Pressure injuries, commonly known as bedsores or pressure ulcers, are localized damage to the skin and underlying soft tissue. These injuries develop over bony prominences or are related to medical devices when intense or prolonged pressure restricts blood flow. Medical professionals classify these wounds into distinct stages based on the depth of tissue damage, with higher numbers indicating greater severity. A Stage 3 wound signifies a serious condition involving full-thickness skin loss that requires immediate and comprehensive medical attention to prevent severe complications like systemic infection.
Classification and Appearance of Stage 3 Wounds
A Stage 3 pressure injury is defined by full-thickness skin loss, meaning the wound extends completely through the outer layers of skin. This deep breakdown reaches the subcutaneous layer, where adipose (fat) tissue becomes visible within the wound bed. The injury often takes on a crater-like appearance, reflecting the considerable loss of underlying tissue.
A key feature of this stage is that while fat tissue is exposed, deeper structures like fascia, muscle, tendon, ligament, or bone are not yet visible; exposure of these structures would classify the injury as Stage 4. The depth of the wound can vary significantly depending on its anatomical location, as areas like the heel or ear naturally have less subcutaneous fat compared to the buttocks or sacrum.
The wound bed frequently contains granulation tissue, which is the pink or red, bumpy tissue indicating new connective tissue growth. Dead tissue, called slough (yellow or tan) or eschar (dark or black), may be present, and the edges of the wound may appear rolled (epibole). This depth of tissue destruction also increases the risk of undermining or tunneling, which are narrow passages that extend from the visible wound area into adjacent tissue.
Identifying the Primary Causes and Risk Factors
Stage 3 pressure injuries result from a combination of mechanical forces and underlying patient conditions that compromise tissue tolerance. The primary mechanical factor is sustained pressure, which typically occurs over bony prominences like the sacrum, heels, hips, and elbows when a person is immobile for extended periods. This unrelieved pressure compresses blood vessels, leading to ischemia, or lack of blood flow, which causes tissue cells to die.
Two other mechanical forces, shear and friction, frequently contribute to tissue damage. Shear force occurs when the skin remains stationary while the underlying tissue shifts, such as when a person slides down in a bed or chair. This internal movement stretches and tears small blood vessels, further impeding circulation. Friction, the rubbing of skin against a surface, damages the outer skin layers, making the tissue more susceptible to the effects of pressure and shear.
Several systemic factors heighten a person’s risk for developing these wounds. Immobility is the most significant risk, whether due to paralysis, illness, or sedation. Poor nutrition, particularly a deficiency in protein, calories, and micronutrients, impairs the body’s ability to repair tissue and withstand pressure. Conditions that affect blood flow, such as diabetes or peripheral vascular disease, also increase vulnerability by reducing oxygen and nutrient delivery to the skin.
Moisture from incontinence or perspiration weakens the skin’s integrity, a process called maceration, making it fragile and prone to breakdown. A diminished ability to perceive pain or pressure, often seen in individuals with spinal cord injuries or neuropathy, removes the body’s natural signal to reposition itself.
Comprehensive Treatment Strategies
The treatment for a Stage 3 pressure injury is multidisciplinary and focuses on removing pressure, managing the wound environment, and supporting the body’s healing processes. The most immediate step is pressure redistribution, which involves completely offloading the weight from the affected area. Specialized support surfaces, such as alternating air mattresses or low-air-loss beds, are used to constantly change the pressure points and minimize tissue compression.
Wound cleansing and debridement are necessary to prepare the wound bed for healing. The wound is typically cleaned gently with a non-cytotoxic solution, such as saline, to remove debris. Debridement involves the removal of non-viable tissue, like slough and eschar, which can harbor bacteria and impede the formation of healthy granulation tissue. This removal can be accomplished through surgical methods, mechanical scrubbing, or the application of enzymatic ointments.
Once the wound is clean, the goal of dressing selection is to maintain a moist wound environment, which is optimal for cell migration and tissue repair. Specialized dressings, including hydrocolloids, foams, alginates, or hydrogels, are chosen based on the amount of fluid (exudate) the wound produces. Alginate dressings are highly absorbent for wounds with heavy exudate, while hydrogels maintain moisture in drier wounds.
Infection management is a significant concern for Stage 3 injuries due to the depth of tissue loss. Signs of infection, such as increased pain, redness, foul odor, or purulent drainage, necessitate prompt assessment. If a localized or systemic infection is confirmed, antibiotics or topical antimicrobials are used to control the bacterial load. Nutritional support is equally important, requiring a diet high in protein and calories to provide the necessary building blocks for tissue reconstruction.
Preventing Recurrence
Preventing the recurrence of a Stage 3 pressure injury involves long-term, consistent management of the underlying risk factors and skin care. The core strategy is maintaining a rigorous repositioning schedule to ensure no single area is subjected to prolonged pressure. For individuals in bed, this often means turning at least every two hours, while those in a wheelchair should perform pressure-relief maneuvers or be assisted to reposition every 15 to 60 minutes.
When repositioning an individual in bed, a 30-degree side-lying position is recommended to avoid direct pressure on the hip’s bony prominence. Caregivers must use proper lifting techniques and devices to prevent friction and shear forces during movement. Daily, comprehensive skin inspections are necessary, focusing particularly on bony areas, to catch early signs of redness or discoloration before a new injury can develop.
Effective moisture management is also a significant preventative measure. This includes using highly absorbent continence products and specialized barrier creams to protect the skin from urine and feces, which can cause maceration and breakdown. Furthermore, the continued use of specialized equipment, such as pressure-reducing mattresses and cushions, is necessary to support the skin’s integrity even after the initial wound has healed.