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Case: When Pressure Ulcer/Injury Happens...

Case: When Pressure Ulcer/Injury Happens...

Case: When Pressure Ulcer/Injury Happens...



This case illustrates real world obstacles that lead to scenarios of increased likelihood of unavoidable pressure ulcers/injuries (PUs/PIs) and delayed transition of care. For a list of guidelines and quality measures related to PUs/PIs, see topic "Pressure Ulcers/Injuries - Overview". For an introduction and assessment of PU/PI including epidemiology, risk factors, etiology, pathophysiology, history, physical examination, diagnosis, differential diagnoses, documentation and ICD-10 coding, see "Pressure Ulcers/Injuries - Introduction and Assessment". For management of PU/PI, see topic "Pressure Ulcers/Injuries - Treatment". For a systematic approach to identifying patients at risk for PU/PI and developing specific care plans, see topic " Pressure Ulcers/Injuries - Prevention". For best practices in care coordination, see "Pressure Ulcers/Injuries -Coordination of Care".


Admission through the Emergency Department 

A 51 year old white male presented to the Emergency Department of a hospital due to shortness of breath and fatigue. The patient had a history of chronic obstructive pulmonary disease and poorly controlled type II diabetes, chronic pain, peripheral vascular disease, chronic narcotic use, obesity and long standing tobacco use. After evaluation and workup, he was admitted to the hospital due to pneumonia. His initial Braden score upon admission was 19, not at risk for PU/PI. See more details on the Braden Scale in section 'Structured Risk Assessment' in "Pressure Ulcers/Injuries - Introduction and Assessment".

On the medical floor

Shortly after his admission, the patient decompensated and developed acute respiratory failure. He was intubated, placed on a ventilator and transferred to the intensive care unit (ICU) for management. 

Tension in the Intensive Care Unit

While in the ICU, the patient had severe agitation due to narcotic withdrawal. He was cared for on a pressure redistribution support surface (i.e., high specification foam mattress). However, due to excessive mucus production and resulting O2 desaturation, the patient was unable to tolerate PU/PI preventative interventions such as head of bed less than 30 degrees and repositioning from side to side. His extreme agitation required sedation. Despite restraints and sedation he still managed to work himself down to the foot of the bed, inflicting extra shear forces to the sacral area, pulling intravenous (IV) lines and nearly extubating himself. Nursing care and ventilator management was difficult requiring constant attention. 

Further workup uncovered poor nutritional status evidenced by low albumin, total protein and prealbumin levels. Other risk factors for skin changes were hypoxia, renal insufficiency, and elevated glucose. These conditions, along with the inability of the nursing care team to implement all skin protective modalities, contributed to his development of sacral and gluteal PU/PI.

Back to the medical floor and discharge home

Over the next 2 weeks his pneumonia improved and the patient was able to be weaned off the ventilator and be transferred to regular nursing care floor. Prior to his discharge, an unstageable PU/PI was present and known to the discharging medical team. As it regards to the PU/PI, the patient's discharge plan included local wound care instructions and a referral to the patient's primary care physician, but did not include interventions to address the patient's pressure redistribution needs at home or a request for home health services.

A visit to the primary care physician and finally...a wound clinic!

The patient was discharged home with follow up with his family doctor after 10 days. The primary care physician referred the patient to a wound center. It took 3 weeks for the patient to be seen at the wound clinic, after being discharged from the hospital.  At the wound center, standard care interventions for PU/PI management were implemented (e.g repositioning, pressure redistribution with support surfaces, management of excessive moisture and shear).  Upon examination, his PU/PI was deemed to be ready for debridement. Ulcer was debrided and classified as a Stage 3 PU/PI. He was placed on Negative Pressure Wound Therapy (NPWT) at 125mm Hg negative pressure using NPWT dressing kits with foam dressings and standard techniques for 4 weeks. A stable granulation bed was seen after 4 weeks of NPWT. NPWT was discontinued and standard local wound care initiated, including foam dressings. All other standard care interventions were maintained and complete closure was achieved over the next 9 weeks. Surgical wound coverage with flaps was not necessary. See details on PU/PI management in "Pressure Ulcers/Injuries - Treatment".


This case illustrates real world obstacles that frequently contribute towards development and delayed healing of PUs/PIs.

Unavoidable PU/PI

Severely ill patients in life threatening situations require intensive care. Pre existing conditions often negatively impact this intensive care and are unpredictable. In this case, the patient's respiratory failure and hypoxia coupled with agitation exacerbated by narcotic withdrawal hampered his ICU care, and made it difficult for the ICU staff to implement appropriate PU/PI preventative interventions. As the patient was under mechanical ventilation, in order to prevent ventilator-associated pneumonia and in order for the patient not to desaturate, head of bed had to be maintained above 30 degrees.[1]This recommendation goes against PU/PI prevention clinical guidelines, which recommend head of bed elevation be limited to less than 30 degrees.[2] While attention to skin issues are important, the first priority was to save the patient’s life. In complex cases like the one described here, we may be left to deal with a PU/PI after the life threatening conditions have been stabilized.

Delayed transition of care

In this case, the patient was initially admitted and treated at a hospital that did not have a hospital-based outpatient wound center. Discharging staff was aware of the PU/PI, however did not refer the patient directly to an external wound center, possibly because they did not know any wound center to which the patient could be directly referred to. Discharge instructions did not address the patient's pressure redistribution needs at home (e.g., specialty mattress, seating surfaces, etc). The patient had to wait 10 days for his appointment with the primary care physician, who then referred the patient to a wound center. It took 3 weeks for the patient to be seen at the wound clinic after being discharged from the hospital.

Key takeaways

Some of the main takeaways from this case study are: 

  • Under certain circumstances, PU/PI are unavoidable despite all proper interventions to prevent PU/PI. Adequate documentation of measures taken to prevent PU/PI is crucial to avoid medico-legal consequences. See other examples of cases with increased likelihood of unavoidable PU/PI in "Pressure Ulcers/Injuries - Introduction and Assessment"
  • If PU/PI happen along the way, it is imperative that clinicians steer the case to the right healthcare professionals as soon as possible. Transition of care needs to be carried out carefully and expeditiously. If the patient has a pressure injury upon discharge, it is essential that hospital discharge planners plug patients into the appropriate wound care provider and ensure that there is an appropriate care plan for the patient.  Provider-to-provider documentation forms can facilitate communication and streamline care.

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NOTE: This is a controlled document. This document is not a substitute for proper training, experience, and exercising of professional judgment. While every effort has been made to ensure the accuracy of the contents, neither the authors nor the Wound Reference, Inc. give any guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omissions in the contents of the work.


  1. The CDC and the Healthcare Infection Control Practices Advisory Committee. Guidelines for Preventing Health-Care--Associated Pneumonia, 2003 . 2003;.
  2. National Pressure Ulcer Advisory Panel (NPUAP), European Pressure Ulcer Advisory Panel (EPUAP), and Pan Pacific Pressure Injury Alliance (PPPIA) et al. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guidelines and Quick Reference Guide. 2014. .;.
Topic 1266 Version 1.0


This case illustrates how a seemingly innocent decision in the life of a person at risk for pressure ulcer/injury (PI/PI) can lead to a new episode of PU/PI