Suspected deep tissue injury
Purple or maroon localised area of discoloured intact skin or blood-filled blister due to damage of underlying soft tissue from pressure,
shear or both.
Further description: the area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler than the adjacent tissue.
Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound
bed. The wound may evolve further and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue,
even with treatment.
Source:National Pressure Ulcer Advisory Panel/European Pressure Ulcer Advisory Panel. Clinical practice guidelines for the prevention
and treatment of pressure ulcers. (in press)