Stage 3 sacral pressure injury, hip precautions and incontinence
Mrs L is 82 and is day 4 after a right hemiarthroplasty for a displaced femoral neck fracture. She is weight-bearing as tolerated with a frame, and hip precautions are in place. On the sacrum there is a 3.5 × 2.5 cm wound with full-thickness skin loss and visible subcutaneous fat; there is no exposed bone, tendon or muscle, and 0.5 cm of undermining at the inferior edge. She is doubly incontinent, has a Braden score of 12 and an albumin of 26 g/L. She spends up to six hours a day in a recliner because "it is more comfortable", and her daughter brings sugary drinks because she "won't eat".
1. Classify the wound and state which interventions you should not use, with your reasoning.
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Classification: Stage 3 pressure injury. There is full-thickness loss of skin with visible subcutaneous fat, no exposed bone, tendon or muscle, and undermining - but the wound bed is not covered by slough or eschar, so it is not unstageable. It is not a Stage 2 (those are partial-thickness, no fat visible) and not a deep tissue injury.
Do not use
- Massage or rubbing of the surrounding skin or the wound margins - it causes further tissue damage and does not improve perfusion.
- Donut or ring cushions - they cause a ring of high pressure and impair venous return.
- Heat lamps or prolonged heat - they dry the wound bed and can burn anaesthetic skin.
- Dry gauze on a clean granulating bed - it adheres, traumatises on removal, and is not a moist wound-healing dressing.
- Over-aggressive cleansing (e.g., hydrogen peroxide, alcohol) - cytotoxic to new tissue.
- Leaving her in the recliner for hours - pressure injury is caused by pressure and shear over time, and the chair is a contributory cause, not a rest.
Appropriate Repositioning schedule, pressure-redistributing support surface, moisture management, offloading, nutrition referral, and a dressing chosen by the tissue viability team for a moderately exuding Stage 3 wound (e.g., a foam or hydrocolloid-type product). Escalate any signs of infection (spreading erythema, purulence, odour, systemic features).
2. Design a 24-hour offloading plan that reconciles hip precautions, continence and her preference for the recliner.
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24-hour plan
- Support surface: pressure-redistributing (high-specification foam or alternating) mattress and a pressure-redistributing chair cushion. Document the equipment.
- Repositioning: two-hourly in bed while awake, with a written turning chart; use the 30° tilted side-lying position where possible, respecting hip precautions (avoid adduction past midline, avoid flexion beyond 90°, avoid internal rotation). Use pillows between the knees.
- Sitting: cap chair time at about 60–90 minutes, then return to bed or mobilise. Six hours in a recliner is the single biggest modifiable factor.
- Seating: ensure the recliner is not a sling seat that pushes the hips into adduction and slides her forward (shear). If it cannot be adjusted, replace it.
- Incontinence: check and change promptly, use a barrier cream, avoid soap-and-water scrubbing; consider a continence nurse review. Moisture plus shear on a sacrum doubles the risk.
- Heels and other sites: offload heels with a pillow under the calves (not under the Achilles), and check ears, elbows, occiput.
- Mobility: use the frame to stand and take steps regularly - the best offloading is getting off the loaded area; this also serves her hip rehabilitation.
- Skin inspection: at every reposition, including under the dressing edges.
- Negotiate, don't dictate: "I know the recliner is comfortable. Let's use it in shorter blocks and put you back to bed before it starts to hurt - the chair is what is making the wound worse."
3. Her daughter brings sugary drinks and refuses supplements. How do you manage this interprofessionally and what do you say?
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Interprofessional actions
- Refer to the dietitian the same day: albumin 26 g/L plus a Braden of 12 and a Stage 3 wound means she needs an estimated protein and energy intake review, not generic advice. Document the referral.
- Tissue viability nurse for dressing selection and wound review; continence nurse for continence products and skin care; nursing for the turning chart and equipment.
- Raise at the multidisciplinary team meeting so the nutritional plan is owned by the team, not by physiotherapy.
The conversation with the daughter
- Start with her intent: "You're bringing her drinks because you want her to keep her strength - that matters." Then give the link plainly: healing a wound like this needs protein and calories, and sugary drinks provide energy without the protein; that is why the dietitian is involved.
- Offer concrete, culturally acceptable options: milky drinks, fortified soups, yoghurt, eggs, small frequent portions; ask what her mother actually likes.
- Ask about barriers - appetite, dentition, nausea, cost, and who shops and cooks after discharge.
- Do not frame it as a conflict about the daughter's care. Frame it as adding to what she already does.
- Document the discussion, who was present and what was agreed, and set a review date with the dietitian.