How should I write orders for an elderly immobile diabetic patient with peripheral vascular disease and an infected stage 3 sacral pressure ulcer?

Orders for Stage 3 Sacral Pressure Ulcer in Elderly Immobile Diabetic Patient with Peripheral Vascular Disease and Infection

Immediately arrange surgical consultation for sharp debridement of all necrotic tissue and obtain urgent vascular imaging to assess for critical limb ischemia, while simultaneously starting empiric broad-spectrum IV antibiotics after obtaining deep-tissue cultures. 1

Immediate Vascular Assessment Orders

• Order ankle-brachial index (ABI) measurement using hand-held Doppler on both dorsalis pedis and posterior tibial arteries bilaterally (note: ABI may be falsely elevated in diabetic patients due to medial arterial calcification) 2, 1
• Order toe pressure measurement on both feet (most reliable test in diabetic patients; <30 mmHg indicates severe ischemia requiring urgent intervention) 2, 1
• Order transcutaneous oxygen pressure (TcPO₂) measurement at the ulcer site and surrounding tissue (<25 mmHg indicates critical ischemia) 2, 1
• Order urgent vascular surgery consultation if toe pressure <30 mmHg, TcPO₂ <25 mmHg, ankle pressure <50 mmHg, or ABI <0.5 1
• Order CT angiography or MR angiography of bilateral lower extremities from aorta to pedal vessels to delineate arterial anatomy before definitive debridement 1, 3

Infection Management Orders

• Obtain deep-tissue cultures via surgical debridement or wound-base scraping before starting antibiotics (if patient is hemodynamically stable for brief delay) 1
• Obtain two sets of peripheral blood cultures 1
• Order complete blood count with differential, C-reactive protein, and erythrocyte sedimentation rate 1
• Start empiric IV antibiotics: vancomycin 15-20 mg/kg IV every 8-12 hours PLUS piperacillin-tazobactam 3.375 g IV every 6 hours (or imipenem-cilastatin 500 mg IV every 6 hours) to cover MRSA, gram-negative bacilli, and anaerobes 1
• Adjust antibiotics based on culture results and local antibiogram 1

Surgical Intervention Orders

• Urgent surgical consultation for sharp debridement of all necrotic tissue, eschar, and surrounding callus 1
• Order plain X-ray of sacrum (AP and lateral views) to assess for underlying osteomyelitis 1
• Order MRI of sacrum and pelvis if osteomyelitis is suspected clinically or radiographically 1
• Drain any identified deep abscesses during operative debridement 1

Glycemic Control Orders

• Target blood glucose <140 mg/dL in acute phase 1
• Order insulin sliding scale with correction factor plus scheduled prandial insulin 1
• Check finger-stick glucose before each meal (AC) and at bedtime (HS) 1
• Consult endocrinology for diabetes management optimization 4
• Target HbA1c <7% for long-term microvascular complication reduction 4

Nutrition Orders

• Consult registered dietitian for high-protein diet plan 1
• Order high-protein diet: 1.25-1.5 g/kg/day protein 1
• Order high-protein oral nutritional supplements three times daily if oral intake <75% of prescribed meals 1
• Monitor daily caloric intake to ensure adequacy for wound healing 1

Pressure Relief Orders

• Order specialty pressure-redistribution mattress (low-air-loss or alternating pressure mattress) 1
• Reposition patient every 2 hours with documentation of position changes 1
• Avoid positioning patient on sacrum; use 30-degree lateral positioning 1
• Consult wound care nursing for daily wound assessment and dressing changes 1

Wound Care Orders

• Order moisture-retentive dressings appropriate for exudate level (avoid antiseptic-only dressings) 1
• Document wound measurements daily: length, width, depth, drainage characteristics, periwound erythema, warmth, and induration 1
• Photograph wound at baseline and weekly for comparison 1

Cardiovascular Risk Management Orders

• Start high-intensity statin therapy: atorvastatin 40-80 mg PO daily or rosuvastatin 20-40 mg PO daily 4, 1
• Start antiplatelet therapy: aspirin 81 mg PO daily OR clopidogrel 75 mg PO daily (choose one unless specific indication for dual therapy) 4, 1
• Target blood pressure <140/90 mmHg (or <130/80 mmHg if tolerated) 4, 1
• Order smoking cessation counseling and pharmacotherapy (varenicline, bupropion, or nicotine replacement) if applicable 4, 1

Monitoring Orders

• Check inflammatory markers (ESR, CRP) daily initially to gauge response to therapy 1
• Daily wound assessments by wound care nursing with documentation 1
• Monitor for clinical deterioration: fever, worsening pain, increased confusion, or greater drainage 1
• Re-evaluate need for revascularization if ulcer shows no improvement after 6 weeks of optimal medical and surgical care 2, 1

Antibiotic Duration

• Plan minimum 2-4 weeks of IV antibiotics for severe soft-tissue infection, adjusting based on clinical response 1
• Extend therapy to 4-6 weeks if osteomyelitis is confirmed on imaging or bone biopsy 1

Multidisciplinary Coordination Orders

• Order daily multidisciplinary rounds including wound care nursing, vascular surgery, infectious disease, endocrinology, and primary medical team 1
• Schedule weekly full-team reassessments when healing progresses; increase frequency if condition deteriorates 1

Critical Pitfalls to Avoid

The most common error is postponing vascular consultation while attempting medical management alone—infected ischemic ulcers constitute a surgical emergency requiring simultaneous management of infection and ischemia. 1 Failure to identify underlying osteomyelitis and incomplete surgical debridement are leading causes of treatment failure. 1 Do not rely on ABI alone in diabetic patients, as medial arterial calcification produces falsely elevated values. 1 Infection raises metabolic demand while ischemia limits perfusion; both must be addressed simultaneously. 1