Comprehensive Wound Care Plan for Stage III Sacral Pressure Ulcer
For a Stage III sacral pressure ulcer, implement complete pressure offloading with an advanced static mattress, perform regular sharp debridement of necrotic tissue, apply hydrocolloid or foam dressings, and provide protein supplementation if nutritionally deficient. 1, 2
Pressure Offloading and Support Surfaces
Use advanced static mattresses or overlays as the primary support surface rather than alternating-air systems, as they provide adequate pressure relief at lower cost without added noise or complexity. 3, 2
Reposition the patient every 4 hours using a 30-degree tilt position rather than 90-degree lateral rotation to minimize pressure on bony prominences (relative risk reduction 0.62). 3
Implement complete pressure offloading from the sacral area to prevent further tissue trauma and allow healing to begin. 2
Air-fluidized beds may be considered for ulcers larger than 7 cm or those failing to improve with standard support surfaces, as they are superior to standard hospital beds for reducing ulcer size. 2
Wound Cleansing
Clean the wound with normal saline or water at each dressing change to remove debris and create an optimal healing environment. 2, 4
Avoid harsh antiseptics that damage healing tissue. 3
Debridement
Perform regular sharp debridement with a scalpel to remove necrotic tissue, which is essential for proper wound healing. 2, 4
If advancing cellulitis or sepsis develops, perform urgent sharp debridement immediately. 4
For stable wounds without infection, mechanical, enzymatic, or autolytic debridement methods can be used as nonurgent alternatives. 4
Dressing Selection
Apply hydrocolloid or foam dressings as the primary dressing modality, as both are superior to gauze for reducing wound size and promoting tissue granulation. 1, 3, 2
Hydrocolloid and foam dressings are equivalent for complete wound healing (moderate-quality evidence). 3
Control exudate to maintain a moist wound environment; change dressings as needed based on exudate volume. 2
Avoid dressings with antimicrobial agents solely to accelerate healing (strong recommendation, low-quality evidence). 3
Infection Control
Assess for signs of infection at each dressing change: increasing pain, erythema, warmth, purulent drainage, or foul odor. 2, 5
For superficial infection signs (increased erythema, warmth, purulent drainage), consider topical antimicrobial therapy. 3
Reserve systemic antibiotics for advancing cellulitis, osteomyelitis, or systemic infection (fever, hypotension, altered mental status). 3, 4
When systemic antibiotics are indicated, provide coverage against Gram-positive, Gram-negative, and anaerobic organisms, as pressure ulcer infections are typically polymicrobial. 3, 2, 4
If bone is exposed or palpable (indicating progression to Stage IV), suspect pelvic osteomyelitis and obtain MRI with IV contrast (sensitivity 96%, specificity 94%). 6
Pain Management
Administer analgesics 30-60 minutes before dressing changes or repositioning to minimize procedural pain. 3
Consider topical lidocaine or morphine gel for wound-related pain during dressing changes. 3
Nutritional Support
Provide protein or amino acid supplementation to patients with nutritional deficiencies, as this reduces wound size (weak recommendation, low-quality evidence). 1, 3, 2
Check serum albumin and total protein levels; typical deficiencies in pressure ulcer patients include albumin <2.6 g/dL and total protein <5.5 g/dL. 5
Avoid vitamin C supplementation alone, as it shows no benefit over placebo. 3, 2
Adjunctive Therapies
Consider electrical stimulation as adjunctive therapy to accelerate wound healing for Stage III ulcers (moderate-quality evidence), though it does not increase complete closure rates. 2
Be aware that frail elderly patients have higher risk of skin irritation and adverse events with electrical stimulation. 1, 2
Negative pressure wound therapy with instillation may be useful for infected wounds after debridement, particularly in cases with severe infection or osteomyelitis. 7, 8
Monitoring and Documentation
Document at each assessment: wound dimensions (length, width, depth), amount and type of necrotic tissue, exudate characteristics, surrounding skin condition, and signs of healing or deterioration. 6
If the ulcer shows no signs of healing within 6 weeks despite optimal management, evaluate for vascular compromise or other barriers to healing. 2
Monitor for complications including undermining, tunneling, or progression to Stage IV with bone exposure. 6
Prevention of Moisture-Associated Skin Damage (MASD)
Manage urinary or fecal incontinence promptly, as moisture is a significant risk factor for pressure ulcer development and progression. 1
Apply skin protectants to periwound skin if excessive exudate is present. 8
Escalation Criteria
Escalate to surgical consultation if: the wound fails to heal after 6 weeks of optimal conservative management, advancing cellulitis or sepsis develops, or bone is exposed with suspected osteomyelitis. 2, 4
Sacral ulcers have lower recurrence rates after surgical repair (12-24% reoperation rate) compared to ischial or trochanteric ulcers. 1, 6
Dehiscence is more common if bone is removed during surgery. 1
Common Pitfalls to Avoid
Do not use alternating-air or low-air-loss mattresses without clear indication, as evidence shows no advantage over static mattresses and they add unnecessary cost. 3, 2
Do not stage a wound covered by eschar or slough; classify as "unstageable" until debrided. 6
Avoid aggressive debridement in patients with poor perfusion or coagulopathy without correcting these conditions first. 4
Do not rely solely on reduction in wound size as a marker of success; monitor for complete healing and prevention of recurrence. 2