How to Treat a Suspected Deep Tissue Injury

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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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