The Boggy Sacrum: Staging and Offloading With What You Have
Mr. R, 82, has been in a skilled nursing facility for 3 weeks after a hip fracture. He is incontinent of urine and stool, has a Braden score of 12, and refuses the bed, spending most of the day in a recliner. Over his sacrum is a 4 × 3 cm area of intact, deep purple-maroon discoloration with a boggy center that does not blanch. He is darkly pigmented. There is no open area, no crepitus, and no fever; WBC is 9.1. The facility owns two alternating-pressure overlays, and no specialty bed is available for 5 days. Staff have been massaging the area with lotion and placing a donut cushion under him when he sits.
1. How do you classify and document this area right now, and what would change your classification?
Read the worked answer
Classification: deep tissue pressure injury (DTPI) - document as such; do not stage it as 1 or 2.
Reasoning from the data:
- Skin is intact and the discoloration is deep purple-maroon, not blanchable - this is the DTPI signature, not the non-blanchable erythema of a Stage 1.
- Boggy center suggests tissue damage below an intact surface. "Boggy" is not a stage; it is a consistency descriptor that belongs in the narrative.
- Darkly pigmented skin makes erythema assessment unreliable, which makes the color/consistency findings the primary data - another reason not to call it Stage 1.
- Absence of crepitus, fever, and leukocytosis argues against a deep soft-tissue infection, so this is not an "unstageable" wound either. Unstageable requires slough or eschar obscuring the base; there is no open area here.
Document: location (sacrum), size (4 × 3 cm), intact skin, exact color, "boggy to palpation," non-blanchable, no drainage or odor, and the words "suspected deep tissue pressure injury." Reassess and photograph each shift per policy.
What changes the classification: if it unroofs. Then stage by the actual depth of tissue loss - a DTPI that opens and reveals fat or deeper is a Stage 3 or 4, and a DTPI that opens into a shallow partial-thickness injury becomes a Stage 2. Never reverse-stage and never carry a lower stage forward "because it started as a DTPI."
2. Build an offloading and prevention plan using only what this facility has today.
Read the worked answer
The central conflict: his refusal of the bed is the risk factor you must actually solve, because a recliner loads the sacrum continuously.
Immediate plan
- Stop the two harmful practices first. Donut cushions concentrate pressure at the ring edge and cause ischemia - remove it and get an order to discontinue. Massage over a bony prominence increases shear and deep tissue damage - discontinue it.
- Put one of the two alternating-pressure overlays on his bed and negotiate scheduled bed time rather than asking him to choose. Frame it as short, frequent periods (e.g., 45–60 minutes in bed, then up) rather than an all-day restriction he will refuse.
- Reposition q2h in bed, including a 30° lateral tilt; keep head of bed at or below 30° when feasible to limit sacral shear. When he must be up, cap chair time (e.g., 30–60 min) and shift weight every 15 minutes - a pressure-redistribution cushion is not a substitute for time limits.
- Float the heels - heels are the second most common site and are being ignored while everyone watches the sacrum.
- Moisture management: check and clean after each incontinence episode, apply a barrier product, and address the stool pattern with the provider.
- Escalate with documentation. Send a note to the provider and DON that a specialty surface is clinically indicated and unavailable for 5 days; record the request, the date, and the response. That note is the difference between a system problem and a nurse problem.
- Add a dietitian consult - a Braden of 12 with an incontinence load rarely improves on a surface alone.
3. The daughter arrives and says, "The aides rub lotion in and use the ring cushion so it doesn't get worse - that's what we did for my mother." What do you say, and what do you document?
Read the worked answer
Answer the belief, not the person. Acknowledge the intent ("You're trying to protect the skin, and that instinct is right") and then correct the mechanism plainly.
- Massage: rubbing a bony prominence damages tissue that is already under pressure from the inside out. It can convert a DTPI into an open wound. This is a care-plan change, not a preference.
- Donut cushion: the hole suspends the area but the ring edge squeezes the surrounding tissue and cuts off perfusion to the very spot being protected. Safer alternatives are a pressure-redistribution cushion plus limits on sitting time - the real fix is less time on the area, not a different cushion.
- What she can do that helps: remind him to shift, help with scheduled bed periods, keep the skin clean and dry, and report any opening, blistering, or color change to staff the same day.
Document: the date, who was present, the specific teaching given, that the massage and donut device were discontinued by order, the daughter's response, and the plan to re-teach at the next visit. Also document that the provider was notified of the specialty-bed delay. If the family continues to request the donut, escalate rather than argue at the bedside.