[Music] when learning to stage pressure injuries or pressure ulcers it's very important to be able to discern the level of tissue destruction that's involved so what I like to use to give a visual representation are grapefruits so if we start with a stage 1 pressure injury we know that the skin is still intact but it will present with an erythema or a redness that is non blanch able meaning if I press on this you will not see the blood evacuate that area and then reap refused meaning it will turn white and then reproduce red again the trick with this however is in patients with non Caucasian skin what we need to look for is subtle changes in their natural skin tone we will see what's called a disc Romeo or a darkening of their skin tone so don't be fooled looking for erythema and darker complected patients but again a stage one is intact skin with non glanceable erythema or a disc ro mia stage two now is actually disrupted the skin barrier function you can see is represented here that the tissue which is supposed to be representative of the epidermis has now been removed with u-s-d-a's ester but basically what you can see is what would be the papillary layer of the dermis so this is still considered a partial thickness injury because it is partially invaded the skin but it's only removed or invaded the epidermis and that first layer of the dermis the papillary layer when we go on to a stage 3 and even a stage 4d tissue injuries we are now talking about full thickness pressure injuries again because of the levels of tissue involved so in a stage 3 you can quickly see the difference from how the stage 2 presented here we have full involvement of the epidermis but now we have invaded both the papillary and the reticular layer of the dermis in two but not through subcutaneous tissue layer as represented here by this fibrous tissue of the grapefruit so again this is a full thickness injury because it is fully invaded the epidermis and the dermis but it has not gone into deeper tissue structure when we invade deeper tissue structures such as this representation this is very similar to how a stage 4 pressure injury will present and what you can see again is you have epidermal involvement also the papillary and the reticular layer of the dermis we have gone through and extended past the subcutaneous tissue and now we are in deep tissue structures this could be muscle bone tendon ligament even metal if patients have had surgery so this is a very deep injury this is something that needs to be readily addressed and we need to protect these tissues to keep them viable the other aspect that we must consider with pressure injuries is the elusive deep tissue injury and again what you will see when these first evolves is intact skin but it will present with a purple or a dark purple red discoloration of that tissue but even though it won't blanch what you will note which is different is the tissue consistency so it's very important not just to rely on your visual assessment skills and looking at pressure injuries but to palpate those tissues too because with deep tissue injury you will often feel extensive tissue consistency changes could be cooler warmer it could be boggy it could be hard it's not going to feel like normal tissue and with pressure injury the pathophysiology we have to remember happens down at the bony tissue interface when perfusion is not allowed to deliver oxygen and nutrients to those structures muscle tendon bone all of those things die relatively quickly they necrosis so these are actually my acute aeneas infarction and the reason being that the skin tends to be the last thing that tends to become involved is skin has the highest resistance to hypoxia so it's very important to be able to recognize the level of tissue involvement so you can adequately stage pressure injuries [Music] you [Music]