Infected Stage 3 Sacral Pressure Injury in Paraplegia: Offloading, Staffing, and Nutrition
Mr. A., 45, has T10 ASIA A paraplegia from a fall four months ago and is admitted for a two-week rehabilitation stay to prepare for community discharge. He has a stage 3 pressure injury over the sacrum, 4.5 by 3 cm with 60% yellow slough; it was last measured five days ago with no documented change. The unit is short-staffed, and repositioning has been done every 4 hours for the past two nights instead of every 2 hours. He uses a pressure-redistribution cushion but sits in his wheelchair 6 to 8 hours a day for therapies. This morning his temperature is 38.7 degrees C, heart rate 118, blood pressure 96/58, respirations 24, and he reports feeling chilled and wiped out. His white count is 15.8 with 88% neutrophils, and his albumin is 2.4 g/dL. The wound edges are now erythematous and indurated, and there is a new foul odor.
1. What do the vital signs and wound changes suggest, and what are your immediate actions?
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The new fever, tachycardia, hypotension, tachypnea, leukocytosis with neutrophilia, and a foul-smelling, erythematous, indurated wound point to an infected pressure injury with possible osteomyelitis or sepsis, not merely a stalled wound. His albumin of 2.4 impairs healing and immunity. Immediate actions: notify the provider now, obtain blood cultures (plus urine or stool if indicated) before antibiotics, and do not delay antibiotics if he is unstable. Monitor vital signs and mental status per the sepsis protocol, start fluids per order, and request wound culture, noting that a surface swab is unreliable for deep infection and the provider may order imaging or a bone biopsy. Remove all pressure from the area and keep him off the sacrum.
2. How do you address the repositioning gap and the long wheelchair sitting times?
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Repositioning every 2 hours is the standard for a stage 3 sacral wound; 4-hour nights are a care gap, not a minor variation, and pressure injury progression is a nursing-sensitive outcome. Fix the system rather than only the chart: escalate to the charge nurse and wound team, build a turning schedule with a buddy system at shift change, use 30-degree lateral tilt positions, provide a specialty support surface, and limit head-of-bed elevation to 30 degrees when possible. Reduce wheelchair sitting to 2 hours or less at a time with pressure-relief lifts every 15 minutes, because he is sitting 6 to 8 hours for therapies. Do not just document repositioned every 4 hours; document the impediment and the plan. If staffing genuinely cannot meet the standard, document and escalate, which is advocacy, not insubordination.
3. What nutritional and wound-care recommendations would you make, and what must he demonstrate before discharge?
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Consult the dietitian and wound/ostomy nurse. Target roughly 1.25 to 1.5 g/kg/day of protein with adequate calories and fluids for a stage 3 wound, and address the low albumin; an arginine- or glutamine-enriched oral supplement may be ordered. Debridement of slough by the wound specialist is needed to assess depth and rule out osteomyelitis. Use a moist wound-healing dressing matched to the wound bed, such as a hydrocolloid or foam if exudate is minimal, offload completely, and avoid harsh antiseptics. Measure and photograph weekly per protocol to track healing. Educate him on pressure relief and daily skin checks; before discharge he must demonstrate a pressure-relief lift and have his wheelchair cushion assessed, since community discharge depends on those skills.