Sacral Erythema Versus Moisture Rash: Staging and Documentation Judgment
Mrs. L is a 79-year-old woman in a skilled nursing facility. She is bedbound, has urinary and fecal incontinence, and a Braden score of 12. Over the sacrum is a 4 x 3 cm area of intact skin that is dark red and does not blanch after 30 minutes of pressure relief. Extending into the gluteal cleft are irregular, macerated, erythematous patches with satellite pustules. She is afebrile; WBC is 7.2. The aide reports the area 'looks worse after episodes of diarrhea.' There is no open wound, no drainage, and no crepitus. The physician documents 'Stage 2 pressure ulcer' and orders a hydrocolloid dressing.
1. Differentiate the sacral lesion from the intergluteal rash. What assessment findings support each, and what is the correct staging of the sacral area?
Read the worked answer
Sacral area: Intact skin with non-blanchable dark redness after pressure relief is a Stage 1 pressure injury, not Stage 2. Stage 2 requires partial-thickness skin loss with a shallow open ulcer or intact/ruptured blister; there is no open wound here. The location over the sacrum and Braden score of 12 support pressure as the cause.
Intergluteal area: Irregular maceration, erythema, and satellite pustules in a moist, incontinent area suggest moisture-associated skin damage with candidiasis, not a pressure injury. Satellite lesions are a key clue. The absence of pressure-point distribution and the worsening after diarrhea support moisture and fungal irritation.
Documentation correction: The physician's 'Stage 2' label is not supported by the assessment. The nurse should document the non-blanchable intact sacral area as Stage 1 and describe the intergluteal rash separately, then clarify the order.
2. What additional assessments and documentation are needed before implementing the hydrocolloid order?
Read the worked answer
Assess and document:
- Sacral lesion: exact size, shape, color, blanching response, temperature, tenderness, and whether any open area or undermining is present.
- Intergluteal rash: borders, maceration, satellite lesions, odor, and moisture source.
- Risk factors: incontinence pattern, repositioning schedule, nutrition/hydration, mobility, and Braden subscales.
- Systemic signs: temperature, pain, and any drainage, though she is currently afebrile with normal WBC.
- Photograph per facility policy and wound-care protocol.
Order concern: A hydrocolloid is occlusive and may trap moisture over the macerated, candidal intergluteal area and worsen it. It is also not the right dressing for intact Stage 1 skin, where the priority is pressure relief and skin protection. The nurse should clarify the order and request a moisture-management plan rather than applying the hydrocolloid blindly.
3. Propose a revised plan for the sacral and intergluteal areas, including positioning and moisture management.
Read the worked answer
Sacral Stage 1: Reposition at least every 2 hours and offload the sacrum with a pressure-redistributing surface; keep the area clean and dry; inspect at each turn. Do not massage the red area. A hydrocolloid is unnecessary and may hide the skin.
Intergluteal moisture rash: Cleanse gently with a pH-balanced cleanser, pat dry, and apply a skin protectant/barrier cream. For suspected candidiasis, request an antifungal agent per provider order. Use absorbent products and change them promptly after incontinence. Avoid occlusive dressings over macerated skin.
System plan: Implement a toileting/incontinence schedule, involve the dietitian for nutrition, and monitor the rash and sacral skin each shift. Document measurements, interventions, and response. Reassess if the skin breaks down, drainage appears, or signs of infection develop.