Jeri Lundgren, RN, BSN, PHN, CWS, CWCN, CPT

We have a resident with a deep tissue injury (DTI) on the sacrum and now the center has an open area. Should we measure and describe just the open area?

It is important to understand how DTIs evolve and to fully capture the extent of the wound. Most DTIs start out as intact skin that is dark maroon and/or purple in discoloration. Then the skin will superficially erode, then form eschar and/or slough, and then form open areas within.

While you might be inclined to measure only the open area, you would not be capturing the entire wound.

Instead, measure the entire DTI and then measure the open area within. Thus, your documentation might state, “Entire sacrum DTI measures 6cm x 8cm with an open area within that measures 3cm x 2.5cm.”

If you have an electronic record that allows only one measurement, enter the full measurement of the DTI and record the measurement of the open area in the progress notes.

When describing the wound base, it is important to describe the entire DTI, not just what is open.

Therefore, your documentation might state, “The sacrum DTI has intact skin with dark purple discoloration with an open area within, that is 80% slough and 20% granulation.” This truly reflects the entire area affected.

Many clinicians err on the side of describing only the open area and then describing the dark purple intact skin as the wound edge. This is incorrect.

The dark purple intact skin is not the wound edge but rather is part of the wound; the skin past the dark purple discoloration would be the wound edge.

Lastly, when noting progress of the DTI, distinguish between the wound’s normal or expected progression and a decline.

Please send your wound treatment-related questions to “Ask the Expert” at [email protected]