In deep tissue pressure 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 epidermis may be intact or non-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 injury may begin to develop in as little as 20 minutes.

When examining the injury, 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

The National Pressure Ulcer Advisory Panel 2016 updated staging system also includes the following:

• Medical device-related pressure injury (describes an etiology) – Results from the use of devices designed and applied for therapeutic purposes. Injury generally conforms to the pattern or shape of the device. Stage using the staging system.
• Mucosal membrane pressure injury – Found on mucous membranes with a history of a medical device in use at the location of the injury. Cannot be staged due to anatomy of tissue.

Related topic: Pressure Injury (overview)