Ulcer Uma — Pressure Injury Staging & Prevention
Non-blanchable redness over the sacrum is Stage 1 — waiting for an open wound means waiting too long
Uma has been bedbound for a week after her stroke, and the night nurse finds a reddened area over her sacrum that stays red even after two fingers press and release it.
Uma is immobile after a stroke, and unrelieved pressure over her sacrum compresses capillaries between bone and mattress until tissue starves of oxygen. Staging depends on the depth of tissue destroyed, from intact but non-blanchable skin to exposed bone, and correct staging guides both documentation and treatment. Shear and friction from being dragged up in bed accelerate damage, and moisture from incontinence breaks down the skin barrier further. Prevention through repositioning and risk assessment is always cheaper and safer than treating an established wound.
Read Ulcer Uma's full story →The story arc
The setup
Uma's stroke leaves her hemiplegic and unable to reposition herself, and she spends long stretches lying on her back.
The turn
A nurse's aide notices a reddened patch over Uma's sacrum that does not turn white (blanch) when pressed and released.
The crisis
Three days later the area has broken down into a shallow open wound with a red-pink wound bed and no slough, and Uma's Braden score has dropped to 11.
The save
The nurse implements a strict turning schedule every two hours, off-loads the sacrum with positioning wedges, keeps the skin clean and dry, optimizes protein intake, and documents wound measurements with each dressing change.
NCLEX study section — Pressure Injury Staging & Prevention
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.