A pressure ulcer, also called a bedsore or decubitus ulcer, is a localized injury to the skin and underlying soft tissue, typically occurring over a bony prominence. This damage results from prolonged pressure or pressure combined with shear forces, which compromise blood flow. Wounds are classified into stages based on the depth of tissue destruction. A Stage 3 pressure ulcer signifies that tissue damage has progressed significantly, extending beyond the surface layers of the skin. This injury represents a serious medical concern requiring immediate and specialized attention.
Anatomical Characteristics of a Stage 3 Pressure Ulcer
A Stage 3 pressure ulcer is defined by full-thickness skin loss, meaning the injury has penetrated completely through the epidermis and dermis. At this depth, the wound base often reveals visible subcutaneous fat tissue, which appears yellowish. The ulcer takes on a crater-like appearance, differentiating it from the shallower wounds seen in lower stages.
A defining feature of this stage is that while fat is exposed, the damage does not extend to expose underlying structures like muscle, tendon, or bone. The true depth of the ulcer can vary significantly depending on its anatomical location. Ulcers over areas with little fat, such as the ear or the bridge of the nose, will appear shallow, while those on areas with significant adipose tissue can be quite deep.
The wound bed may contain dead tissue, known as slough (moist and yellow) or eschar (dry, black, or brown). For the injury to remain classified as a Stage 3 ulcer, any present slough or eschar must not completely obscure the extent of the tissue loss. If the base is completely covered by this dead tissue, it is considered an unstageable pressure injury until the base is visible.
Stage 3 ulcers frequently present with tissue destruction beneath the wound edges, described as undermining or tunneling. Undermining refers to tissue destruction that occurs under the intact skin surrounding the wound margin. Tunneling is a narrow passage extending from the visible ulcer into deeper tissues, making the actual size of the wound much larger than its surface area suggests.
Immediate Management and Treatment Goals
The management of a Stage 3 pressure ulcer focuses on two primary goals: removing damaged tissue and establishing an optimal environment for healing. The first step is complete pressure redistribution, which involves using specialized mattresses or cushions to ensure no further weight is placed on the injured site. Pressure relief is a foundational requirement for healing to occur.
A significant intervention is debridement, which is the removal of necrotic tissue like slough and eschar from the wound bed. This removal is necessary because dead tissue harbors bacteria and impedes the formation of healthy new tissue. Debridement can be performed surgically using sharp instruments, or non-surgically through the application of special enzymes or dressings that help dissolve the dead tissue (autolytic debridement).
Once the wound bed is clear, the focus shifts to maintaining a clean, moist healing environment while controlling exudate, the fluid that drains from the wound. This is achieved through the careful selection of specialized wound dressings. Dressings such as hydrocolloids, foams, or alginates are commonly used because they absorb excess moisture while insulating and protecting the wound from contamination. Alginate dressings are particularly effective for highly draining wounds due to their high absorbency.
Infection control is another central pillar of management, involving the regular cleaning of the wound with saline solution or a prescribed cleanser. Systemic support is equally important, as the body requires sufficient resources to repair the extensive tissue loss. This includes optimizing nutritional status by ensuring adequate intake of protein and calories, which are necessary for tissue repair.
Serious Health Risks and Complications
Because a Stage 3 pressure ulcer involves a deep, open breach in the body’s protective barrier, it poses severe health risks, primarily related to infection. The exposed subcutaneous tissue serves as an entry point for bacteria, leading to localized infections. Signs of infection, such as a foul odor, increased pain, or green pus, require immediate medical evaluation.
If the localized infection is not contained, it can spread to the surrounding soft tissue, a condition known as cellulitis, which presents as redness, warmth, and swelling beyond the wound’s edge. The depth of the ulcer also places deeper structures at risk for infection. Bacteria can travel through the exposed tissue layers to reach the bone, causing a serious complication called osteomyelitis.
Infections that reach the joints are called septic arthritis; both bone and joint infections are difficult to treat, often requiring prolonged courses of intravenous antibiotics. The most severe complication is sepsis, or blood poisoning, which occurs when the bacterial infection enters the bloodstream. Sepsis is a systemic reaction that can lead to organ failure and is a major cause of death associated with advanced pressure ulcers.