Non-blanching sacral redness on post-operative day 2
Mr. K, 64 years old, 168 cm tall and 82 kg, is on his second day after an emergency laparotomy for a perforated duodenal ulcer in a district hospital. He has a nasogastric tube on free drainage, a Foley catheter, and an IV line in the left forearm. He lies flat on his back and has not been turned since the previous evening shift, because he says the wound will open if he moves. Temperature 37.9 °C, pulse 96/min, respiration 22/min, BP 128/78 mmHg. The sacral area shows a 3 cm patch of redness that does not fade when you press it with a finger. The staff nurse is busy with a new admission and you are the only nursing student on the ward. Visiting hours begin in 20 minutes and his daughter is asking why her father is not being turned.
1. What does the sacral redness that does not blanch signify, and how would you stage it? Justify your answer.
Read the worked answer
It is a Stage 1 pressure injury, not "just heat" or a rash.
Reasoning:
- Blanching test. Over a bony prominence, redness that fades on light finger pressure is reactive hyperaemia - blood returning after pressure is relieved. Redness that stays is skin that is already injured: capillaries are compressed, blood is forced into the tissue, but the skin surface is still intact. Intact skin plus non-blanching erythema is the definition of Stage 1.
- Site fits the history. The sacrum is the commonest pressure site in a patient lying supine. He has not been turned for many hours, his abdominal wound makes him avoid movement, sweat keeps the area moist, and he is obese and post-operative - all recognised risk factors.
- Why it matters. Stage 1 is reversible if pressure is removed within hours. Left alone it becomes a blister (Stage 2) or full-thickness loss (Stage 3 or 4), which in a laparotomy patient can mean infection and a longer stay.
- Do not confuse it with infection. The temperature 37.9 °C and pulse 96/min do not explain the mark. They must be reported separately as possible wound, chest or urinary infection.
2. Write a repositioning and skin-care plan for the next 8 hours (18:00 to 02:00) with positions, timing and reasons.
Read the worked answer
Timing. Turn every 2 hours - 18:00, 20:00, 22:00, 00:00, 02:00 - because pressure above about 32 mmHg (capillary closing pressure) held for more than roughly 2 hours causes ischaemia. Shorten to hourly if the redness does not fade after a turn.
Positions.
- 30° right lateral tilt (wedge pillow behind the back)
- Supine with the head of the bed at 30°
- 30° left lateral tilt
- Repeat, and record each turn.
Avoid full 90° side-lying: it pulls on the midline laparotomy wound. Keep the head of the bed at 30° or less when his breathing allows, because sitting up makes him slide down and produces shear exactly on the sacrum.
Technique. Use a draw sheet and a two-person log roll; splint the wound with a folded pillow while turning; support the NG tube and drain so they do not drag. Do not rub or massage the red area - massage increases tissue damage.
Skin care. Clean with lukewarm water, pat dry, keep the sheet dry and wrinkle-free, no powder in the natal cleft.
Offloading. Pillow under the calves so the heels are free; check heels, elbows and occiput at every turn.
Support. Request a pressure-relieving mattress, adequate protein and fluids, and pain relief before turning.
3. The patient refuses to be turned. How would you handle this, and what must be reported and to whom?
Read the worked answer
Manage the refusal first, then escalate; do not simply wait.
- Find the real reason. He fears dehiscence. Ask what he expects will happen, and correct the belief with a simple explanation: the wound is held by sutures; it is the pressure that will harm him. Show him the red area in a mirror.
- Make turning tolerable. Splint the wound with a pillow, ask for prescribed analgesia 30 minutes before turning, and turn with two people so he does not have to pull himself over.
- Negotiate what he will accept. A 30° tilt, not a full side turn; a pillow under the calves now; a draw sheet under him. This still relieves the sacrum.
- Involve the daughter. She is asking questions, and a familiar voice often succeeds where the nurse does not.
- Document. Write the refusal, what was explained, what was done instead, and the condition of the skin.
- Report it - this is not optional. Tell the staff nurse and the treating doctor that a Stage 1 injury has appeared and that the patient is refusing position change. Ask for analgesia, a pressure-relieving mattress and a skin-integrity entry in the chart. A pressure injury that develops on the ward is a reportable event; silence shifts the blame to you.