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Hi. When a patient has a dti to sacrum but there is a small area of epidermal skin loss, do you treat the open area? Or is just a foam dressing and offloading adequate? Thanks.
Sep 15, 2019 by Melissa Khoo,
4 replies
Samantha Kuplicki
MSN, APRN-CNS, AGCNS-BC, CWS, CWCN-AP, RNFA
Hi Melissa! Thanks for your question :) Sometimes when one wound has varying characteristics and exists in multiple stages of tissue damage, choosing a dressing can be challenging. Offloading is the primary intervention, as you have already described; including repositioning, low air loss surface if needed depending patient mobility, or ROHO if wheelchair is used.
The use of a foam dressing for offloading is considered offlabel, though it is an extremely common practice; also, foams are typically for moderate to highly exudating areas. If the wound is partial thickness at the deepest, ensure the dressing caters to the characteristics of the wound; keep the open area moist and protect the areas of intact tissue with a nonadherent barrier such as alcohol free skin prep or barrier cream/paste. If you have a large foam dressing, this may be applied over the entire area as to avoid applying adhesive over the area of SDTI; you can place a small piece of impregnated gauze over the open area to keep it moist and change the dressing every 3-5 days. In the home setting this is much easier than in the outpatient setting if DME must be ordered, as a partial thickness wound will not qualify for a foam dressing.

Also, to clarify, based on your description, this would be documented as a Stage 2 Pressure injury.
Sep 15, 2019
According to npaup guidelines, dti can be non intact.
Sep 15, 2019
Samantha Kuplicki
MSN, APRN-CNS, AGCNS-BC, CWS, CWCN-AP, RNFA
Hi Melissa! Yes, this is correct. I misunderstood your wound description and did not understand the area of epidermal loss was also consistent with the color changes of a deep tissue pressure injury (DTPI). Sometimes without photos, I tend to conjure an image in my mind and work from there. If the non intact area is dark like the surrounding area, this could be consistent with the definition of DTPI.
Sep 15, 2019
Elaine Horibe Song
MD, PhD, MBA
Hi Melissa, thank you for your question. Agree with Samantha that it'd be important to ensure the care plan includes adequate offloading, repositioning, pressure redistribution with support surface for Stage 3/4 PU/PI, nutrition optimization and management of excessive moisture and incontinence (if present), and that local wound care aims to keep the small area of epidermal skin loss moist and protect the areas of intact tissue with moisture barrier products and skin protectants. And as you suggested, a soft-silicone foam dressing (silicone/polyurethane 5-layer foam dressing Mepilex Border, Allevyn Life) may be used as well, as those may help prevent progression of DTI.[1]

Of note, DTIs can progress to healing or can evolve to full-thickness PU/PIs despite optimal treatment. It has been shown that DTIs can progress to Stage 3-4 PU/PIs in ~10-70% of the cases.[2] Evolution can be quite rapid, with significant changes every 24-48h, thus frequent inspection is warranted. As DTIs evolve, skin may open up superficially, epidermal loss may be seen, or a thin blood-filled blister may form. DTI may then show thin eschar, and deeper layer of tissues may become exposed. If that happens, it'd be important to continue to document the characteristics of the lesion, including how the blisters/ superficial open areas have formed. Once the DTI opens to an ulcer and affected layers can be assessed, PU/PI can be reclassified into the appropriate stage.[3,4]

Hope that helps, please let us know if any other questions. Thanks!

References:
[1] Sullivan, 2013 https://woundreference.com/app/reference?id=2709
[2] https://woundreference.com/app/topic?action=preview&id=pressure-ulcersinjuries---introduction-and-assessment#dti
[3] CMS, 2018 https://woundreference.com/app/reference?id=2506
[4] https://woundreference.com/app/topic?id=pressure-ulcersinjuries---classificationstaging#guidance-on-pu/pi-staging
Sep 15, 2019
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