How to Treat a Suspected Deep Tissue Injury

Definition

• Localized area of discoloration (purple/maroon) with the skin intact, or a blood filled blister
• The area may be painful, firm, mushy, boggy, warmer, cooler prior to discoloration

Goal

• If possible, remove cause
• Attempt to prevent further tissue damage

Treatment

Obtain a physician order:

1. Use Standard Precautions
2. Cleanse area gently
3. Pat dry: do not rub
4. Apply a thin Hydrocolloid Dressing such as Duo Derm Extra Thin or Tegaderm Clear to area
5. Change once a week and/or PRN
6. Apply skin prep for intact heels
7. Educate patient and family about pressure ulcers, turning frequently (as patient chooses/allows) and document education/response by caregiver
8. Document per agency protocol

Mattress Recommendation

• Foam

* Note: These are wound care guidelines only. Consult with the primary physician for specific orders.

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