What is an appropriate order for wound care for a stage 3 pressure injury in the sacral region?

Wound Care Management for Stage 3 Pressure Injury in the Sacral Region

For stage 3 pressure injuries in the sacral region, implement a comprehensive wound care protocol following the T.I.M.E. framework (Tissue debridement, Infection/inflammation control, Moisture balance, and Epithelial advancement) with appropriate dressings and regular assessment. 1

Initial Assessment and Documentation

• Document wound size, depth, presence of slough, exudate amount, and surrounding skin condition 1
• Assess for signs of infection using NERDS/STONES assessment tools (NERDS: Nonhealing, Exudate, Red friable tissue, Debris, Smell; STONES: Size increasing, Temperature elevation, Os (probes to bone), New breakdown, Erythema/Edema, Exudate, Smell) 1
• Evaluate for biofilm presence, which is present in 80-90% of chronic wounds 1
• Obtain wound cultures only when infection is suspected, using the Levine technique for swab collection 1

Wound Care Order Components

Pressure Relief and Support Surfaces

• Complete offloading of the sacral area using an air-fluidized bed or specialized pressure-redistribution surface 1, 2
• Implement a strict turning schedule every 2-4 hours 3
• Use appropriate support surfaces for all settings (sleeping, seating, transportation) 1

Wound Cleansing and Debridement

• Clean wound with normal saline or water at each dressing change 2
• Perform sharp debridement to remove all necrotic tissue and slough 1, 2
• Consider enzymatic debridement agents if sharp debridement is contraindicated 1

Infection and Biofilm Management

• Apply antimicrobial dressings containing silver, iodine, or medical-grade honey to control biofilm and prevent infection 1
• Target wound pH between 4-6 using stabilized hypochlorous acid solutions 1
• Monitor for signs of local or systemic infection that would require systemic antibiotics 1

Dressing Selection

• Primary dressing: Hydrocolloid or foam dressing to maintain moist wound environment and absorb exudate 1, 2, 4
• For moderate to heavy exudate: Consider alginate or hydrofiber dressings 2
• For wounds with depth/tunneling: Consider appropriate wound fillers to prevent dead space 2
• Change dressings as needed based on exudate levels, typically every 1-3 days 1

Adjunctive Therapies

• Consider electrical stimulation as an adjunctive therapy to accelerate wound healing (moderate-quality evidence) 1, 2, 5
• For non-healing wounds, evaluate for negative pressure wound therapy 1, 2
• Consider collagen matrix dressings to reduce protease activity and promote dermal fibroblast proliferation 1

Nutritional Support

• Provide protein supplementation (1.2-1.5 g/kg/day) to support wound healing 1, 2
• Consider vitamin and mineral supplementation if deficiencies are present 3, 2

Monitoring and Reassessment

• Document wound measurements and characteristics weekly 2
• Take wound photographs to monitor progress (with patient consent) 6, 7
• Reassess treatment plan if no improvement is seen within 2-4 weeks 2
• Monitor for complications such as infection or deterioration 1

Special Considerations

• Implement strict hand hygiene and aseptic technique when cleaning wounds 1
• For wounds with no healing potential, follow S-P-E-C-I-A-L approach (Stabilize wound, Prevent new wounds, Eliminate odor, Control pain, Infection prevention, Advanced dressings, Lessen dressing changes) 1
• Be aware that sacral pressure injuries have lower recurrence rates after surgery compared to ischial pressure injuries 1

Common Pitfalls to Avoid

• Do not mistake exudates, debris, and slough for biofilm 1
• Avoid using gauze dressings as they are inferior to hydrocolloid dressings for reducing ulcer size 1, 4
• Do not rely solely on intermediate outcomes like reduction in wound size without considering complete healing 2
• Avoid using advanced support surfaces without clear indication as evidence for effectiveness is limited 2