Documenting Temperature in Skin and Wound Assessment

In addition to the National Pressure Injury Advisory Panel’s definition of Deep Tissue Pressure Injury, the 2019 Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guidelines (CPG)¹ recognize the significant role temperature plays in skin and tissue assessment.

Definition: Deep Tissue Pressure Injury

Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. 

This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. (1)

According to the CPG:

2.4: Assess the temperature of skin and soft tissue.
(Strength of Evidence = B1; Strength of Recommendation ↑)

-Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline The International Guideline (1)
Ischemic-Buttock

Relative skin temperature changes over areas of ischemia
can present as colder than surrounding skin and tissue.¹

Inflammatory-Heel

Relative skin temperature changes over areas of inflammation
can present as warmer than surrounding skin and tissue.¹

2.7: When assessing darkly pigmented skin, consider assessment of skin temperature and sub-epidermal moisture as important adjunct assessment strategies.
(Strength of Evidence = B2; Strength of Recommendation ↑)

-Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline The International Guideline (1)
Ischemic-Buttock-Dark-Skin

Relative skin temperature changes over areas of ischemia
can present as colder than surrounding skin and tissue.¹

Ischemic-Heel

Relative skin temperature changes over areas of ischemia
can present as colder than surrounding skin and tissue.¹

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