# A nurse is assessing a 78-year-old bedridden patient who has been hospitalized for 10 days. Which assessment finding would be the MOST concerning and require immediate intervention for a suspected deep tissue pressure injury?

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> subject: Adult Health

## 문제

A nurse is assessing a 78-year-old bedridden patient who has been hospitalized for 10 days. Which assessment finding would be the MOST concerning and require immediate intervention for a suspected deep tissue pressure injury?

The nurse observes an area on the patient's sacrum that appears intact but shows specific concerning characteristics.

## 보기

1. A purple or maroon localized area of discolored intact skin that is painful and feels different in temperature or consistency compared to adjacent tissue. **✔ 정답**
2. A shallow open ulcer with a red-pink wound bed and partial-thickness skin loss involving the epidermis and/or dermis.
3. A stage 1 pressure injury with non-blanchable erythema over a bony prominence that blanches with fingertip pressure.
4. An area of skin that appears slightly red but returns to normal color when pressure is applied and resolves within 30 seconds.

**정답: 1**

## 해설

Deep tissue pressure injury (DTPI) with purple/maroon discolored intact skin indicates compromised deep tissue requiring immediate intervention to prevent rapid progression. Other options describe less severe pressure injuries (stage 1, stage 2, or blanching erythema) that are managed with standard care.

## 심화 해설

Understanding the Clinical Scenario

This question presents a 78-year-old bedridden patient hospitalized for 10 days, placing them at high risk for pressure injuries due to prolonged immobility. The nurse's assessment reveals an intact area on the sacrum with specific characteristics, and the task is to identify the most concerning finding requiring immediate intervention for a suspected deep tissue pressure injury (DTPI).

Analyzing the Correct Answer: Option 1

The correct choice is the observation of a purple or maroon localized area of discolored intact skin that is painful and feels different in temperature or consistency compared to adjacent tissue. This description aligns precisely with the defining characteristics of a suspected deep tissue injury. According to the provided evidence, the classic presentation for patients with light skin tones is a "purple or maroon" discoloration with a defined border [1]. The finding that the area is painful and has a different temperature or consistency (e.g., firmer, boggy, warmer, or cooler) indicates damage to underlying soft tissue from pressure and shear, even though the skin surface remains intact. This represents a serious, evolving injury where the deep tissue is already compromised, and it can rapidly deteriorate into an unstageable wound with eschar or a full-thickness ulcer. Immediate intervention is critical to prevent further tissue necrosis.

Why the Other Options Are Incorrect

- Option 2 describes a shallow open ulcer with a red-pink wound bed and partial-thickness skin loss. This is the definition of a Stage 2 pressure injury. While it requires appropriate wound care and pressure redistribution, it is not a deep tissue injury. The damage is confined to the epidermis and dermis, and it does not present the same risk of rapid, unseen deterioration into a deep cavity wound as a DTPI does.

- Option 3 describes a Stage 1 pressure injury with non-blanchable erythema. The critical error here is the contradictory phrase "that blanches with fingertip pressure." By definition, a Stage 1 pressure injury is characterized by intact skin with non-blanchable erythema. If the redness blanches (turns white) when pressure is applied, it indicates reactive hyperemia, a normal physiological response to pressure that resolves quickly and is not a pressure injury. This option contains a clinical inconsistency, making it incorrect.

- Option 4 describes an area of skin that appears slightly red but returns to normal color when pressure is applied and resolves within 30 seconds. This is a textbook description of blanchable erythema or reactive hyperemia. It signals that the capillaries are intact and the tissue is not injured. While it indicates the patient was exposed to pressure, it is a normal compensatory response and not a concerning finding for a pressure injury. No intervention beyond routine repositioning is required.

Deep Tissue Pressure Injury: Key Assessment Findings

The differential diagnosis of a DTPI is challenging because other conditions, such as bruising, incontinence-associated dermatitis, or venous insufficiency, can mimic its appearance [1]. A thorough history is essential to account for the duration of unrelieved pressure, such as "time down" at the scene of an accident or a period when the patient was immobile and unresponsive [1]. The assessment findings that should raise immediate concern for a DTPI include:

- A persistent, non-blanchable area of deep purple or maroon discoloration on intact skin.

- A clearly defined border around the injured area, often with surrounding erythema [1].

- Pain in the area, which may be disproportionate to the visible skin changes.

- An alteration in tissue consistency (firm, boggy, or mushy feel) or temperature (warmer or cooler) compared to adjacent skin.

This evolution from a DTPI can be rapid. The area may quickly become covered by a thin eschar, masking a much larger, full-thickness wound underneath. Therefore, recognizing the subtle signs of a suspected DTPI, as described in option 1, is the most critical finding for a nurse to act upon immediately by implementing strict pressure offloading and comprehensive skin protection protocols.References (research sources)

- [1]Differential diagnosis of suspected deep tissue injury.Research articleBlack JM, Brindle CT, Honaker JS. (2016) · DOI: 10.1111/iwj.12471

## 임상 시나리오

Suspected Deep Tissue Injury: Key AssessmentIdentifying the most critical finding in immobile patients
A suspected deep tissue injury (sDTI) presents as a localized area of purple or maroon discolored intact skin or a blood-filled blister. The hallmark is pain and a change in temperature (warmer or cooler) or consistency (firmer or boggy) compared to adjacent tissue.

This finding indicates damage to underlying muscle and soft tissue from pressure and shear, even with an intact skin surface. It can evolve rapidly to a full-thickness injury, making immediate offloading and intervention critical.

CautionDo not confuse a sDTI with a Stage 1 pressure injury (non-blanchable erythema) or reactive hyperemia (blanchable redness). A sDTI is deeper and more severe, often appearing like a deep bruise.

## 핵심 개념

- **Deep Tissue Pressure Injury (DTPI)** — Persistent, non-blanchable deep red, maroon, or purple discoloration of intact or non-intact skin, resulting from intense and/or prolonged pressure and shear forces at the bone-muscle interface.
- **Non-blanchable Erythema** — Redness of the skin that does not turn white when pressed, indicating Stage 1 pressure injury where damage is present but the skin is still intact.
- **Reactive Hyperemia** — A temporary, blanchable redness of the skin following a period of pressure relief, caused by vasodilation to restore blood flow; it is not a pressure injury.
- **Shear** — A mechanical force that acts on an area of skin in a direction parallel to the body's surface, damaging deep tissues and blood vessels, often occurring when the head of the bed is elevated and the patient slides down.
- **Unstageable Pressure Injury** — Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar.

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