Pressure-induced Injuries: Stages (Nursing)

00:05 Now, let's take a look at the stages of pressure injury.

00:09 So one thing I want you to think about with stages, basically, the lower the stage, the better off we are.

00:15 Still not good, but the higher the stage, the worse the pressure injury.

00:20 And guys, these can get really, really bad.

00:23 And we're going to talk about nursing responsibility here in a little bit later.

00:27 But here's something and this gives you a general guideline about staging pressure injuries.

00:34 Now, here's some criteria, but we can definitely, as nurses miss-stage these.

00:39 So be really conscious to work with your wound care team and make sure you guys are working together, staging and assessing appropriately before you document.

00:50 So let's start here with stage one.

00:52 So luckily here, this is the beginning of it all, right.

00:56 So stage one, this is where the skin's intact if you see this image.

01:00 So let me actually take a minute and orient you to this image you see here.

01:04 We've got this nice little block, it looks a little funny, but really what we're looking at, this top part here is our epidermis.

01:11 Underneath here that's going to be our dermis.

01:14 And you see that little yellow kind of odd looking line here that's showing our adipose or subcutaneous layer.

01:22 And then you see those striations that's supposed to be our muscle and then you see that porous bone.

01:28 So, again, as I'm talking through these stages, when you're looking at this image, you're looking at epidermis, dermis, that subcutaneous layer, the muscle and then the bone.

01:39 So just to let you know what we're looking at here, So let's go back to those stages.

01:43 So stage one, that top skin is intact.

01:47 You are going to see some redness here and that's the first clue that someone's getting a pressure injury.

01:54 Now, here's where it matters about assessment.

01:57 So these are nonblanchable.

01:59 So what does that mean to you? Okay, so what I mean by nonblanchable, you know, when sometimes you maybe touch your skin and press down and it immediately returns to color, that's a good sign.

02:13 That means we're getting good perfusion, everything's healthy.

02:16 But sometimes we'll push down and it stays white.

02:22 That's nonblanchable or it stays as a discoloration and doesn't return to its normal state.

02:28 That can be a problem and an indicator that something's wrong.

02:32 Now, the good thing here with a stage one, we don't have an open wound, a break or a tear yet.

02:38 So if we start prevention in this stage, an early treatment, we can save it from getting much worse.

02:48 So now let's move to stage two.

02:50 Here's where we're starting to get an issue here.

02:53 As you can see on this image, that skin is no longer intact now.

02:57 We're having some partial thickness loss at the top layer of our epidermis and sometimes this can go into the underlying layer, the dermis.

03:07 Now, again, it's an earlier stage.

03:10 We have not quite reached that yellow subcutaneous layer yet, but this could be a progressive problem pretty quickly.

03:21 Now, look at this image, man, this is stage three, we're getting into some serious issues here, guys.

03:28 So as you can see on this image, we've got full thickness loss of the skin layer all the way down to that subcutaneous layer.

03:38 That is deep.

03:39 So the also issue with this is they can go so deep, it could have what we call undermining or tunneling, meaning we may see part of this, there could be some extra tunneling underneath that layer that we can't even hardly see until we really get in there.

03:56 So meaning this stage three could be deeper than what we think.

04:01 Now, this stage has not quite reached that muscle where you see the striation there, the tendon or the bone.

04:08 But again, guys, this is a pretty serious pressure injury here.

04:13 Now, lastly, this is what we call a stage four.

04:17 Guys, if we're in a stage four, we're in trouble.

04:20 The patient has, this is going to be really, really difficult to heal.

04:25 It's going to take a lot of nutrition support, hydration, support, a lot of treatment, and it's going to take some time to heal.

04:32 This thing will not heal overnight.

04:34 So as you can look at this image, you see a full thickness loss, epidermis, of the dermis.

04:41 You see it's going through that subcutaneous tissue, but more importantly, it is getting the muscle, the tendon and the bone can be even exposed.

04:51 So if you're listening to this, you may think, okay, well, you know, this sounds crazy, guys, we see it in practice all the time.

04:58 I've seen patients with these injuries and they are those populations, like we talked about, immobility, maybe a spinal cord injury, maybe they've got infection and altered LOC But these patients are really at risk and we can get wound so deep that it goes down to the bone like this.

05:16 And I assure you, you're going to run across this in your nursing practice and you may even see the bone.

05:21 It's pretty crazy to see but this is why it's so important to prevent these.

05:28 Now, let's take a little recap just for a visual.

05:31 So as you see here on this slide, it goes from stage one, which the skin was nice and intact, little bit of nonblanchable issue here.

05:41 Right now, we can prevent.

05:43 Well if we don't treat this early., it can progress to that stage two.

05:47 If you remember, involves the epidermis and the dermis, then that can progress to stage three all the way down to the subcutaneous layer.

05:56 And again, man, that treacherous stage four to where we're going through the muscle, the bone could be even exposed.

06:02 So this is a really good image just for you guys to see here.

06:06 See how deep this progresses throughout the stages.

06:10 So why nursing responsibility and assessment is so key.