Deep Tissue Injuries and Their Impact
Can a bruise turn into a life-threatening injury? Deep tissue injuries (DTIs) often go unnoticed in nursing homes until they become serious wounds. These injuries are painful, preventable, and a red flag for neglect. In this week’s episode, nursing home abuse lawyer Rob Schenk welcomes guest Bridget Carey to discuss pressure injuries, DTIs, and what families should watch for to keep residents safe.
Carey:
If somebody’s laying on the ground after a fall and their skin looks good, that’s fine. The next day their skin could be fine. And on that day three, they have this massive bruise to a bony area. That’s not to say that something was done wrong. That could simply be the deep tissue injury manifesting.
Intro
Schenk:
Hey, out there. Welcome back to the Nursing Home Abuse podcast. My name is Rob. I will be your host for this episode. We are having a wonderful conversation about deep tissue injuries, but we’re certainly not doing that alone. We have the fantastic Bridget Carey on the show. And again, you’re gonna wanna stick around for the entire thing because this is one of those where it’s like you’re gonna be jotting down notes as you’re driving down.
Don’t jot down notes as you’re driving in your car, but pull over to the, if you’re in Atlanta, pull over to the qt. And take your notes. QT is amazing. Like I love QT. It’s got the cheapest gas. I don’t know, is QT everywhere? I feel like I only see QTS in Georgia, but that could just be me being ignorant.
QT is an amazing gas station. It has this, it’s basically, it has an entire a. I don’t know, ecosystem. It’s like Bucky’s. It’s kind of I don’t wanna say that for people that love Bucky’s. It’s not as big as Bucky’s, but I love it. Anyway, this is way too much talking about gas stations. Anyway, pull over, take notes. It’s gonna be an amazing episode.
Bridget Carey is a board certified wound care nurse, legal nurse, consultant, and medical rider with over 17 years of experience and long-term care, home care, acute care academia. And the medical industry. She holds a master’s in nursing education and specializes in pressure injury prevention and management.
Bridgette blends clinical and legal insight to support healthcare and legal professionals and is passionate about making complex wound care topics clear and practical. Clear. As of the time of that, we are recording this episode. She’s developing courses for attorneys and nurses on pressure injuries and deep tissue injuries, so be sure to check the show notes for that information.
And with that, Bridget, welcome to the show.
Carey:
Happy to be here, Rob.
What is a DTI?
Schenk:
So most everybody gets the softball question up top to frame what we’re talking about. So yours is what is a deep tissue injury?
Carey:
Ah, the softball that has iceberg layers. But just looking at it, a deep tissue injury from a high level is an injury that comes from prolonged consistent, lack of better terms, deep pressure.
It’s something that, and we’ll get into it, and we talked about this before, I get really excited about deep tissue injuries because they’re so misunderstood. But they are those injuries that just simply occur from deep, consistent, intense, prolonged pressure.
Explore key data on the impact of preventive health measures in elderly populations and how they shape clinical decisions in long-term care.
Are DTIs different from pressure injuries?
Schenk:
Why do we have a different word for pressure injury versus deep tissue injury if they’re both? Wounds that are related to pressure or am I saying something wrong? You tell me.
Carey:
Oh no. And that’s, see me, see my arm or my eyes twinkle there a little. So pressure injuries as a whole, which I’m just gonna just review because just to get everybody on the same page. They are your injuries caused by pressure and you’re probably thinking bridge, you just said that for deep tissue.
So what’s the difference? So deep tissue injuries are a subcategory to the umbrella of pressure injuries from the traditional stance. We know that pressure injuries have different stages, meaning. How long or how intense the tissue damage was from that unrelieved pressure. Now, deep tissue injuries are in a subcategory of their own because they don’t follow the rules of traditional pressure injuries.
For a Canadian perspective on wound care management, see this open-access resource on the impact of preventive health measures in elderly populations.
These are. So right now, as you see me shifting and you’re doing a really good job of not shifting, but you’re relieving that pressure, if I were to stay here, even just to shift a little bit, I’m still at risk of developing a pressure injury for those that do not have access to mobility. Think or, I know we’re in the long-term care space, which yes, but the easiest way to grasp it is if somebody’s on the operating table, they don’t have that capability of moving.
So deep. Intense. Prolonged unrelieved pressure causes damage and destruction of structure from the inside out. And we may not necessarily see that right away. Whereas with your pressure injuries, you start to see that redness that slow manipulation and deterioration of the skin. So deep tissue injuries are almost like surprises.
Nice. That we can have, yeah, I’ll stop there ’cause try to reign me in.
How do DTIs progress (i.e. stages?)
Schenk:
Sure. No, that makes sense. So I guess the idea here is that, when you have a pressure injury, a traditional pressure injury, you’re, it’s there, there’s gonna be something that’s happening to the surface layer. The epidermis, whether it’s partial thickness or full thickness, something’s happening because you, it’s observable on the surface of the skin.
And then of course it might open up or whatever. I guess from what I hear you say. There, there doesn’t necessarily have to be anything going on observably with the surface of the skin, but something’s happening below That would be why it’s a subcategory, correct?
Carey:
Yes, that is correct. So even though they both let me rewind.
So yes, to your point, when we see the traditional stage one to four that is partial thickness, full thickness. Separation, a deep tissue injury. Pathophysiologically is a full thickness wound. And I love that you brought that up ’cause I wanted to dive into that because that’s really where we get into the nitty gritty of differentiation of identification, of treatment, of expectations for healing.
Read an in-depth analysis of diagnostic imaging on the impact of preventive health measures in elderly populations in pressure ulcer identification.
So deep tissue injury in my brain is automatically full thickness, right? Because we’re going from the inside out and we’re going through those muscles, the fat layers, which. Let me chacha a little bit. Sure. So just for those that may not know, when we’re looking and talking about pressure, injuries and skin, partial thickness is your first two layers of skin, epidermis and dermis.
Everything else underneath is full thickness. So fats muscle fascia, all that is full thickness tissue injury. So when we talk about DTIs we’re coming with that intense pressure from the. Inside out, it’s destroying all of those underlying structures.
This ScienceDirect article explores global care standards on the impact of preventive health measures in elderly populations and how they may inform U.S. eldercare protocols.
Schenk:
Okay. So let me interject because this is important.
Yeah. ’cause this is a, this is going to fix my unwarranted assumptions with these words. I have always assumed that when you say full thickness. There has to be some type of destruction to the epidermis, which you’re saying that’s not the case. Full thickness only has to do with destruction of the underlying tissue.
Whether or not the epidermis is being destroyed. Is that right?
Carey:
Yes. And I like that you put it that way ’cause it sounds almost the reverse, but that’s exactly what we’re looking at with deep tissue injuries. So that’s almost like an inversion of what we see. Like we see stage one, the redness. And then stage two we have the skin stripping epidermal lift. Sure. We can stop it there. Relieve the pressure. Stop it there. Deep tissue. It’s already done.
If you’re concerned about wound neglect in a Georgia facility, visit our dedicated Atlanta bedsore lawyer page.
Schenk:
It’s already done. Okay. Okay. So then, and I might have cut you off. I don’t know if you remember where you were going or not, but I just wanted to make sure that was clear, because that’s something for me that’s new for me in this episode that I just learned. Okay.
Carey:
And that’s a really good distinction because. It’s not that common to understand. You just think all pressure injuries are the same and they’re not, and how they’re treated are not the same. So when we talk about that deep tissue and where you wanna think about, like that bone, that pressure is pushing.
It’s deteriorating those underlying layers to get to the surface. So by the time a deep tissue injury makes it to. On the surface, we see the blood blister, the bruise appeal because that damage has happened already.
Learn about the most common risk factors for pressure ulcers in nursing homes and what families should watch for.
Schenk:
Okay, so then, gosh, so many questions then. It’s, it might be confusing to the caregiver who’s not experienced.
It’s gonna, they’re gonna say, oh something’s happening on the surface. Maybe it’s a stage three, but in reality, there’s so much damage underneath it’s not, or it’s way worse than you think because the damage is already done. It’s just now that the skin is opening up that there’s an correct, that there’s an ulceration.
Carey:
It’s the evolution. And it’s not just the caregiver, like nurses, even those that may not have. An obsession like I do. No. Or have that experience to understand. So that’s why, and we can pivot to treatment and identification, like what does this mean and what does this mean for documentation? Because if, so here’s another little thing.
Another little fact is that it can take 48 to 72 hours for a deep tissue injury to present itself on the surface.
See clinical visuals and care explanations in our guide to pressure sore stages with pictures.
Schenk:
Wow. Okay.
Carey:
That’s interesting because you can have, so where long-term care may see this, or if somebody’s coming, in their care journey from, they had a fall at home to the hospital, to the long-term care.
If somebody’s laying on the ground after a fall for who knows, an X amount of time and their skin looks good, that’s fine. The next day their skin could be fine. And on that day three, they have this massive bruise to a bony area. That’s not to say that something was done wrong. That could simply be the deep tissue injury manifesting.
So when they have that deep bruise that shows up or that discoloration, it doesn’t necessarily mean that it was missed or wrong. It is just the DTI that has manifested. Now this is important because we wanna make sure that we’re addressing and really checking on these areas because as we talked about, the damage is done and we.
Discover the variables that affect healing time in our post on how long it takes pressure ulcers to heal.
As providers and caregivers can’t necessarily stop what’s going to happen. And what I mean by that is if day three of a fall is a fall incident and all of a sudden we have this giant, I’m looking at my hip, I’ll do my elbow. We have this giant blood blister. Now that’s actually a bad area, but you know what I’m trying to say, right?
So we have a big blood blister on the area and. What’s gonna happen is gonna happen. So what do we have to do and how do we treat that? It’s not to say, we just say, oh, it’s a DTI, we can just have on with it. We wanna protect that integrity because the body, even though the injury has happened, may be working underneath the heel.
For families exploring their legal rights, learn more about whether you can sue a nursing home for pressure ulcers.
Schenk:
I see.
Carey:
Let’s do some scenarios, or actually, if you wanna ask, I have some scenarios in my head that kind of paint this a little better because I think that just blew some minds with that.
Go behind the scenes in Episode 201: Unpacking the Truths About Pressure Injuries in Nursing Homes.
Schenk:
Okay. But hang on, let me ask this. Yeah, let me ask, I’ve got two things that I’ve been wanting to ask.
So the first thing is this, is there any mechanism that is creating a DTI that’s not creating a pressure injury? Is there, or is it just. Random, forced majeure. We don’t know why a DTI is forming on one person in the exact same position that of another person, but they got a pressure injury the traditional quote unquote way.
Carey:
Sure. So factors generally are the same. I say generally this is like a huge gray asterisk type situation. Because factors like mobility, medications, all of the same underlying factors, they influence both. The difference with the DTI is that unrelieved, prolonged pressure, and it could be from a simple incident, so a fall, if somebody’s laying on the ground,
Think at home for days and they look okay, and then all of a sudden they’re in a hospital.
It’s oh my gosh, they’re bruised from head to toe, like whatever that may be. That’s DTI, and they were unrelieved. Whereas we have our stage one, stage twos. On a healthy individual could just be like a minor, shift problem or repositioning, but their body’s already trying to heal that you see.
So it’s not just cut, it’s not black and white of this person’s gonna get a DTI, that one’s, it’s just gonna manifest as a regular pressure injury.
Hear from experts in Episode 205: Co-Morbidities, Unavoidability, and Pressure Injuries.
Schenk:
And I guess that’s what’s so confusing to me is ’cause it’s. Do, why would even if you, somehow you can wave a magic wand and it’s the same person, okay?
And you put them in a spot. They’re gonna develop a DTI. Okay. And then you wave your wand, it goes away or whatever like it are you, is it gonna be the case that they might, in the same scenario get a pressure injury instead and it works itself traditionally? And if there is a difference, like why is there a DTI on one circumstance and a pressure injury in another circumstance?
That’s the $64,000 question that is in my brain right now.
Carey:
Multimillion dollar question, honestly. But I wanna say and this is a great discussion. Like even clinicians can talk about it. It’s, I wanna say, no, there’s no real magic wand. It’s all situational.
And looking at the full picture, the full patient scenario. Their body, the external factors. Now, if you get a case, now, this is where we get into how we know and how we treat it, right? ’cause at the end of the day, it is a pressure injury. That’s it. Now we can play the game of timing, if this is speaking in long-term care, specifically if this person comes from the outside hospital, if they’re a new admission, readmission from home.
Discover key metrics in Episode 208: Top Three Crucial Data Points from the MDS About Pressure Injuries.
You do your head to toe skin assessment and they look fantastic, they’re a fall and no one can tell you how long they were a fall or how long they were on the ground, whatever. If they develop this maroon spot over their hip or their sacrum and it’s oh my gosh, like we have turned, we’ve implemented the care plan.
This is not, you gotta remember if they were at fault and you can’t account for that, you cannot stop. DTI from forming. But it is also the responsibility now to ensure that you’re protecting it, caring for it, and what you do after is just as important as identifying it correctly.
Schenk:
So that wouldn’t, that would mean definitionally that if you document and you diagnose that there is a DTI, that necessarily means that person had prolonged pressure at that spot for X amount of hours or days. By definition
Carey:
Good by definition? Yeah. Like loosely? Yes. Yep.
Schenk:
Okay.
Carey:
Oh, go ahead. I was gonna say, okay,
Schenk:
So how, okay, what I am, is there a methodology, I don’t know if methodology is the right word. Is there a best practice for. A situation where let, yeah, okay, we this person has come into the or whatever, and they, we found ’em on the ground.
Is there a way to check for deep tissue injuries? And also, would that be the case for anybody? That’s just a high risk for developing pressure injuries. Is there something that you can do to check for dti?
Carey:
Yeah. You just, and this is gonna sound simple. Basic skin checks and being consistent and documentation must be consistent.
And I say that’s that. Sometimes that’s the crux of where we run into issues. And I wanna just pinpoint this, just jump to the front of my brain. Heels. Heels are the most common DTIs. We see these blood blisters and these heel caps because just of the anatomic, how they sit, unrelieved pressure.
How to, check for them. We check for them. We just assess. There’s nothing to say, and do all of the preventative measures that you would normally do for traditional, skincare and pressure injury prevention’s, the same thing. Now with DTIs, they’re a little tricky.
And we used to, so the National Pressure Injury Advisory panel used to have a suspected DTI. That’s no longer a true definition because it, either it is or it isn’t. I see. And that’s something that’s interesting because there’s a lot of verbiage and vernacular like trying to like, it’s like it either is or it isn’t.
And how can you tell if it’s just a bruise, whatever. I don’t wanna say it’s just a pressure injury because the treatment for both is the same, right? It’s the presentation and that’s where documentation is key. Gotta describe, is it, deep purple. Red blood blister filled, whatever. And we never want to pop that.
Learn about classification and care in Understanding Pressure Ulcer Staging (Ep135).
We never want to open it. Even if a DTI has progressed to a scar cap like dark leathery, as long as that’s intact. And this is, I know this is like a, we’ve talked about this. It’s like golden, don’t touch it if there’s no signs of infection. Don’t touch it. Because the body may be trying to naturally heal that deep tissue injury from the surface.
Now where the question comes in, it’s how do I document that? What, how do I look at that? This goes, this is where the pressure injury documentation is the same across the board. If you cannot appreciate the full depth of the wound, it is unstageable. So talking about unstageable kind of freaks people out.
It’s one of my favorites, and it shows the most knowledge to the documenter. If you’re looking at a pressure injury, deep tissue injury, and you can’t see the full depth, meaning you can’t see bone, there’s no chronic tissue in the way. There’s an eager cap, and you know that it’s caused by pressure.
It is an unstageable pressure injury. Now, what this tells me. If I’m looking at it, I’m looking at documentation that this is a full thickness injury, which A DTI is right. Sometimes a DTI may not open, right? We call ’em deroofing or whatever and they turn into escar caps. That’s fine, that’s perfectly fine.
We just protect it. Now where it gets tricky is if we have our DTIs that progress and they start to peel back and they start to reveal themselves, I’ve seen the mis documentation of skin tears. If people who don’t understand like this is a pressure injury versus, they call it skin tears, they may call it a stage two.
Now it is a DTI. It is never a stage one or a stage two. Do we know why?
Schenk:
It’s already full thickness. It’s already full thickness,
Carey:
Correct? Correct. And that’s because we’re sitting here talking about it, but you can see even as it presents, you have the epidermal lift meaning like the DTI is starting to peel.
Literally the skin is starting to peel back and it looks like moisture. It looks like stage two looks like a skin tear. Absolutely. But this is a deep tissue injury. We need to document it as such, because then if you look at documentation. If you’re documenting a stage two and then all of a sudden it’s a stage four, the optics, that looks terrible.
But if we already know that we have a full thickness injury and we’re working towards healing or what, whatever the goal is there’s no real question there.
Are the treatments for DTIs different from pressure injuries?
Schenk:
But I guess though, because the treatment is the same, so it wouldn’t matter. I’m if I’m understanding you correctly, it wouldn’t matter if you put DTI versus stage three or stage four pressure injury. Like the, it would be, the treatment would be the same.
Carey:
The treatment is the same now. It matters by documentation because we document to see what’s working and what’s not, and also for CMS and reimbursement.
Schenk:
I see.
Carey:
And all of that. That’s super important.
Schenk:
You gotta get that reimbursement.
Carey:
Yeah, that, and if you’re telling me like in the morning you have a stage three in the afternoon, you have a stage four, and then the next day you have a stage three. Again, that inconsistency really brings to question, what are we looking at? So I always. Tell nurses or advise, if you don’t know, if you’re not comfortable or sometimes you’re not even permitted per policy to stage.
Don’t. There’s nothing to say like documenting what even with DTIs, because I’ll see this we know it’s a deep tissue injury, stage two, and then it’ll go on to describe it and I’m like, it’s literally contradicting itself there. And can run into trouble with.
Quality of care and education of stuff, like all of that. Snowball effect that we can run into, especially in a legal perspective.
Schenk:
Can I draw you back to something you said about how we can discover whether or not there is a DTI and you were saying there could be bruising, blood cap, et cetera.
These are things that are observable. Is there a way that you can maybe test the blanch ability of the skin or things like that when there is nothing observable? Just to see, is that possible?
Carey:
So that is possible. A little star. Okay. It’s, but not necessarily for DTI because we should be testing the blanch ability of the skin.
And that would tell us the stage one. And you’re like, wait, we’re talking about DTI stage one. If the injuries are already happening, it’s just making its way to the surface. It’s, I have seen an assessed skin that it’s fine. It’s, but there’s still some perfusion. If the injury is done on the inside and making its way to the surface, it hasn’t quite got there yet.
Schenk:
I, okay, so then I get that. So that relieves, there’s probably nurses listening. They’re like, okay, whew. Okay. But is there a certain amount of time in your experience where it’s not observable on the skin, but if you did the little skin test, you did the, and I’m using my thumb, like you did the blind stool test, right?
That you will see there’s something going on. Is that possible?
Carey:
It maybe.
Schenk:
Maybe
Carey:
I say maybe because we have, that’s a good lawyer answer.
Schenk:
That’s a good lawyer answer.
Carey:
It’s a maybe because no, because we know that it can take 48 to 72 hours. To just appear. So I could check it at eight in the morning and I’m like, it’s a little funky.
It’s a little pink. It’s getting, I see some edges, like I’m gonna keep an eye on that. Come back a couple hours later and oh my gosh, we’ve got purple. A couple hours later, oh my gosh, we’ve got almost black. And it’s, that’s like triggering to say, this isn’t just a regular injury. This isn’t just a bruise.
Knowing that person has been on their backside for so long, they refuse turning like, what, whatever circumstances may be. Now, we can at least do that now. We never assume, because you’ll, you never want to really just quicken the document. If you see a bruise on a bone to say the tissue injury, you don’t need to rush to do that again, just describing what consulting wound care because if you document there’s a DTI and it’s not, you just bought a full thickness injury.
Understand the evolving clinical definitions and implications of deep tissue injuries on the impact of preventive health measures in elderly populations.
How long does it take DTIs to heal?
Schenk:
Okay. Then let’s say that you have a DTI confirmed, but it’s only presented itself as a bruise typically. How long would it take an injury like that to heal?
Carey:
I’m gonna give you my lawyer’s answer.
Schenk:
Okay.
Carey:
It depends. Now again, this is multifactorial. It depends on the patient, depends on their underlying conditions, their medications, the environment. A true, deep tissue injury can take weeks. If not months to heal.
Depending on the complications, depending on the capability of healing every single person’s different. And this is true for any treatment. It may work perfectly for you to say let’s just put some skin prep on that heel and protect it. And for me, my body’s nah, I’m gonna deteriorate and get infected.
So it just, it depends. The individual, the circumstances and the treatment and the response to treatment.
How are DTIs treated?
Schenk:
What’s, what is the typical treatment for A DTI that hasn’t that, that hasn’t ulcerated at all? It’s literally just a bruise other than offloading, what are you doing?
Carey:
Offloading, I love you said that because it is. Get ’em off. Get ’em off.
Raise it. Levitate. But skim prep. Skim prep, or non-adherent dressings. To just protect that area. ’cause if so, thinking, and I know heel caps are real big with that heels, like skin prep, the heels, put ’em on a we say non-adhesive because you don’t wanna if that as at risk skin, you don’t want to damage it or potentially damage.
And offload I see. To try to let the body do it. So Yeah. You don’t have to do anything. And some can heal on their own, and it could even be like you, you just don’t know.
Schenk:
Bridget, oh my goodness. This episode has flown by. We really appreciate you coming by and sharing your knowledge with us.
Carey:
Yes, thank you so much. I’m. Told you I love talking about this.
Schenk:
Folks, I hope you found this episode educational. If you have an idea for someone that you would like for me to talk to, please let me know. If you have an idea for a topic that you would like for me to talk about, let me know that as well.
Be sure to enter the contest, the giveaway, whatever it is for the Nursing Home Abuse podcast, coffee mug. It’s a. It’ll be an heirloom one day heirloom, that’s not the right word. It’ll be a collector’s item. One day maybe it’ll be the heirloom too. You’ll pass it on to your kids. New episodes of the Nursing Home Abuse Podcast come out every single week.
And with that folks. We’ll see you next time.
Bridget Carey’s Contact Information: