SCALE Wounds: Unavoidable Pressure Injury

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


Wounds. 2015;27(4):92-94. 

In This Article


Mrs. S. was in the end stages of her life. Unfortunately, she suffered a large tape-induced skin tear over her left buttock during work-up for cachexia in an acute care facility. Upon readmission to the SNF, Mrs. S was placed on hospice and palliative wound care that included the use of a pressure relieving support surface. Nonetheless, the injury rapidly progressed into a SCALE wound.

The wound care plan of care for a person with a SCALE wound must be consistent with the patient's overall plan of care.[5] In this case, the goal was to provide comfort and relieve pain and suffering at the end of life. Holistic care for Mrs. S. meant changing her turning schedule from every 2 hours to every 4 hours side-to-side to minimize the pain of frequent turning and repositioning. A foam dressing was changed on an as-needed basis, and the patient was provided with a peaceful and dignified death.