Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents for evaluation of a sacral pressure ulcer, stage IV. The wound has been present for [Duration], with reported progression despite conservative management. Patient reports [Pain/No pain] at the site. No systemic symptoms of sepsis, fever, or chills noted. Current offloading measures include [e.g., air mattress, frequent repositioning].
Clinical Examination Findings
Physical examination of the sacral region reveals a full-thickness skin loss with extensive destruction, tissue necrosis, and damage to muscle, bone, and supporting structures (tendons/joint capsules). Wound dimensions: [Length] x [Width] x [Depth] cm. Exposed bone is [visible/palpable]. Presence of undermining/tunneling noted at [Clock positions]. Wound base displays [e.g., slough/eschar/granulation tissue]. Surrounding skin shows [e.g., erythema/maceration/induration].
Treatment Protocol
Surgical plan: Debridement of necrotic tissue and assessment for potential flap reconstruction (e.g., rotational flap). Optimization of nutritional status (high protein/vitamin C/zinc). Implementation of strict pressure redistribution protocol. Wound care: [e.g., negative pressure wound therapy (NPWT) or specialized dressings]. Antibiotic coverage initiated per culture results.