SCALE Wounds: Unavoidable Pressure Injury

Diane L. Krasner, PhD, RN; Thomas P. Stewart, PhD

Disclosures

Wounds. 2015;27(4):92-94. 

In This Article

Case Study

Mrs. S. was a 92-year-old long-term resident of a skilled nursing facility (SNF), Rest Haven-York in York, PA. In the last months of her life she was in the late-stage of Alzheimer's disease, immobile, contracted, and incontinent. As a result of her cachexia, Mrs. S. was transferred by her primary care physician to an acute care facility for a work-up at the request of the patient's family and power of attorney. While there, she developed a full-thickness coccyx pressure ulcer. Tape from the pressure ulcer dressing caused a large skin tear to the left buttock. On readmission to the SNF, the skin tear to the left buttock was maroon and showed evidence of pressure injury (Figure 1). Within several days of readmission, the skin tear evolved into a full-thickness SCALE wound—as signaled by the rapid wound deterioration—with eschar (Figure 2).

Figure 1.

The patient's wound upon readmission to a skilled nursing facility with a stage 4 coccyx ulcer and maroon-colored skin tear to the left buttock

Figure 2.

The skin tear evolved into a Skin Changes at Life's End Wound with eschar within days of admission.

Mrs. S. was placed on hospice and palliative wound care and a topical enzymatic debriding agent was started daily. She rested upon a pressure-relieving support surface. The eschar was substantially debrided, but the SCALE wound continued to deteriorate (Figure 3). Two days before her death, Mrs. S's wound deteriorated into a large, full-thickness SCALE wound (Figure 4).

Figure 3.

At this stage, the patient was in hospice care. The eschar was substantially debrided, but the Skin Changes at Life's End wound continued to deteriorate.

Figure 4.

The wound 2 days prior to the patient's death, with large, full-thickness Skin Changes at Life's End wound.

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