Sacral Moisture Lesion vs. Pressure Injury in a Darkly Pigmented, Incontinent Patient
Mrs. R is a 78-year-old woman who returned home two weeks ago after surgery for a hip fracture. She uses a walker with two-person assist and must observe hip precautions. Her BMI is 34; she has type 2 diabetes with an A1c of 8.9%, urinary and fecal incontinence, and wears an adult brief. The aide reports "a rash on her bottom." On assessment the sacrum shows a 3.5 x 2.5 cm irregular, shallow area of bright red, moist, denuded tissue; maceration and satellite erosions extend into the gluteal cleft and perianal skin. The borders are indistinct and do not stop at the bony prominence. The right heel shows a 2 cm oval of intact purple-brown skin that is firm centrally and boggy at the rim; she winces when it is palpated. Temperature 36.9 C, WBC 7.2, Braden 12.
1. Is the sacral lesion incontinence-associated dermatitis, a pressure injury, or both? Explain what in the presentation drives your conclusion, and state exactly how you would document and stage it.
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Reasoning from the presentation, not from the label on the referral.
- Points to moisture-associated skin damage (MASD/IAD): distribution follows the gluteal cleft and perianal skin rather than stopping at the bony prominence; satellite erosions; diffuse, indistinct borders; maceration; coexisting urinary and fecal incontinence.
- Points to pressure injury: sacrum is a classic pressure point; immobility with hip precautions and two-person assist; Braden 12; a shallow partial-thickness loss can look identical to severe IAD.
The two are not mutually exclusive, and the presence of obvious moisture does not rule out pressure. The safest judgement is that this is a mixed lesion until proven otherwise.
What I would add before committing: palpate for induration or boggy areas beyond the visible denudement, look for undermining, measure and photograph with a scale reference, check whether the heel lesion shares a pressure mechanism, and use subepidermal moisture scanning if available (a localized rise above the patient's baseline suggests deep inflammation before skin breaks).
Documentation: describe both processes explicitly and stage only the pressure component. For example: "MASD/IAD, sacrum and gluteal cleft, with suspected Stage 2 pressure injury, sacrum, 3.5 x 2.5 cm, partial-thickness, moderate serous exudate, no odor, pain 3/10." IAD is never staged as a pressure injury. Request a WOC nurse consult and reassess at least daily.
2. Classify the heel lesion and describe your immediate management, including anything you must specifically avoid.
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Classification: an intact, purple-brown, firm-to-boggy area over the heel is a suspected deep tissue pressure injury (DTPI). It is not staged; it is reported as a DTPI until the depth of tissue loss declares itself. The pain on palpation is consistent with deep damage and is a warning sign.
Immediate actions:
- Float the heel completely - pillow or heel-suspension device under the calf so the heel hangs free. A boot that still rests the heel on the mattress does not offload.
- Offload at all times, including during sleep, and confirm the offloading stays in place between visits (ask the aide to demonstrate).
- Mark the borders and measure serially; note color and consistency changes at each visit.
What I must avoid: massaging the area, applying heat, and debriding intact DTPI skin - there is nothing to debride, and cutting into it converts a closed injury into an open, infected one.
Additional workup: given diabetes, check pedal pulses, capillary refill, and consider ABIs; remember ABI can be falsely elevated with medial calcinosis, so toe pressures or a toe-brachial index may be needed. Escalate to the provider for vascular evaluation, increase repositioning frequency, and document a turn schedule. Blistering, spreading erythema, or a new open area is an urgent change in condition.
3. What would you change in this week's plan of care, and which outcome measures would tell you whether the plan is working?
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Plan changes:
- Structured repositioning at least every 2 hours, including overnight, with a written schedule the aide can initial.
- Check and change the brief frequently rather than on a fixed long interval; cleanse with a pH-balanced no-rinse cleanser, then apply a moisture barrier at every change. Avoid tape on fragile skin and avoid occlusive films over denuded perineal skin.
- Surface and equipment review: is the mattress appropriate for her weight and immobility? Is the walker transfer technique dragging her sacrum?
- Nutrition referral - she has diabetes and a healing wound; ask for a dietitian review rather than guessing at supplements.
- Premedicate before repositioning, and treat pain so she does not resist turning.
- Teach the aide and family what a new purple or blister area looks like and to report it the same day.
Outcome measures: weekly wound dimensions and photographs; heel color and consistency at each visit; Braden score each visit; number of incontinence episodes and barrier use; pain scores; no new lesions; and the aide's documented adherence to the turn schedule.
Escalation triggers: heel develops blistering, darkening, or breakdown; sacral wound deepens or becomes painful with purulent drainage or odor; no measurable improvement in 2 weeks; new fever.