Whether you’ve just discovered your resident’s skin breakdown or you’re caring for a known, existing stage 3 pressure ulcer, you must focus your efforts on healing and continuous prevention. This includes a multi-disciplinary approach that involves the nurse, attending physician, wound care specialist, social worker, dietician, surgeon and sometimes occupational and physical therapy1. Let’s review some identification and care strategies that you and the team can implement to aid the resident in healing as quickly and comfortably as possible.
Pressure ulcers are staged based on severity. It’s imperative that you correctly stage your resident’s pressure ulcer so that the care plan and interventions are appropriate for the resident’s level of skin breakdown. Keep in mind, however, that you may discover a pressure ulcer that never progressed through the stages and instead began as a stage 32. Conversely, it’s expected that your resident’s skin won’t heal in reverse order2. Staging is simply a communication tool, not to be thought of as a gauge of your care or an indication of progress.
When assessing a stage 3 pressure ulcer, you should expect to see full-thickness skin loss. Unlike a stage 2 pressure ulcer where you’ll find a shallow, pink wound bed, the stage 3 wound will be deeper red, and you may note yellow, fatty tissue3. The edges of the wound may roll under, and undermining or tunneling may be present3. Slough or eschar may also be present but will not prevent the visualization of the extent of tissue loss (this would make the wound unstageable)3.
If you can visualize muscles, tendons or bones within the wound, you’re looking at a stage 4 pressure ulcer3.
Each organization will develop policies for assessing resident risk levels and factors related to skin breakdown. Whether your facility chooses to use the Braden Scale, the Norton Scale or another integumentary risk scale, be diligent in your assessments and ensure that each resident’s risk level and risk factors are thoroughly communicated with the care team4.
Managing your resident’s stage 3 pressure ulcer will involve various measures to prevent further breakdown, infection prevention, debridement where appropriate, and treatment to advance healing5.
Most of the preventative measures mirror those with a stage 1 or stage 2 pressure ulcer. Always thoroughly assess the risk factors leading to your resident’s skin breakdown using assessment tools such as the Braden and Norton scales4. Also, record your resident’s progress utilizing the PUSH tool if available through your organization6. Analyzing these scores can assist you in determining what caused your resident’s pressure ulcer and if your treatments are effective.
When caring for a resident with a stage 3 pressure ulcer, you must be diligent in your assessment of the wound itself and the resident’s condition. Start by assessing the resident's overall condition and monitor for signs and symptoms of infection or sepsis. If the resident develops a fever, increased heart rate, decreased blood pressure, chills, nausea, vomiting, pain, confusion, shortness of breath or lethargy, notify the attending physician immediately7.
Assess the wound frequently and document its features carefully. Take note of8:
● Wound location
● Wound shape
● Wound size
● Wound bed color
● Slough (percentage of wound covered)
● Eschar (percentage of wound covered)
● Odor
● Discharge (color, consistency, amount)
● Epibole (rolled wound edges)
● Tunneling
● Undermining
● Condition of the surrounding skin
● Patient pain level
Depending on the current treatment regime, the resident’s wound may not always be visible during your skin check. Even so, assess the resident’s condition and thoroughly check all other skin areas, particularly those closest to the wound, to identify any new areas of breakdown before they progress.
Necrotic tissue within the wound bed promotes the growth of bacteria and will slow healing. Therefore, a physician may order a debridement if dead tissue is present in the wound bed. In wounds with only small amounts of dead tissue, applying moist dressings will allow the body to naturally debride the wound over time. However, autolytic debridement methods will take more time than some of the others we’ll discuss8.
For some wounds, debridement can be done at the bedside utilizing a scalpel or scissors, with the nurse performing an assistive role. More extensive wounds may be debrided in an operating room setting8.
In some cases, debridement is performed utilizing a wet-to-dry dressing. A gauze, moistened with sterile solution, is applied to the wound. Once dry, the gauze is removed without re-moistening. The dead tissue adheres to the dry dressing and is removed with the dressing change. However, this method can be uncomfortable for the resident and can result in the inadvertent removal of healthy tissue8.
If debridement via scalpel or wet-to-dry dressing are not appropriate or tolerated, an enzymatic debridement may be ordered8. This method takes longer than the first two methods but involves a more gentle approach. A collagenase ointment, often Santyl, is applied to the wound bed daily. It works to loosen the collagen that attaches the necrotic tissue to the wound bed, allowing it to easily release during dressing changes9.
For those who can stomach the idea, Maggot therapy is a viable option for the debridement of a pressure ulcer when other methods have been unsuccessful, or the wound has advanced and is struggling to heal10. Fly larvae are ideal for wound debridement because they only consume necrotic tissue and cause no harm to the healthy tissue. Additionally, their secretions are antimicrobial, a beneficial infection prevention measure10. In most instances, the wound care team will place the larva and perform dressing changes.
Always choose your resident’s wound dressing under the guidance of the attending physician and the certified wound care specialist. However, if you’re performing a dressing change and feel that the current dressing is not appropriate, be confident in speaking up. As a wound heals, treatment changes are inevitable. Let’s review a few of the most commonly used dressings and their advantages and disadvantages.
Hydrogel dressings are water or glycerin-based and provide soothing, hydrating coverage for the wound bed. They are most appropriate for healthy wound beds with minimal debridement needs as they promote autolytic (done automatically through the body’s natural processes) debridement that is slow and gentle. When applying, cut the dressing to the size and shape of the wound and keep it covered to maintain a moist environment. Monitor the wound closely for signs of maceration (skin breakdown due to excess moisture) and report immediately if noted8.
Dressings containing alginate are ideal for pressure ulcers with extensive discharge. The soft fibers are highly absorptive, pulling up to 20 times its weight from the wound bed. If alginate is ordered for your resident’s wound, monitor the wound closely for discharge and notify the team if light or minimal discharge is noted, as alginate may dry the wound bed and impede healing8. Once applied, cover the alginate dressing to hold it in place and prevent leakage from the area.
Foam dressings are ideal for pressure ulcer care, providing a soft barrier between the wound and nearby surfaces. However, they are not primarily ordered as a means to reduce pressure but as a coverage over other wound dressings. They are typically soft and absorbent with an adhesive border for easy application8. Be sure to carefully monitor the resident’s skin when removing the adhesive and avoid using them on especially fragile skin.
Hydrocolloid dressings are ideal for wounds with slough or eschar and minimal discharge. Soft and moist, these pads protect the wound from contaminants and mold well to problematic areas such as heels and knees. Avoid using these dressings on fragile skin or packed wounds8.
Honey-infused dressings and gels possess antibacterial properties and can promote healing at 4 times the rate of some other dressings. It’s important to know that honey gels and dressings are created using medical-grade honey11. The application of food-grade honey may result in adverse effects.
Infected wounds often benefit from the use of silver-infused dressings. Like honey-infused options, these dressings utilize the naturally occurring antibacterial properties of silver to prevent and treat infections12. Monitor your resident closely for silver toxicity, including skin discoloration, poor wound healing and difficulty breathing.
Simple moistened gauze dressings are easy to apply, readily available, and can be used on deep wounds. Moisten the gauze with sterile saline and apply it to the wound bed. Rehydrate the gauze regularly and during dressing changes to keep the wound bed moist and for resident comfort8.
Composite dressings combine the benefits of one or more of those we’ve discussed13. When choosing your resident’s dressings, carefully follow orders and choose only those most appropriate for your resident’s wound.
Wound VACs, sometimes called Negative Pressure Wound Therapy (NPWT), are devices used to assist in wound healing and closure. The device applies negative pressure (suction) to the wound to gently pull fluids and discharge from the wound, reduce swelling, stimulate the growth of new tissue and pull the edges of the wound together14.
Wound VAC dressings are typically changed every 24-72 hours. During this time, you’ll trim a foam or gauze dressing to fit inside the wound. Then, you’ll apply an adhesive film over the wound to create a tight seal. A portable vacuum pump and drainage tube are then attached and begin cycling through negative pressure cycles to promote healing. If the tube becomes clogged or the seal is broken, an alarm will sound and will require nursing attention14.
Carefully monitor residents on NPWT therapy to ensure that the device and its attachments do not create additional pressure areas and that the wound bed is healing with no signs or symptoms of infection.
In some cases, a stage 3 wound will not heal properly. This can be due to many factors, but if other methods have failed, the physician may choose to perform a surgical intervention. If surgery is necessary, the resident will be transferred to a surgical center to receive care. Depending on the specific wound condition, the surgeon may close the wound by pulling together the edges, or by reconstructing a closure using skin from another area of the body1. Once the resident returns, avoid positioning the resident in any way that applies pressure to the area, and monitor the post-surgical wound carefully for signs of infection. Immediately report any signs of infection or other concerns to the attending physicians.
In addition to providing preventative and healing care to your resident, you must also consider the resident’s overall health, social and emotional needs.
Ask yourself questions such as:
● Does the resident have a diagnosis or comorbidities contributing to their pressure ulcer risk?
● What additional care or treatment will improve their overall health?
● Is their nutritional intake adequate and appropriate?
● Do they have access to their preferred foods?
● Do they have healthy dentition?
● How do they feel about their current living situation?
● How is their mental health?
● What are their social needs?
● What is their level of independence with ADLs?
● Are they able to ambulate independently?
There are a myriad of factors that influence your resident’s health and wellness and will have a significant impact on their ability to heal. Ensure you provide interventions wherever necessary to give the resident the best chances of success.
11. https://pubmed.ncbi.nlm.nih.gov/17413836/
12. https://westcoastwound.com/types-of-wound-dressings-and-when-to-use-them/
Tammy McKinney, RN, is a seasoned registered nurse and skilled healthcare writer. Specializing in patient and caregiver education, she leverages her diverse experience in acute care, long-term care, and hospice & palliative care to simplify complex medical concepts and deliver informative and engaging content. To learn more about Tammy, visit her LinkedIn page.
