Home Health & Hospice

Guidance on Stage III and Stage IV Pressure Ulcers

Homecare Insider, July 8, 2011

Stage III and Stage IV pressure ulcers, which are full thickness pressure ulcers, heal through a process of contraction, granulation, and epithelializaton. Though they can never be considered to be “fully healed”, they can be considered to be closed when they are fully granulated and the wound surface is covered with new epithelial tissue.

Let’s take a look at the characteristics of Stage III and Stage IV pressure ulcers according to the Wound Ostomy Continence Nurses Society (WOCN) and the National Pressure Ulcer Advisory Panel (NPUAP) guidance.
 
Characteristics of Stage III pressure ulcers include:
  • Full thickness tissue loss.
  • Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed.
  • Slough may be present but does not obscure the depth of tissue loss.
  • May include undermining or tunneling.
  • The depth of a Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput, and malleolus do not have subcutaneous tissue. Stage III ulcers in these locations can be shallow. In contrast, areas of significant adiposity can develop extremely deep Stage III pressure ulcers.
  • Bone/tendon is not visible or directly palpable.
 Characteristics of Stage IV pressure ulcers include:
  • Full thickness tissue loss with visible bone, tendon, or muscle.
  • Slough or eschar may be present on some parts of the wound bed.
  • Often includes undermining and tunneling.
  • The depth of a Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput, and malleolus do not have subcutaneous tissue. Stage IV ulcers in these locations can be shallow.
  • Stage IV ulcers can extend into muscle and/or supporting structures (eg, fascia, tendon, or joint capsule); osteomyelitis is possible.
  • Exposed bone/tendon is visible or directly palpable.
 Providers may not be aware that in April 2011 the WOCN issued a revised position statement on pressure ulcer staging supporting the use of NPUAP’s staging system. It’s important to note that neither entity supports down-staging or reverse staging of pressure ulcers. In its revised position statement, WOCN also addresses staging of healing pressure ulcers further, staging of pressure ulcers totally or partially covered with slough or eschar and pressure ulcers on mucous membranes.
To learn more, download the NPUAP guidelines and read the revised position statement from WOCN.