A nurse is assessing a 78-year-old patient who has been bedridden for 10 days following hip fracture surgery. The nurse notices a localized area of intact skin that appears purple or maroon colored over the patient's sacral area. Which assessment finding would be most indicative of a deep tissue pressure injury?
A 78-year-old patient has been bedridden for 10 days following hip fracture surgery. The nurse notices a localized area of intact skin that appears purple or maroon colored over the patient's sacral area.
1Partial-thickness skin loss with exposed dermis that appears pink and moist
2Full-thickness skin loss with visible subcutaneous fat and possible bone exposure
3Intact skin with non-blanchable erythema and warmth to touch
4Intact skin that is purple or maroon colored and may feel boggy or firm✓ 정답
해설
Deep tissue pressure injury presents as intact skin that is purple or maroon colored and may feel boggy or firm, indicating underlying tissue damage from pressure. Other options describe different pressure injury stages or characteristics.
Core Nursing ExplanationKey Concept Analysis: This question tests the identification of a Deep Tissue Pressure Injury (DTPI). DTPI is a unique type of pressure injury where the damage begins in the deeper tissues (muscle, fascia) before it becomes visible on the skin surface. The hallmark is intact skin that is discolored (purple/maroon) due to blood pooling from damaged blood vessels in the deep tissue. This is a critical assessment finding because it signals severe underlying damage that can rapidly progress to a full-thickness wound if pressure is not relieved.
Answer Rationale: Key Point! The scenario describes the classic presentation of a Deep Tissue Pressure Injury: a localized area over a bony prominence (sacrum) in a high-risk, immobile patient, with intact skin that is purple or maroon colored. Option ④ accurately adds the associated tactile finding: the area may feel boggy or firm compared to surrounding tissue, which indicates edema or necrosis deep under the skin. This is the most indicative finding of DTPI.
Distractor Analysis:
Watch out for confusion! Option ① describes a Stage 2 pressure injury (partial-thickness loss with a pink wound bed). The key difference is that the skin is not intact.
Option ② describes a Stage 3 or Stage 4 pressure injury (full-thickness loss with visible fat or bone). Again, the skin is open, not intact.
Option ③ describes a Stage 1 pressure injury (non-blanchable erythema of intact skin). The color is red, not purple/maroon, and the skin is warm, not boggy/firm. This is a superficial warning sign, while DTPI indicates deep damage.
Related Concepts: Recognizing DTPI is a nursing priority because it requires immediate intervention (pressure redistribution) to prevent progression. It is often misclassified. The National Pressure Injury Advisory Panel (NPIAP) staging system is essential knowledge for wound assessment and documentation.
Nursing Clinical Practice GuideClinical Scenario: You are the nurse for Mr. Johnson, a 78-year-old with limited mobility post-hip surgery. During your turn, you perform a full skin assessment and discover a 4x4 cm area of intact, deep purple skin over his sacrum. The area feels slightly boggy when you palpate it gently.
Nursing Intervention Strategy:
1AssessmentDocument the finding meticulously: location, size, color, skin integrity, temperature, and texture (boggy/firm). Use a pressure injury staging tool (e.g., Braden Scale) to reassess his overall risk. Do NOT stage this as a Stage 1, 3, or 4 injury.
2Immediate ActionKey Point! Implement aggressive pressure redistribution. This is non-negotiable. Reposition the patient off the area immediately. Use a pressure-redistributing mattress (e.g., air-fluidized or low-air-loss mattress) and establish a strict turning schedule (at least every 2 hours).
3Monitoring & CommunicationNotify the physician or wound care nurse. Monitor the site closely for any changes—especially for the skin to break open, which would then be staged as a Stage 3 or 4 injury. Photograph the area if facility policy allows, with patient consent.
4Patient & Family EducationExplain the finding in simple terms: "This purple spot means the skin and tissue underneath are very vulnerable because of pressure. Keeping him off this spot is our top priority to prevent a serious wound."
Patient Safety and Precautions: Watch out for confusion! Never massage the area of a DTPI or any reddened skin. Massaging can cause further damage to the compromised microcirculation. Avoid using donut-shaped cushions, as they can increase pressure on the surrounding tissue.
Nursing Procedure & Medication Flow
While there is no specific medication for DTPI, nursing procedures are paramount:
1Repositioning ProcedureUse a draw sheet to lift, not drag, the patient. Maintain proper body alignment. Use pillows or foam wedges to keep bony prominences from direct contact.
2Skin CareKeep the skin clean and dry. Use gentle, pH-balanced cleansers. Apply skin barrier creams to protect from moisture (incontinence), but avoid applying anything directly to the purple area that might mask assessment.
3Nutritional SupportCollaborate with a dietitian. Ensure adequate protein (1.2-1.5 g/kg/day), calories, and vitamins (especially Vitamin C and Zinc) to support tissue resilience.
A Word from Your Senior Nurse
"Finding a deep tissue pressure injury can be scary—it looks dramatic under that intact skin. But remember, you are the one who found it! Your sharp assessment skills are the first and most critical step in preventing a catastrophic wound. In clinical practice, never dismiss a purple spot on a high-risk patient. It's not a 'bruise'; it's a red flag (or rather, a purple flag!) demanding immediate action. On the NCLEX, they test this because missing a DTPI is a serious failure in preventative nursing care. Connect the dots: immobility + bony prominence + purple skin = sound the alarm and get that pressure OFF!"
Deep Tissue Pressure Injury — Localized damage to underlying soft tissue (muscle, fascia) from pressure or shear, presenting as intact skin that is purple/maroon or a blood-filled blister. It may feel boggy, firm, mushy, warmer, or cooler than adjacent tissue.
National Pressure Injury Advisory Panel — The leading organization that defines the classification/staging system for pressure injuries, including the definition of Deep Tissue Pressure Injury.
Non-blanchable Erythema — Redness of intact skin that does not turn white (blanch) when finger pressure is applied. This is the defining characteristic of a Stage 1 pressure injury.
Braden Scale — A validated tool used to assess a patient's risk for developing pressure injuries. It scores six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction/shear.
Shear Force — A mechanical force that occurs when tissue layers slide over each other (e.g., when a patient slides down in bed), stretching and tearing blood vessels and contributing to pressure injury development, especially DTPI.