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DTPI - ✔✔✔deep tissue pressure injury: intact or non-intact skin with localized area of persistent non-blancheable deep red,
maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature
change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin
This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface.
The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss.
Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions.
should be offloaded as soon as it is discovered. With reperfusion, some injured and ischemic tissue may recover.
eschar - ✔✔✔a thick layer of dead tissue and tissue fluid (dry, black, hard necrotic tissue)
Full thickness pressure injury - ✔✔✔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.
Healing Process - Full Thickness Pressure Injuries - ✔✔✔The healing of full-thickness wounds occurs in phases.
Inflammation Phase
Proliferation Phase
Maturation Phase (also called Remodeling Phase)
During the Inflammatory Phase, hemostasis is established. Neutrophils and macrophages migrate to the wound to remove
bacteria, devitalized tissue, and other debris. Cytokines released during this phase promote cell proliferation and the synthesis
of extracellular matrix molecules important to processes in the proliferation phase
Healing Process - Partial Thickness Pressure Injuries - ✔✔✔occurs predominantly through re-epithelialization.
MDR - ✔✔✔Medical Device Related Pressure Injuries
an etiology not a stage
Mucosal Membrane Pressure Injuries should not be staged. - ✔✔✔
mucous membrane pressure injury - ✔✔✔Unstageable because
Nonblancheable erythema cannot be seen in mucous membranes
It is difficult to distinguish between superficial tissue loss and deeper full thickness ulcers