Pressure Injury Case Study: Stage 4 Wound to Closure

Pressure Injury Case Study: From Stage 4 to Wound Closure

A Stage 4 pressure injury is among the most complex wounds a clinician manages. The tissue destruction extends through the full thickness of skin into muscle, tendon, or bone. Healing requires not just wound care but systemic optimization: nutrition, pressure redistribution, infection control, and sustained caregiver commitment. When any of these elements fails, the wound stalls or deteriorates.

This pressure injury case study follows a hypothetical patient from initial Stage 4 presentation through staged closure over 24 weeks. All patient details, clinical findings, and outcomes are composite and hypothetical, created for educational purposes. No real patient data is represented.

Initial Presentation and Staging

The hypothetical patient is a 78-year-old male, bed-bound following a stroke with residual left-sided hemiparesis. He resides at home with a spousal caregiver. He is referred to a mobile wound care practice after his home health nurse identifies a worsening sacral wound that has not responded to 6 weeks of gauze dressing changes.

Wound Assessment

The sacral wound measures 8.2 cm x 6.5 cm x 3.8 cm with undermining of 2 cm at the 3 o'clock and 9 o'clock positions. The wound bed shows 40% granulation tissue, 30% yellow slough, and 30% necrotic tissue. There is no exposed bone palpable on probing, but the depth of tissue destruction through subcutaneous fat and into the fascial plane confirms Stage 4 classification. Periwound skin shows erythema extending 2 cm from wound margins. Wound odor is present. Exudate is moderate, purulent.

Systemic Assessment

Nutritional status: Albumin 2.6 g/dL (normal > 3.5), prealbumin 11 mg/dL (normal > 18). The patient has lost 14 pounds over the past 3 months. He reports poor appetite and difficulty swallowing liquids (mild dysphagia post-stroke).
Mobility: Bed-to-wheelchair transfers with maximum assist. Unable to reposition independently. Braden Scale score: 11 (high risk).
Support surface: Standard hospital bed mattress. No alternating pressure or low-air-loss surface in place.
Continence: Urinary incontinence managed with absorbent briefs. The sacral wound is at constant risk of contamination.

For a comprehensive overview of pressure injury staging criteria and assessment, see the Pressure Injury Staging Guide.

Treatment Plan: Five Concurrent Interventions

1. Nutrition Optimization

Wound healing is a metabolically demanding process. A Stage 4 pressure injury cannot close when the body lacks the protein and calories to synthesize collagen and support immune function. The nutrition plan includes:

Caloric goal: 30-35 kcal/kg/day, adjusted for the patient's current weight and activity level.
Protein goal: 1.25-1.5 g/kg/day. A high-protein oral nutritional supplement (twice daily) is added to meals.
Micronutrients: Vitamin C (500 mg twice daily) and zinc sulfate (220 mg daily) to support collagen synthesis and immune function.
Dietitian referral: A registered dietitian is consulted to develop a meal plan that accommodates the patient's dysphagia and appetite limitations.

2. Wound Bed Preparation and Debridement

The necrotic tissue and slough are debrided sharply at the initial visit. The wound bed is converted to approximately 75% granulation tissue post-debridement. The wound is irrigated with normal saline at appropriate pressure to reduce bacterial load. A wound culture (tissue biopsy, not swab) is obtained given the purulent drainage and periwound erythema.

3. Negative Pressure Wound Therapy (NPWT)

After debridement reveals a clean granular wound bed, NPWT is initiated at week 2. The continuous negative pressure at -125 mmHg serves multiple purposes:

Removes excess exudate and reduces periwound edema.
Promotes granulation tissue formation by applying mechanical stress to the wound bed.
Manages the wound environment between weekly visits in a home setting where daily dressing changes are not feasible.

The NPWT dressing is changed three times weekly by trained home health aides, with wound reassessment by the wound care clinician weekly.

For a detailed guide on NPWT indications, contraindications, and billing, see Negative Pressure Wound Therapy Guide.

4. Support Surface Upgrade

The standard mattress is replaced with a group 2 alternating-pressure support surface. The surface alternates inflation cycles to redistribute pressure across the sacral area and prevent sustained interface pressure at the wound site. The caregiver is trained on proper surface operation and the importance of keeping the surface plugged in and functional at all times.

5. Caregiver Education and Repositioning Schedule

The spousal caregiver is the most important member of the treatment team. She is trained on:

Repositioning every 2 hours when the patient is in bed, with a written schedule posted at bedside. The patient is positioned at 30-degree lateral tilts, alternating sides, to keep pressure off the sacrum.
Incontinence management: Immediate skin cleansing after each episode using a pH-balanced perineal cleanser, followed by application of a moisture barrier cream.
Heel protection: Foam heel elevators are placed to prevent secondary pressure injury development.
Signs requiring immediate contact: fever, increased wound odor, expanding periwound redness, or new wound drainage.

Wound Progression: Weeks 1 Through 24

Weeks 1-4: Debridement and wound bed preparation. Culture returns positive for moderate bioburden but below the threshold for clinical infection after debridement. Wound dimensions decrease modestly as necrotic tissue is removed. NPWT is initiated at week 2. Albumin rises from 2.6 to 2.9 with nutritional supplementation.

Weeks 5-8: Granulation tissue fills the undermined areas. The wound base begins to shallow. Volume decreases by approximately 40%. NPWT continues. The caregiver demonstrates consistent repositioning compliance. The support surface is functioning properly.

Weeks 9-14: The wound transitions from a deep cavity to a shallow wound. NPWT is discontinued at week 12 as the wound depth is now less than 1 cm and granulation tissue fills the wound base. The wound is transitioned to a collagen-based dressing with a foam secondary. Wound area has decreased from 53.3 cm² to approximately 18 cm².

Weeks 15-20: Epithelialization begins from wound margins. The wound is now superficial with a healthy pink granular base. Wound area decreases to approximately 5 cm². Albumin has normalized to 3.6. The patient has regained 6 of the 14 pounds lost.

Weeks 21-24: Full epithelialization achieved at week 23. Week 24 visit confirms stable closure. The wound site is thin and fragile. The support surface and repositioning schedule are maintained indefinitely because the underlying risk factors — immobility, incontinence, age — have not changed.

Post-Closure Surveillance

Ongoing Prevention

Healing a Stage 4 pressure injury does not eliminate the risk. It confirms the risk is real and proven. The post-closure plan includes:

Continued use of the group 2 support surface.
Continued 2-hour repositioning schedule.
Weekly skin checks by the caregiver with monthly professional skin assessments for 6 months.
Nutritional monitoring with quarterly albumin levels.
Immediate re-referral if any skin breakdown is detected at the wound site or at new pressure points.

Key Takeaways

Nutrition is non-negotiable in Stage 4 pressure injury healing. An albumin below 3.0 predicts wound healing failure. Nutritional optimization must begin at the first visit, not after weeks of stalled progress.
NPWT bridges the gap between debridement and epithelialization. It manages the wound environment in settings where daily skilled nursing visits are impractical, making it especially valuable in home-based wound care.
The caregiver is the most important treatment team member. A perfectly executed wound care plan fails if the patient sits on the wound for 8 hours between visits. Caregiver education and compliance monitoring are clinical interventions, not administrative tasks.
Support surface selection must match the wound stage and risk level. A standard mattress is inadequate for any patient with a Stage 3 or 4 pressure injury. Group 2 surfaces are a minimum standard.
Post-closure surveillance is indefinite for immobile patients. The risk factors that caused the original pressure injury persist after healing. Prevention is a permanent commitment, not a discharge order.