Pressure Ulrich — Pressure Injury Staging: Redness That Blanches and Wounds You Never Massage
His heel is red and it does not fade when pressed — the clock on his skin started two hours ago
Ulrich cannot turn himself. The nurse finds a red patch on his sacrum that stays red when pressed — stage one, and the two-hour clock is already running.
Ulrich has been immobile for weeks and the skin over his sacrum and heels is paying for it. Pressure injuries are staged by depth: Stage 1 is intact skin with non-blanchable redness; Stage 2 is a shallow open ulcer or intact serum-filled blister; Stage 3 is full-thickness loss where fat is visible; Stage 4 exposes muscle or bone; a wound covered in slough or eschar is unstageable until debrided, and purple intact skin is a deep-tissue injury. Prevention beats treatment: reposition every two hours, keep heels floated off the bed, manage moisture and nutrition, and never massage reddened bony prominences.
Read Pressure Ulrich's full story →The story arc
The setup
Ulrich has been on bed rest for three weeks. His sacrum shows a red patch that does not blanch under pressure.
The turn
Despite turning, a shallow open sore appears on his heel, pink and moist like a burst blister.
The crisis
A new admission's sacrum is a deep crater with yellow fat visible, and another wound is hidden under black eschar that cannot be staged.
The save
Ulrich is repositioned every two hours with a strict schedule, his heels float on pillows, his skin stays clean and dry, and protein joins every meal.
NCLEX study section — Pressure Injury Staging: Redness That Blanches and Wounds You Never Massage
What this chapter is testing: the recognition cues, the numbers and the priority action.
Study section: Health Assessment
Take this chapter into practice questions on the same topic.