Management of Stage 3 Ulcers

Characteristics and Assessment

A stage 3 ulcer is defined as a full-thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia, presenting as a deep crater with or without undermining of adjacent tissue 1
Stage 3 ulcers involve full-thickness skin loss with damage to subcutaneous tissue but not extending to muscle, tendon, or bone 1
These ulcers typically present as deep craters that may contain slough in the wound bed 1
Slough is commonly found in Stage 3 pressure injuries and presents as a layer of dead tissue in the wound bed 1
In diabetic foot ulcers, a Stage 3 equivalent is described as an "extensive, deep ulcer involving forefoot and/or midfoot; deep, full thickness heel ulcer with calcaneal involvement" 2
Evaluate vascular status, especially in lower extremity ulcers, considering ankle pressure or ABI measurements 3
Assess for signs of infection such as increasing pain, erythema, warmth, or purulent drainage 3
Inspect the ulcer thoroughly to determine the extent of tissue damage and necrosis 3

Sharp debridement is the preferred method for removing slough and necrotic tissue from Stage 3 ulcers 1, 3
Alternative debridement methods include autolytic, biological, and enzymatic debridement 1
Repeat debridement as needed until all necrotic tissue is removed 3
Select appropriate dressings based on wound characteristics, such as alginates or foams for moderately exudative wounds 3
Dressings should be selected based on exudate control, comfort, and cost after slough removal 1
If infection is present, empiric antibiotic therapy should target S. aureus and streptococci for superficial infections 3
Ensure complete offloading of pressure from the affected area 3
For heel ulcers, consider shoe modifications, temporary footwear, or orthoses 3
Optimize glycemic control in diabetic patients 2

Consider vascular assessment and possible revascularization if healing is delayed 3
Evaluate for systemic hyperbaric oxygen treatment for poorly healing wounds 3
Mistaking slough for biofilm can lead to inappropriate treatment strategies 1
Failing to remove slough can result in increased risk of infection and delayed wound healing 1
Aggressive debridement in patients with severe ischemia requires careful consideration of risks versus benefits 1