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New Definition Added to the Criteria of Pressure Ulcer Development by the National Pressure Ulcer Advisory Panel

Some recent discoveries have shown that there is a need to redefine the National Pressure Ulcer Advisory Panel’s (NPUAP) definition of deep tissue injury.  Although etiological studies of deep tissue injury (DTI) primarily pertained to the characterization of biomechanical factors influencing its onset and progression, new findings suggest that the criteria of DTI should be evaluated and refined.  According to a recent article published by Ostomy Wound Management (OWM), there are several reasons why the current definition is insufficient:
1. Discoloration of the skin—i.e., skin color that is significantly different from the local skin color from surroundings—may signify that a DTI is present, but color is not applicable in quantifying the injury’s severity.
2. The definition of pressure and/or shear is not accurate because it indicates a false distinction between pressure and shear, which are physically coupled, and because it does not take tensional loads into account.
3. Palpating tissue firmness at the wound site does not provide adequate assessment information because tissue firmness depends on the point in time following the course of DTI development.  Tissue that is damaged could appear stiffer than the tissue around it if assessed when “muscle tissue is locally contracted due to local rigor mortis but at a later stage damage might manifest as tissues that are softer than their surroundings when digestive enzymes start decomposing necrotic tissues”
4. Inflammatory response may occur, causing skin temperature changes around the DTI site (i.e. local heating or local cooling).
5. Due to stiffening muscle tissue at the rigor mortis phase, rapid deterioration of the skin in the DTI region is likely occurring. It is also noted that “stiffened tissues abnormally deform adjacent tissues and this effect is amplified if muscles are atrophied.”

Interdisciplinary research is being used to help clinicians and researchers move away from evolving terminologies, staging systems, and injury definitions, and move toward valid and effective clinical instruments, which will increase the effectiveness of clinical practice. The National Pressure Ulcer Advisory Panel (NPUAP) formally added a new criteria to its pressure ulcer staging system in February 2007: suspected deep tissue injury (DTI).  This definition has since been widely used in nursing literature and is displayed on NPUAP’s website as follows:
“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.”
A further description was added by NPUAP:
“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.”

The population of nursing home patients who are vulnerable to DTIs is prevalent.  Bedbound patients must be turned every two hours to prevent DTIs from forming.  It is the responsibility of the nursing staff to ensure that their residents are turned in a timely matter.  If you or a loved one has experienced neglect that resulted in injuries such as DTIs in a nursing home, such as one in Eagle Rock or Los Angeles, California, contact the Law Offices of Ben Yeroushalmi immediately for a free consultation.