Wound Care, part 2: Staging Pressure Injuries


In this video, Cathy discusses how to identify a pressure injury (i.e. pressure ulcer, which is an outdated way to describe a pressure injury). She shares some of the more common places for pressure injuries, including the elbows, heels, hips, coccyx, and sacrum. Cathy then reviews the layers of skin and which layers of skin are impacted by stage 1, 2, 3, and 4 pressure injuries. She then shows examples of each pressure injury: stage 1, stage 2, stage 3, stage 4, unstageable, and deep tissue injury (DTI). Lastly, she talks about pressure injuries that are caused by medical devices.

Cathy Parkes RN, covers Wound Care for Nurses - Staging Pressure Injuries. The Wound Care for Nurses video tutorial series is intended to help RN and PN nursing students study for your nursing school exams, including the ATI, HESI and NCLEX.

  • 0:00 What to Expect
  • 0:26 Pressure Injuries
  • 1:07 Common Locations
  • 2:33 Stages of Pressure Injuries
  • 2:59 Illustration of Stages
  • 4:05 Stage 1
  • 4:53 Stage 2
  • 5:50 Stage 3
  • 7:02 Stage 4
  • 7:29 Unstageable Pressure Injury
  • 8:41 DTI
  • 10:13 Medical Devices

Full Transcript: Wound Care, part 2: Staging Pressure Injuries

All right. In this video, we are going to talk about pressure injuries and how to stage pressure injuries. You may be familiar with the old terminology, which is pressure ulcer, which we don't use anymore because a lot of pressure-related wounds don't appear as ulcers on the skin. So pressure injury is the more up-to-date and accurate terminology that you'll want to use. So a pressure injury is where we have damage to the skin and/or the underlying tissue over a bony prominence or under a medical device due to intense or prolonged pressure. Okay?

So when you see a wound on a patient's body, if it is not over a bony prominence, like if it's on their arm, maybe a skin tear, or on their stomach, then that is not over a bony prominence. So the only way that that would be a pressure injury is if there was some kind of medical device in that area that was putting a lot of pressure onto the tissue. Typically, you will find pressure injuries over bony prominences. So when I say bony prominences, you can kind of feel around on your body and think about the places that may be susceptible to pressure injuries. So like elbows; your elbows are bony. So if there's prolonged or intense pressure on your elbows, you can end up with a pressure injury there. Your scapula are bony. Your coccyx bone is very bony as well as your sacral bone. Your heels are also bony. So that's a very common place for pressure injuries is on the heels of patients who are bedridden and have just prolonged pressure there on the heels. And then there could be other places as well. So the hips may have pressure injuries. So if a patient spends a lot of time on one hip or the other, then that can cause pressure injuries. And then on the buttocks, you can end up with pressure injuries over the ischial tuberosities. So this is kind of the sitting bones. So when the patient's laying down, you'll think, "Oh, it's just on their buttocks. It's not really a bony place." But if you kind of feel underneath there and think about when you sit down where those ischial tuberosities may put pressure on the skin and tissue, then you will see that this is also a place that is susceptible to pressure injuries.

So let's talk about the different stages of pressure injuries. We can have stage one, stage two, stage three, stage four, unstageable, and a deep tissue injury. So I am going to talk more in depth about these different stages, and show you some pictures so you can get really good clarification for what the wounds will look like at each stage. Okay. Let's review the different layers of skin, and for stages one, two, three, and four, which layers are affected. So if you recall, we have the epidermis and then the dermis underneath that, then subcutaneous tissue, then tendon or muscle, and then bone. So with stage one, the skin is intact, but the epidermis is damaged. Nothing below the epidermis is damaged, though, for a stage one. For stage two, we have damage to the epidermis as well as the dermis, but it does not extend into the subcutaneous tissue. With stage three, we have damage to the epidermis, the dermis, and then now the wound extends into the subcutaneous tissue. And then lastly, with stage four, we have damage to all layers of the skin, and the wound extends to either the muscle, bone, or tendon. So you will see one of those things at the base of the wound.

Okay. Here we have an example of a stage one pressure injury. So the skin will be intact over the bony prominence, but it will be red, and it will be nonblanchable, meaning, when we push on it with our finger, it will not turn white. It will stay red. If it stays red, it's nonblanchable, and it means we have a stage one pressure injury. If we push on it, and it does blanch or turn white, then it is not a pressure injury yet. They may be at risk for a pressure injury, so you'll probably want to put a pillow under that elbow or offload them from whatever bony prominence this is. But if it is nonblanchable, then it's a stage one, and that's how you should document this wound.

Okay. Here we have some examples of stage two pressure injuries. So the skin is open, right? It's not closed like we had with stage one, but it's very, very shallow. So we just have that top layer of skin missing here, so just that epidermis, and we have injury into the dermis. Typically, with stage two pressure injuries, the wound bed will be pink or red and will be very moist. So here you can see that we have pressure injuries over the ischial tuberosities or the sitting bones. And we also kind of have damage up here into the coccyx area as well. So again, with stage two, the skin is not intact, so it is open, but it is very shallow. Just that top layer of skin is damaged, and the wound bed will be pink and moist.

Okay. Here is what I would consider a stage three pressure injury. So the skin is broken. This is an open wound, but it's a little deeper than the last wound. So with the last wound, it was just that top layer of skin that was missing, and the wound bed was nice and pink or red and moist. In this wound, we can see some white there in the middle of the wound, which means we extend into the subcutaneous tissue, which would make this a stage three. However, we don't see any bone, tendon, or muscles, so we're not looking at a stage four. Sometimes, nurses have trouble with staging when it comes to stage three. So I usually offer this advice. If the wound is open and over a bony prominence, if it's really shallow, just the top layer of skin is missing, it's a stage two. If you see bone, tendon, or muscle, then it's a stage four. And if it's anything in between, it's a stage three. So with stage threes, usually the wound base will be more on the white side as opposed to pink. So hopefully, that's helpful. And next, we'll look at stage four.

Okay. In this picture, we have a stage four pressure injury. So this is over the coccyx sacral area. And if you probe this part of the wound here, you will feel bone. So you can kind of see the bone here. So this makes it a stage four because anytime you have exposed bone, tendon, or muscle in a pressure injury over a bony prominence, then that makes it a stage four.

Okay. So this picture is an unstageable pressure injury. It is unstageable because most of the wound base is covered in eschar or slough such that we cannot visualize the wound base. So this black stuff here is eschar. Eschar can be kind of black and rubbery, or it may be black and hard. And then it looks like slough down here. So for lack of a better description, slough will usually present like chicken fat. So it's kind of a yellowish-white kind of rubbery substance. So this is a wound over the coccyx bone, and it needs to be debrided and most likely surgically debrided. Once we get this eschar and slough off, it will likely extend very deep. My guess is it will be a stage four pressure injury once we remove this eschar and slough. However, for now, it is considered unstageable because we really don't know how deep it goes because of this layer of eschar. So this is unstageable.

Okay. In this picture, we have a deep tissue injury or DTI that is evolving here. So this purple intact skin is a DTI or deep tissue injury. It is different than a stage one. So remember, a stage one is where we had red intact skin over a bony prominence that is not blanchable. So with a stage one, the damage is kind of limited to the epidermis. With a deep tissue injury, the damage goes much, much deeper. And in many cases, with the DTI, this skin will eventually come open, as it is here on this part, and it can extend very deep. So this part right here that is opened up on the DTI, it's definitely at least a stage three right here. So it's more than just the top layer of skin that's missing here. We definitely have damage down into the subcutaneous tissue. So this is a DTI that is evolving currently with one spot that is a stage three pressure injury. So you notice that a lot of the pictures I've shown you have all been the booty, right, the coccyx sacral area. And so it's so important to really assess this area very carefully when you admit your patient, in addition to all the other bony prominences such as the heels and the elbows and the scapula, etc.

Okay. Before we wrap up this video, let's talk about pressure injuries from medical devices. So there are a couple of common pressure injuries that can occur from medical devices. So one is from oxygen tubing. So when a patient has oxygen tubing in place, if that tubing is on them for a prolonged amount of time, it can cause skin breakdown here behind the ears. So there are some special foam protectors that are very inexpensive but very effective that you can just slide onto the tubing and rest it behind their ears, which will protect the patient's skin. Also, NG tubes often cause pressure injuries. So if the way the NG tube is stabilized on the patient's nose makes the tube kind of rest against their nare, it can cause a pressure injury. If the wound is inside the nare on the mucosa, then we don't stage that pressure injury. We just call it a mucosal pressure injury. However, if the damage from the NG tube is to really the surrounding skin there on the nose, then we can stage it just like we did with the other wounds. Also, just be aware of IV lines and other tubing catheters. Make sure your patient's not laying on them. Make sure it's not taped down too tight because those can also cause pressure injuries. So just be aware and just check all the lines before you leave the patient's room. So hopefully, this video has been helpful for helping you to identify pressure injuries and to be able to stage them appropriately. So in my coming video, we will talk about care of pressure injuries as well as other wounds. Thanks so much for watching.

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