(SPEECH) [MUSIC PLAYING] (DESCRIPTION) Text, 3M, Science, Applied to Life. Where Practice Meets Perspective, Understanding Skin and Wound Care with Dr. Heather Hettrick. How a grapefruit can help you stage a pressure ulcer/injury. Dr. Hettrick stands at a table with three grapefruits in front of her. (SPEECH) 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 (DESCRIPTION) Text, Stage 1, Intact skin with non-blanchable erythema or dyschromia. She picks up an unpeeled grapefruit. (SPEECH) 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-blanchable, meaning if I press on this, you will not see the blood evacuate that area and then reperfuse, meaning it will turn white and then reperfuse, spread again. (DESCRIPTION) She presses her index finger into the grapefruit. (SPEECH) 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 dyschromia or a darkening of their skin tone. So don't be fooled looking for erythema in darker-complected patients. But again a stage 1 is intact skin with non-blanchable erythema or a dyschromia. (DESCRIPTION) She turns the grapefruit to show a patch of the peel that has been abraded. Text, Stage 2: A partial-thickness injury with visibility to the papillary layer of the dermis. (SPEECH) Stage 2 now is actually disrupted the skin barrier function. You can see, as represented here, that the tissue, which is supposed to be represented of the epidermis, has now been removed. We've used a zester. 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. (DESCRIPTION) She places the grapefruit back on the table and picks up the middle grapefruit and shows a large patch of the skin has been peeled away exposing the white pith underneath. Text, Stage 3: Destruction of the papillary and reticular layers but not the subcutaneous tissue. (SPEECH) When we go on to a stage 3 and even a stage 4 or deep tissue injury, 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 into, but not through, the 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 structures. (DESCRIPTION) She turns the grapefruit to show a patch of the skin peeled away to expose the flesh of the grapefruit. Text, Stage 4: Deep, full-thickness tissue loss with exposed bone, tendon or muscle. (SPEECH) 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. (DESCRIPTION) She picks up the third grapefruit with intact skin but with a small reddened patch. Text, Deep Tissue Injury: Intact, but bruised or discolored skin with potential for rapid deterioration. (SPEECH) And again, what you will see when these first evolve 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, which you will note, which is different, is the tissue consistency. So (DESCRIPTION) She presses the discolored patch of the grapefruit with her fingertip all over. (SPEECH) it's very important not just to rely on your visual assessment skills in looking at pressure injuries but to palpate those tissues, too. Because with deep tissue injury, you will often feel extensive tissue consistency changes. It 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 necrose. So these are actually myocutaneous infarctions. And the reason being that the skin tends to be the last thing that tends to become involved. The 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 PLAYING] (DESCRIPTION) Text, Learn more at 3-M dot com/pressureinjury. 3M, Science, Applied to Life. 3M is a trademark of 3M. Copyright 2017, all rights reserved.