If a patient has a stage 2 pressure injury (pressure ulcer) and develops purple discoloration with epithelial tissue present, should it be reclassified as a deep tissue injury (DTI)?

Reclassification of Stage 2 Pressure Injury with Purple Discoloration

Yes, a stage 2 pressure injury that develops purple discoloration should be reclassified as a deep tissue injury (DTI), even if epithelial tissue is present. 1

Understanding Deep Tissue Injury vs. Stage 2 Pressure Injury

• A stage 2 pressure injury involves partial-thickness skin loss with exposed dermis, while a deep tissue injury (DTI) indicates damage to underlying tissues that may not be immediately visible at the skin surface 1
• Purple discoloration is a hallmark sign of DTI, indicating damage to deeper tissues even when the epidermis appears intact or healing 1, 2
• The presence of epithelial tissue with purple discoloration suggests a mixed presentation where superficial healing may be occurring while deeper tissue damage is present 3

Diagnostic Criteria for Deep Tissue Injury

• The primary visual indicator of DTI in light-skinned patients is purple or maroon discoloration with a defined border, often with surrounding erythema 1
• Purple discoloration represents blood and fluid from damaged blood vessels in the deeper tissues, which is pathognomonic for DTI 4
• Even with epithelialization occurring, the purple discoloration indicates ongoing deep tissue damage that requires different management than a simple stage 2 injury 2

Evolution and Progression of Deep Tissue Injuries

• DTIs often evolve rapidly despite appropriate preventive interventions, with 9.3% deteriorating to full-thickness tissue loss even with standard care 3
• The purple discoloration may precede rapid deterioration as damaged muscle tissue stiffens and abnormally deforms adjacent tissues 5
• DTIs can remain "invisible" for up to 48 hours before manifesting visible signs, making early recognition of any purple discoloration critically important 2

Management Implications

• Reclassifying as DTI changes the management approach, requiring more aggressive pressure redistribution and more frequent assessment 4
• DTIs require more vigilant monitoring as they can rapidly deteriorate despite appropriate interventions 3
• The presence of epithelial tissue should not provide false reassurance when purple discoloration is present, as the deeper damage may continue to evolve 1, 2

Differential Diagnosis Considerations

• Other conditions can present with purple discoloration and should be ruled out, including bruising, hematoma, venous engorgement, and arterial insufficiency 1
• A thorough history to account for pressure exposure is essential for accurate diagnosis of DTI 1, 2
• The combination of previously documented stage 2 injury with new purple discoloration strongly supports reclassification as DTI rather than these alternative diagnoses 1

Documentation and Monitoring

• When reclassifying the injury, document the change in appearance, specifically noting the purple discoloration and any other changes in the wound bed 4
• Implement more frequent assessments (at least daily) to monitor for rapid deterioration that may occur with DTIs 3, 2
• Document the size, depth, and characteristics of the wound to track progression and response to interventions 4

By correctly reclassifying the pressure injury as a DTI when purple discoloration appears, you ensure appropriate care planning and interventions that address the deeper tissue damage, potentially preventing further deterioration and improving outcomes.