intact deep purple
skin 3 cm in length × 5 cm in width that was boggy and nonblanchable when palpated (A). By postoperative day 4, the wound’s size
measured 4 cm in length × 5.5 cm in width, and the blister that had formed the previous day had ruptured, resulting in partial-thickness
skin loss (B). On postoperative day 7, the wound measured 4.5 cm in length × 6 cm in width, and its appearance was noted as full-thickness
skin and tissue loss with eschar obscuring the base. It was reclassified as an unstageable pressure injury (C). Identifying patient informa-
tion is covered by the white bar.

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 WOUND WISE
4.5 cm in length × 6 cm in width. At this time, the
provider on the cardiac surgery team arranged for a
consultation with a plastic surgeon; however, the plas-
tic surgeon did not feel that Mr. A.’s wound required
sharp debridement. The wound care nurse consid-
ered enzymatic debridement with collagenase, but
ultimately recommended continued treatment with
medical-grade honey, a preference based on ease
of use and low cost. While evidence on the use of
medical-grade honey as an autolytic debriding agent
is limited, several case studies support it.20, 21 On post-
operative days 8, 9, and 10, the nurses maintained
Mr. A.’s treatment plan. On postoperative day 11, the
wound measured 5.6 cm in length × 6.2 cm in width
× 1.3 cm in depth and was composed of 60% yel-
low slough and 40% red tissue. The interprofessional
team determined that Mr. A. could be safely discharged
home with home care nurses to continue his wound
treatment plan, ­including the daily application of
medical-grade honey.
On postoperative day 15, the home care nurse
noted that the wound base was adequately debrided
and reclassified it as a stage 4 pressure injury, measur-
ing 5 cm in length × 6 cm in width × 2 cm in depth.
On postoperative day 19, the home care nurse noted
that although the wound was free of nonviable tissue,
it still had a depth of 2 cm and the presence of healthy
granulation tissue was limited. Therefore, she recom-
mended negative pressure wound therapy (NPWT)
to actively accelerate the growth of granulation tissue
and facilitate healing.17 Using a suction device that
evenly distributes negative pressure at the wound site
and a combination of polyurethane open-cell foam to
fill the wound cavity and a transparent wound dress-
ing that completely covers the wound, NPWT technol-
ogy promotes exudate removal and tissue granulation
formation while drawing the wound’s edges together.
Innovation continues in the development of new vari-
ations of NPWT systems. The system used to treat
Mr. A.’s wound had soft, conformable tubing that re-
duced the risk of a device-related pressure injury. Over
the next three months, the home care nurses updated
Mr. A.’s treatment plan as the wound healed. By his
three-month follow-up visit with his cardiac surgeon,
Mr. A’s wound had completely healed.
DTPI MANAGEMENT
This section reviews DTPI assessment, documentation,
prevention, and treatment, as well as other key con-
siderations in wound management.
Assessment and documentation. Both visual in-
spection and manual palpation are important parts of
assessing for the presence of a DTPI. On inspection,
DTPIs initially appear as discolored intact areas on a
person’s skin, usually purple or maroon on lighter
54 AJN ▼ May 2017 ▼ Vol. 117, No. 5 ajnonline.com
skin and as hyperpigmentation (increased browning
or darkening) on darker skin.3 Sometimes, the injury
may resemble an upside-down heart or a horseshoe
shape over the sacrum and upper buttocks; this pre-
sentation is likely due to vertical shear forces. The skin
may also feel indurated (unusually firm) and/or cooler
or warmer than the surrounding tissue. Because DTPIs
can be extremely painful, careful pain assessment that
includes nonverbal signs of pain, particularly on pal-
pation, is critical.17
As a DTPI evolves, accurately staging the wound
often proves challenging because features of a DTPI
can resemble pressure injuries at other stages. For
example, during the phase of blistering or partial-
thickness skin loss, a DTPI can easily be mistaken
for a stage 2 pressure injury. As the wound evolves,
it must be reassessed and reclassified based on its cur-
rent appearance and tissue consistency. Once eschar
becomes visible, the wound description should be
changed to an unstageable pressure injury; and when
the wound base becomes visible, it should be docu-
mented as either a stage 3 or stage 4 pressure injury,
as appropriate.5, 8 In addition to a comprehensive as-
sessment of the wound with measurements, docu-
mentation should include photographs, particularly
for patients with early manifestations of DTPIs.9
Prevention and treatment. The strategies used to
prevent DTPIs—or to intervene as soon as a DTPI is
detected—are similar to standard pressure injury pre-
vention and treatment techniques. The SKINCARE
bundle should be initiated for all at-risk patients.2, 8
The primary focus of treatment is to redistribute
pressure or shear or both to help tissues recover
and decrease the resulting damage.3 To minimize
damage to vulnerable tissue, taking pressure off
bony prominences via appropriate support surfaces,
proper positioning, and frequent repositioning is es-
sential.3 For patients deemed to have a very high risk
of pressure injury development—or upon discovery
of a DTPI—specialty support surfaces that provide
enhanced pressure redistribution, shear reduction,
and microclimate control (low-air-loss support sur-
faces, for example) should be considered. Proper
positioning can be achieved with the use of devices
including pillows, wedges, gel- or air-fluidized posi-
tioners, ceiling mounted lifts, or a combination of
these.17
Hospital beds that allow the angle of the head
and foot sections to be adjusted independently can
optimize patient positioning, while mitigating co-
occurring risks such as shear, pressure, and ventilator-
associated pneumonia. To minimize vertical shear
stress, the head of the bed should remain at or below
30°—ideally, at the lowest possible angle unless con-
traindicated by medical conditions or feeding and
digestive considerations.17, 22 Raising the foot of the Figure 3. Optimal Patient Positioning
bed so that the lower legs are elevated in relation to
the upper legs and pelvis can help distribute weight
more evenly along the support surface (see Figure 3).3
Advantageously, this practice also reduces edema in
the lower extremities and heels.3 Heels are particu-
larly vulnerable to injury, so heel protectors should be
used consistently to remove pressure, maintain neutral
alignment, and provide additional support to the feet
to reduce the incidence of foot drop.10
Continuous lateral rotation therapy beds are
also effective in reducing the incidence of ventilator-
associated pneumonia. These beds are effective in
training the body to tolerate side-to-side movement,
which is helpful for patients who are too unstable
to reposition frequently using standard methods.
The beds are not specifically designed to redistrib-
ute pressure, however. In fact, they should be used
with caution because they can contribute to lateral
shear stress damage.17 Dragging patients up in bed
also increases shear; therefore, patient lift mechanisms,
such as ceiling lifts, should be used if available, because
they allow for repositioning without friction and shear
and promote safe patient handling.17 Shear stresses are
worsened in the presence of other complicating fac-
tors, such as excessive perspiration and urinary and
fecal incontinence.10 Therefore, nurses should initi-
ate prompt cleansing with pH-balanced skin cleansers
and use moisture barriers, air-permeable underpads,
and fecal management devices to prevent moisture-
associated skin damage. In addition, a registered dieti- Reprinted with permission from Gefen A, et al. A review of deep tissue injury develop-
ment, detection, and prevention: shear savvy. Ostomy Wound Manage 2013;59(2):26-35.
cian should be consulted for a comprehensive nutrition
evaluation.17
In at-risk surgical patients, several interventions
can be used throughout the perioperative period to consulted to assist with progressive mobilization and
prevent the development of pressure injuries. A preop- early ambulation.23 Further, patients with sacral pres-
erative baseline Braden score should be determined sure injuries should be encouraged to use pressure-
and a skin assessment should be performed as the pa- redistributing chair cushions and limit sitting on a
tient is prepared for surgery. Based on this assessment, chair to three times per day for periods of 60 min-
a gel-filled pressure redistribution surface may be used utes or less.17
on the operating table. During surgery, proper posi- Other key considerations for effective manage-
tioning and padding is critical. While the position of ment. In addition to ongoing assessment, documen-
the patient’s legs varies according to the type of sur- tation, and evidence-based treatment, maintaining a
gery (the patient may be frog-legged, or the legs may patient- and family-centered approach and focusing
be straight with the knees positioned in slight flexion, on transitions in care are essential. For patients and
for example), the heels should be elevated off the sur- families, coping with a sacral wound after heart sur-
face of the operating table with a foam positioner.17 In gery is unexpected and distressing. Unlike other po-
addition, maintaining a steady systolic pressure and tential postoperative complications, pressure injuries
minimizing surgical times, to the extent possible, may are visible and can be malodorous and painful. They
be beneficial.9 often impede recovery and limit the patient’s ability
For critically ill patients, other interventions that to progress. The presence of a pressure injury inhibits
may help to halt the progression of a DTPI and sal- mobility, increases nutritional demand and potential
vage viable tissue include optimizing perfusion through narcotic use, and complicates bowel and bladder
fluid administration, transfusions, and oxygen deliv- elimination. Pressure injuries also increase risk of in-
ery.9 Following surgery, a physical therapist should be fection and the need for complex treatment (NPWT,

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 WOUND WISE
enzymatic or sharp debridement, or other surgery,
for example). Consequently, patients may experience
altered body image, depression, longer lengths of
hospital stay, and increased likelihood of discharge
to a long-term care facility.24, 25
Partnering with surgical patients—especially high-
risk patients—and family caregivers from the time of
admission to develop a plan of care and provide edu-
cation on the possibility of pressure injury occurrence
is essential. Upon discovery of a pressure injury, pa-
tients and families express many concerns. They often
question how this complication could have occurred,
the plan for resolution, and how long the wound will
take to heal.
To address these concerns, nurses should commu-
nicate openly and transparently to establish trust. Spe-
cifically, nurses need to educate patients and families
on contributing factors, the prevention and treatment
plan, and the expected trajectory for healing. Re-
cently, interprofessional experts reached a consensus
that some pressure injuries are unavoidable because
of the magnitude and severity of risk, contraindicated
preventive measures, patient nonadherence to preven-
tive or treatment plans, or a combination of these.26
Communicating with patients and families to help
them understand the causes of and treatment plans
for pressure injury can build trust and engage them
as active participants in preventing and treating these
injuries.
In many settings, asking the family to leave the
room during procedures to provide patient privacy
is common. This practice can, however, limit family
members’ understanding of how to manage and cope
with these complex wounds. To avoid potential confu-
sion, Mr. A.’s family, with his permission, was invited
to be present during dressing changes and shown the
photos that were taken.
Mr. A.’s nurse also invited him and his family to
participate in daily interprofessional bedside rounds,
at which the team discussed Mr. A.’s surgical recov-
ery in addition to his wound healing, nutritional sta-
tus, and pain management goals. Throughout the
hospital stay, the team also devoted time to educating
Mr. A. and his family on his transition plan (from the
ICU to intermediate care and from hospital to home).
The wound care CNS in the ICU communicated the
patient’s history and wound plan of care to the inter-
mediate care unit CNS. Further, the interprofessional
team worked with Mr. A. and his family to identify
posthospitalization resources that would be needed,
such as home care nursing and follow-up wound care.
EMERGING EVIDENCE
There is a growing body of evidence on the preven-
tion, detection, assessment, and treatment of DTPIs.
56 AJN ▼ May 2017 ▼ Vol. 117, No. 5 ajnonline.com
Two recent randomized controlled trials demonstrated
that the application of specialty foam dressings over
the sacrum can decrease pressure injury incidence27, 28;
other studies have also pointed to the potential effec-
tiveness of this intervention in preventing the develop-
ment of DTPIs.29, 30 The 2014 guidelines issued by the
NPUAP in conjunction with European and Pan-Pacific
peer organizations added a recommendation (and gave
it a “B” strength of evidence) to “consider applying
a polyurethane foam dressing to bony prominences
(e.g., heels, sacrum) for the prevention of pressure ul-
cers in anatomical areas frequently subjected to fric-
tion and shear.”17
Identification of biomarkers, such as those associ-
ated with muscle damage, may help detect the pres-
ence of a DTPI. Certain diagnostic techniques, such
as thermography to measure skin temperature31 and
ultrasound3 may detect the presence of a DTPI be-
fore it is visible. Some authors have suggested that
ultrasound can be used for skin screening of at-risk
patients on hospital admission and to determine the
extent and severity of pressure-related intact skin
discolorations and disruptions as soon as a DTPI is
suspected.32, 33 However, these proposals are debated
among experts in the field.34
To slow the progression of DTPIs, studies suggest
that the early use of noncontact, low-frequency ul-
trasound may be of therapeutic benefit.35 Addition-
ally, in a small case series of five patients, applying
air-fluidized support within 12 hours of DTPI diag-
nosis prevented progression to stage 3 or 4 pressure
injuries in all study patients.36
The Honaker Suspected Deep Tissue Injury Sever-
ity Scale is a new instrument that uses visual inspec-
tion to assess DTPI severity and progress over time.
This instrument is currently undergoing testing for
use in the clinical setting.37 Additional research is
needed in all these areas.
In high-risk patients, the consistent application
of evidence-based interventions has decreased the
­incidence of pressure injuries. DTPIs remain an
enigmatic challenge. Research is needed to better
­understand the pathophysiology of these injuries.
An increased understanding of the mechanism and
evolution of pressure injuries will inform preven-
tion and management strategies to further decrease
DTPI incidence. ▼
Ave Preston is a clinical nurse specialist at the Hospital of the
University of Pennsylvania, Philadelphia, where Aditi Rao is di-
rector of nursing practice and Magnet program director, Robyn
Strauss is a clinical nurse specialist, Rebecca Stamm is associate
director of clinical implementation, and Demetra Zalman is an
NP. Contact author: Ave Preston, ave.preston@uphs.upenn.edu.
The authors have disclosed no potential conflicts of interest, fi-
nancial or otherwise.
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