Wound, Ostomy and Continence Nurses Society (WOCN) Practice Exam

What is the best description of a deep tissue injury?

1. Localized area of persistent blanchable redness

2. Persistent non-blanchable discoloration or epidermal separation

3. Visible bruising without skin disruption

4. Completely intact skin with slight swelling

The correct answer is: Persistent non-blanchable discoloration or epidermal separation

A deep tissue injury is best described as persistent non-blanchable discoloration or epidermal separation. This type of injury occurs when there has been damage to the underlying tissue while the overlying skin may appear intact or show minimal signs. The defining characteristic is the presence of a discoloration that does not turn white or blanch when pressure is applied, indicating that the injury is deeper and more serious than surface-level wounds. This description aligns with the understanding that deep tissue injuries often arise from prolonged pressure or shear forces, leading to tissue necrosis beneath the skin. Recognizing this distinction is crucial for proper assessment and management in clinical practice, as deep tissue injuries can signify a more significant risk of progressing to deeper pressure injuries if not addressed appropriately.