Pressure Injury Classification: eLearning Module

 

This e learning tool will introduce you to:

The Skin and its Layers

The Layers of Skin


The 3 Layers of Skin

Epidermis: 

  • the top layer acts as a protective water-repellent barrier
  • stores melanin to create the pigment in our skin and protects from UV light 
  • and creates new skin cells
  • contains phagocytes that prevent bacteria from penetrating

Dermis: 

  • contains sebaceous/sweat glands, capillaries, and nerves
  • Regulates temperature by via dilation and constriction of the capillaries.
  • the capillaries also supply nutrients to the epidermis

Subcutaneous or Fatty Tissue or Hypodermis: 

  • where fat is stored 
  • contains collagen fibroblasts, and hair follicles
  • protective layer for tissues, organs, and structures 
  • and also regulates temperature via dilation and constriction of the arterioles.

(LeMone et al, 2014).


Watch the following animations about Skin and the Layers of Skin

Video sourced from  AniMed (2017).

How the Skin works:

If the video does not play please click the following link:

https://www.youtube.com/watch?v=nCzGflPoHa0

Video sourced from  KidsHealth.org (2017).

Here is a fun kids animation on the skin layers:

If the video does not play please click the following link:

https://www.youtube.com/watch?v=aMGgCxUyXT8

What is a Pressure Injury?

What is a Pressure Injury

Definition of a Pressure Injury

According to the National Pressure Ulcer Advisory Panel (NPUAP) (2017) a pressure injury is: 

  • a localised damage to the skin and soft tissues 
  • predominantly on bony areas of the body or related to a medical device
  • The injury can be as intact skin or an open wound, that may be painful. 
  • The injury occurs after prolonged pressure to the skin, that may include shear or friction.


Prevalence of Pressure Injuries

 According to Clinical Excellence Commission (2016), in Australian Public Hospitals during 2016:

  • 23,201 pressure injury incident notifications made in IIMS
  • over 12,500 patients suffered harm from a pressure injury
  • 7,500 notifications were recorded where the injury was not present on admission
  • 80% of notifications were for patients aged 65 years or older
  • 39% of injuries notified were located on the sacrum or buttocks and 21% on the heels
  • 56% were Stage 1 and 30% were Stage 2.
  • treatments costs were estimated to be A$983 million per annum (in 2012-13)
  • a total number of 524,661 bed days were lost.

(p4-7).

Although prevalence rates for hospital-acquired Pressure Injuries have declined over the past 10 years, Pressure Injuries are still a huge burden on patient health, and the Australian healthcare system.

How does a Pressure Injury develop?

Pressure Injuries are localised ischaemic areas of the skin and tissue caused by pressure that impairs the flow of blood and lymph; the restriction of blood prevents the supply of much needed nutrients to the skin and tissues in order to remain healthy. The pressure and lack of nutrients to the skin and tissue cause inflammation from increased capillary permeability, necrosis from lack of blood and nutrients and, and eventually ulceration (LeMone et al, 2014; NPUAP, 2017).

Where do Pressure Injuries develop?

Pressure Injuries appear on bony areas of the body, but may also appear anywhere on the body that is subjected to prolonged pressure, friction or shearing (LeMone et al, 2014).

If the video does not play, click on the following link to view:

https://www.youtube.com/watch?v=Eyuguc7KKC4

Video sourced from Nucleus Medical Media (2011)


Pressure Injuries develop on bony prominences, or in areas with prolonged pressure.

How do you prevent Pressure Injuries?

Pressure Injuries are preventable with a pressure area care plan; this involves skin integrity assessments, regular repositioning, and using protective dressings or equipment depending on the risk to the patient of developing pressure injuries (NPUAP, 2017)..

It is best to follow local pressure injury care protocol and procedure when assessing, attending, and managing your patient.


Reflect on: what is a Pressure Injury?

  • How does prolonged pressure affect the blood vessels in the Dermis and Subcutaneous Layers?  
  • How does this develop a Pressure Injury? 

Who is at risk of developing a Pressure Injury?

Risk Factors for Pressure Injuries

Risk Factors for Pressure Injuries

Pressure injuries can develop quickly in older people, or anyone with reduced mobility, or inactivity (CEC, 2017); other intrinsic factors that contribute toward pressure injuries are poor nutrition, sensory loss, co-morbidities/disease, incontinence and body type (LeMone et al, 2014). 

Extrinsic factors include, moisture, heat, duration of pressure and positioning.


Reflection:

Can you think of any patients or people you know that may be at risk of developing a Pressure Injury? or who have experienced a Pressure Injury?

Explain what risk factors they have.

Classification of Pressure Injuries

Pressure Injury Classifications

What are the Pressure Injury Classifications?

According to The National Pressure Ulcer Advisory Panel (NPUAP) (2017) there are 6 classifications:

Stage 1 Pressure Injury: Non-blanchable erythema of intact skin 

  • Skin is intact skin with non-blanching erythema
  • this may appear differently in darkly pigmented skin. 
  • There may be changes in sensation, temperature, or firmness.

Stage 2 Pressure Injury: Partial thickness skin loss with exposed dermis 

  • Partial-thickness skin loss, with loss of the epidermis and some of the dermis. 
  • appears as a shallow ulcer with a red-pink color. 
  •  may also appear as an enclosed or open serum-filled blister.
  • No slough or necrotic tissue is present in the base.

Stage 3 Pressure Injury: Full-thickness skin loss 

  • Full-thickness loss of skin, in which with dermis and epidermis loss
  • subcutaneous fat may be visible 
  • granulation tissue and epibole (rolled wound edges) are often present. 
  • Slough and/or eschar may be present. 
  • Undermining and tunneling may occur. 
  • No fascia, muscle, tendon, ligament, cartilage and/or bone are exposed.

Stage 4 Pressure Injury: Full-thickness skin and tissue loss 

  • Full-thickness skin and tissue loss 
  • exposed fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. 
  • Slough and/or eschar may be visible.
  • Epibole (rolled edges), undermining and/or tunneling often occur. 
  • If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury.

Unstageable Pressure Injury: Depth unknown

  • Full thickness skin and tissue loss (but cannot be seen as it is obscured by slough or eschar )
  • cannot assess how deep the injury is 
  • base is covered in slough (yellow, grey, green or brown), and/or eschar (tan, black, brown), and has necrotic areas

Deep Tissue Pressure Injury (DTPJ): Depth Unknown

  • Persistent non-blanchable dark red, purple or maroon discoloration 
  • or a dark wound bed or blood filled blister
  • intact or non-intact skin 
  • There may be changes in sensation, temperature, or firmness
  • It is also important to be aware of other factors that may have a similar presentation to DTPJ, such as a dermatitis or incontinence rash.

 

Reflection:

  • What are the differences in each classification?

  • How is each classification different to the next? or different to each other?


Glossary:

Erythema: when the skin becomes reddened; reddening occurs when capillaries dilate and skin cells are damaged. 

Eschar: dead necrotic tissue, may be dry, moist, or leathery

Slough: yellow or white devitalized tissue, that can be stringy or thick and adherent on the tissue bed.

Tunneling: a channel/ forms from the wound bed into or through the subcutaneous layer or muscle.

Undermining: the tissue erodes under the wound edges

Stage 1

Stage 1 Pressure Injury: Non-blanchable erythema of intact skin 

  • Skin is intact skin with non-blanching erythema
  • this may appear differently in darkly pigmented skin. 
  • There may be changes in sensation, temperature, or firmness.

Glossary:

Erythema: when the skin becomes reddened; reddening occurs when capillaries dilate and skin cells are damaged. 

Stage 2

Stage 2 Pressure Injury: Partial thickness skin loss with exposed dermis 

  • Partial-thickness skin loss, with loss of the epidermis and some of the dermis. 
  • appears as a shallow ulcer with a red-pink color. 
  •  may also appear as an enclosed or open serum-filled blister.
  • No slough or eschar is present in the base.

Glossary:

Eschar: dead black/brown/tan necrotic tissue, may be dry, moist, or leathery

Slough: yellow or white devitalized tissue, that can be stringy or thick and adherent on the tissue bed.

Stage 3

Stage 3 Pressure Injury: Full-thickness skin loss 

  • Full-thickness loss of skin, in which with dermis and epidermis loss
  • subcutaneous fat may be visible
  • granulation tissue and epibole (rolled wound edges) are often present.
  • Slough and/or eschar may be present.
  • Undermining and tunneling may occur.
  • No fascia, muscle, tendon, ligament, cartilage and/or bone are exposed.

Glossary:

Erythema: when the skin becomes reddened; reddening occurs when capillaries dilate and skin cells are damaged. 

Eschar: dead black/brown/tan necrotic tissue, may be dry, moist, or leathery

Slough: yellow or white devitalized tissue, that can be stringy or thick and adherent on the tissue bed.

Tunneling: a channel/ forms from the wound bed into or through the subcutaneous layer or muscle.

Undermining: the tissue erodes under the wound edges

Stage 4

Stage 4 Pressure Injury: Full-thickness skin and tissue loss 

  • Full-thickness skin and tissue loss
  • exposed fascia, muscle, tendon, ligament, cartilage or bone in the ulcer.
  • Slough and/or eschar may be visible.
  • Epibole (rolled edges), undermining and/or tunneling (channels into the tissue) often occur.
  • If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury.

Glossary:

Erythema: when the skin becomes reddened; reddening occurs when capillaries dilate and skin cells are damaged. 

Eschar: dead black/brown/tan necrotic tissue, may be dry, moist, or leathery

Slough: yellow or white devitalized tissue, that can be stringy or thick and adherent on the tissue bed.

Tunneling: a channel/ forms from the wound bed into or through the subcutaneous layer or muscle.

Undermining: the tissue erodes under the wound edges

Unstageable

Unstageable Pressure Injury: Depth unknown

  • Full thickness skin and tissue loss (but cannot be seen as it is obscured by slough or eschar )
  • cannot assess how deep the injury is
  • base is covered in slough (yellow, grey, green or brown), and/or eschar (tan, black, brown), and has necrotic areas

Glossary:

Eschar: dead black, brown, tan necrotic tissue, may be dry, moist, or leathery

Slough: yellow or white devitalized tissue, that can be stringy or thick and adherent on the tissue bed.


Deep Tissue Pressure Injury

Deep Tissue Pressure Injury: Depth Unknown

  • Persistent non-blanchable dark red, purple or maroon discoloration
  • or a dark wound bed or blood filled blister

Watch this video for Pressure Injury classification examples:

Please feel free to return to other sections of the module to revise, reflect, and develop your understanding.



Video sourced from FTP Lectures (2017).


Pressure Injury classifications made out of sponges, cotton buds, and paint.

During your next class, in small groups you will create your own examples of Pressure Injury classification: 

  • Pressure Injury classification examples using sponges, cotton buds, and paint.


If the video does not play please click on the following link:

https://www.youtube.com/watch?v=XdwW7PAwizs


Have a Practice

Drag and drop to the appropriate image

  • Stage 1 Pressure Injury
  • Stage 2 Pressure Injury
  • Stage 3 Pressure Injury
  • Stage 4 Pressure Injury
  • Deep Pressure Injury
  • Unstageable Pressure Injury

Match to the correct description

  • Stage 1
    Skin is intact with non-blanching . This is usually over a bony areas.
  • Stage 4
    Full-thickness loss of skin, tissue necrosis, and damage to bone, muscle, or other supporting structures that are exposed. Slough, eschar, tunnelling or undermining may be present.
  • Stage 3
    Full thickness skin loss, epidermis and dermis loss, subcutaneous fat may be visible. Bone, tendon or muscle are not exposed. Slough or eschar (black, necrotic) may be present.
  • Unstageable
    Depth unknown, base is covered in slough (yellow, grey, green or brown), and/or eschar (tan, black, brown), has necrotic areas. The depth cannot be determined until necrotic tissue is cleared.
  • Deep Tissue Injury
    Depth unknown, discolored intact skin that is dark red, purple or maroon in color. It may also appear as a blood-filled blister resulting from damage to underlying soft tissue.
  • Stage 2
    Partial-thickness skin loss, with loss of the epidermis and some of the dermis. It appears as a shallow ulcer with a red-pink color. No slough or necrotic tissue is present in the base. It may also appear as an enclosed or open serum-filled blister.
  • Stage 5
    This classification does not exist
  • Stage 6
    This classification does not exist

Which of the following is Stage 1 classification?

Select the magnifying glass icon to view the full picture, then choose the appropriate option

Which of the following is Stage 2 classification?

Select the magnifying glass icon to view the full picture, then choose the appropriate option

Which of the following is Stage 3 classification?

Select the magnifying glass icon to view the full picture, then choose the appropriate option

Which of the following is Stage 4 classification?

Select the magnifying glass icon to view the full picture, then choose the appropriate option

Which of the following is the Unstageable classification?

Select the magnifying glass icon to view the full picture, then choose the appropriate option

Which of the following is the Deep Tissue Injury classification?

Select the magnifying glass icon to view the full picture, then choose the appropriate option

Reflection

What have you learnt so far?

Reflect on your learning:

Write down what you understand the following to be:

  1. The 3 Layers of Skin
  2. A Pressure Injury 
  3. the risk factors of a Pressure Injury
  4. The areas that are prone to Pressure Injury
  5. The Pressure Injury classifications: 
  6. Stage 1
  7. Stage 2
  8. Stage 3
  9. Stage 4
  10. Unstageable
  11. Deep Tissue Injury

Be prepared to discuss your answers in a small group, and as a class.

Go back and view previous resources if you wish to revise your understanding.


When you are ready, take the post-quiz and compare with your pre-quiz results.