Pressure Ulcer Stage 3

Stage 3 pressure ulcer is full thickness skin loss with visible subcutaneous fat, often with granulation tissue, rolled wound edges, slough, undermining or tunnelling. Fascia, muscle, tendon, ligament, cartilage and bone are not exposed.

• Depth varies with anatomy: shallow over the nose, ear and malleolus where there is little fat; deep over the sacrum and buttocks.
• Risk factors: immobility, malnutrition, incontinence, shear, spinal cord injury, diabetes, vascular disease, advanced age, critical illness.

Open crater with visible yellow fat, moist base, pale or red granulation, slough, and exudate, sometimes with odour.

• Undermined edges and sinus tracts are common.
• Pain may be absent in neuropathic or sensory impaired patients.
• Differential diagnosis: stage 4 ulcer with hidden depth, diabetic or arterial ulcer, venous ulcer, pyoderma gangrenosum, necrotising fasciitis, malignant ulcer, calciphylaxis, tuberculous ulcer, abscess.
• Complications: infection, cellulitis, abscess, osteomyelitis from undermining, sepsis, haemorrhage, anaemia, hypoalbuminaemia, progression to stage 4, chronic wound.

Clinical assessment, with staging by the deepest tissue seen.

• Measure length, width, depth, undermining and tunnelling; document wound bed tissue, exudate, odour and periwound skin; photograph.
• Full blood count, CRP, glucose, albumin, urea and creatinine; HIV test where status unknown.
• Tissue or deep swab culture only if infected; probe to bone test and MRI or radiograph if bone is suspected.
• Nutritional assessment.

Remove pressure, clean and debride the wound, fill dead space, support nutrition and treat infection.

• Supportive: alternating pressure or high specification mattress, repositioning every 2 hours using a 30 degree side lying position, heel suspension, seat cushion with limited sitting to 1 hour, continence management, protein 1.25 to 1.5 g/kg/day and energy 30 to 35 kcal/kg/day, vitamin and zinc replacement when deficient, glycaemic control, smoking cessation.
• Pharmacological: paracetamol 1 g before dressing changes, add morphine 2.5 to 5 mg orally if needed; antibiotics only for cellulitis or systemic infection: amoxicillin clavulanate 625 mg three times daily for 7 days, or ceftriaxone 2 g IV daily plus metronidazole 500 mg IV every 8 hours for severe infection; tetanus toxoid 0.5 mL IM if immunisation is out of date; topical antiseptic (dilute povidone iodine or silver dressings) for short periods in critical colonisation.
• Procedures: sharp or surgical debridement of slough and devitalised tissue; pack dead space loosely with alginate, hydrofibre or hydrogel gauze and cover with foam or hydrocolloid; negative pressure wound therapy for clean deep wounds; surgical flap closure for clean wounds in fit patients.
• Special groups: spinal cord injury, flap surgery with strict pressure avoidance for 6 weeks; elderly, address malnutrition and dehydration; HIV, start antiretroviral therapy and screen for tuberculosis; palliative patients, aim for comfort and odour control.
• Red flags: fever, spreading erythema, crepitus, foul pus, exposed bone, undermining beyond 2 cm, rising CRP, no reduction in size in 2 to 4 weeks.
• Follow-up: weekly measurement; reassess for osteomyelitis if non healing; plan prevention after healing with permanent pressure relief.