A Red Patch on the Sacrum: Pressure Injury Prevention at Home
On a home visit in a village you find a 72-year-old woman who had a stroke three months ago. She is bedbound with weakness of the left side and cannot turn herself. Her daughter-in-law says she changes her position "whenever I remember, maybe twice a day." The woman lies on a plastic sheet spread over a cotton mattress, with no pillow between her knees, and she is incontinent of urine. On inspection, over the base of her spine there is a 3 cm red patch; the skin is intact, but the redness does not fade when you press it with a finger. She eats one meal and drinks two cups of tea a day; the family says "she has no appetite, what can we do." The nearest PHC is 6 km away and the ANM visits the village on Thursdays.
1. What is the red patch and why does it matter? Explain why the plastic sheet and the incontinence make it worse.
Read the worked answer
This is a Stage 1 pressure injury: intact skin with non-blanching redness over a bony prominence in a person who cannot move herself. The redness does not fade on pressure, which means the tissue underneath is already being starved of blood, even though the skin has not broken.
It matters because Stage 1 is the last point at which the damage is fully reversible. Left alone, it progresses to a blister or open sore, then to full-thickness loss, and an open sore in an elderly, undernourished, incontinent woman can become infected, deepen to bone, and be life-threatening.
The plastic sheet traps heat and moisture and does not breathe, so the skin becomes soft and easily damaged, and it also makes the surface slippery so she slides down and drags the skin over the sheet. Urine keeps the skin wet and alkaline and irritates it, and the sacrum is exactly where urine pools. Pressure, moisture, friction and shear are acting together on the same 3 cm of skin, so this is not a small problem.
2. Give a repositioning and skin-care plan that this family can realistically carry out, and say what you would teach them to check.
Read the worked answer
The plan has to be simple enough that a tired daughter-in-law will actually do it.
- Turn and reposition every 2 hours during the day and at least once at night. Tie it to something fixed - after each meal, after each drink, after each change of cloth - rather than to memory.
- Use a 30-degree tilted side position, with a pillow behind the back and one between the knees so the bony points do not press on each other. Avoid lying flat on the back for long periods and avoid raising the head too high, which makes her slide down.
- Remove the plastic sheet from direct contact. Use a cotton draw sheet over a waterproof cover that is tucked under, not against, the skin.
- Keep the skin clean and dry: change the cloth as soon as it is wet, wash with plain water and mild soap, pat dry, and do not rub the red area or massage it.
- Check the whole body at every turn - sacrum, heels, hips, shoulders, ears, back of head - and look for new redness, blisters or broken skin.
- Record the date, the position changes and what the patch looks like, so the ANM can see whether it is improving on Thursday.
3. What nutrition and hydration advice would you give, and at what point must this woman be referred?
Read the worked answer
Nutrition and hydration: healing needs protein, calories, vitamin C and fluids, and "no appetite" is not a reason to stop offering food. Suggest small frequent meals - five or six a day instead of one large one - of dal, curd, milk, egg, khichdi, seasonal vegetables and fruit, with a glass of water or buttermilk between meals. Fluids should be offered at every position change, and the colour of the urine is a simple guide: pale yellow means enough fluid, dark and strong-smelling means too little.
Refer to the PHC or ANM if:
- the redness spreads, becomes purple or black, or the skin breaks, blisters or weeps;
- there is swelling, warmth, foul smell, pus or fever;
- she stops eating or drinking, her urine output falls, or she becomes more drowsy or confused;
- she has pain at the site, or the sore does not improve within a week of good care.
A Stage 1 injury that is properly offloaded can recover; one that is not will not. The family should also be told that this is not their fault, but it is now their job, and the Thursday visit is the review point.