Stage 4 Pressure Ulcers: Symptoms, Causes, Treatment, and Prevention

Introduction

A pressure ulcer is skin or soft tissue damage that develops over a bony prominence due to prolonged pressure or pressure combined with shear. Early diagnosis is essential to prevent ulcers from worsening into stage 4 pressure ulcers, which carry a high risk of infection and life-threatening complications.

Case Example
A 92-year-old male with advanced dementia has been a long-term resident of a nursing home for 4 years. He is bedbound, incontinent, and fully dependent for activities of daily living. Two months ago, he was diagnosed with a stage 1 pressure ulcer on his sacrum but resisted frequent repositioning. On weekly wound rounds, the wound nurse now observes exposed bone. The wound is classified as a stage 4 pressure ulcer.

What Is a Stage 4 Pressure Ulcer?

A stage 4 pressure ulcer is the most severe form of pressure injury, involving full-thickness tissue loss with exposed fascia, muscle, tendon, or bone. Common sites include the sacrum, heels, hips, and elbows. These ulcers may present with rolled wound edges, granulation tissue, slough, or eschar. They often feature tunneling (deep channels in tissue) or undermining (separation under wound edges).

Early Warning Signs of Stage 4 Pressure Ulcers

Stage 3 ulcers can progress into stage 4 pressure ulcers without proper treatment. Early warning signs include:

Open ulcers with visible dermis and red or pink wound beds

Presence of granulation tissue, slough, or eschar

Full-thickness skin loss with visible fat layers

Recognizing these changes quickly can help stop progression to a stage 4 ulcer.

How to Treat a Stage 4 Pressure Ulcer

Once diagnosed, a stage 4 pressure ulcer requires urgent, specialized care:

• Relieve pressure with proper positioning, pillows, or specialty mattresses
• Protect and dress wounds with padding and absorptive dressings
• Debridement may be necessary if slough or eschar is present
• Infection management with antibiotics if exudate or fever occurs
• Monitor for osteomyelitis (bone infection) if bone is exposed
• Surgical interventions like grafts or flaps may be needed for severe ulcers
• Advance care planning should be discussed if the ulcer reflects a poor prognosis

Preventing Stage 4 Pressure Ulcers

Preventing stage 4 pressure ulcers is more effective than treating them. Facilities should:

• Reposition at-risk residents regularly
• Perform weekly skin assessments
• Monitor weight, nutrition, and hydration closely
• Use pressure-relieving cushions and mattresses
  
  

Building a Facility-Wide Culture of Skin Integrity

Strong leadership is essential to reducing stage 4 pressure ulcer rates. Strategies include:

• Interdisciplinary teamwork for ulcer prevention and healing
• Ongoing staff education and competency checks
• Tracking and sharing pressure ulcer data at QAPI meetings
• Recognizing and celebrating successful ulcer prevention and healing outcomes

Conclusion

Stage 4 pressure ulcers involve complete tissue loss with exposure of muscle, tendon, or bone. They often arise from untreated stage 3 ulcers, making early prevention critical. Treatment requires a combination of pressure relief, wound care, infection control, and sometimes surgery. Nursing homes and healthcare teams can reduce stage 4 ulcer risk by prioritizing prevention strategies, frequent assessments, and strong leadership support.

Frequently Asked Questions (FAQ)

Can stage 4 pressure ulcers heal on their own?

Stage 4 pressure ulcers can heal on their own, but they are considered open wounds, so they require appropriate care to allow healing and to prevent worsening. Stage 4 pressure ulcers with signs of tunnelling or undermining require longer periods of time to heal. Stage 4 pressure ulcers that become infected also take longer to heal.

How long does it typically take for a stage 4 ulcer to heal in a long-term care resident?

Stage 4 pressure ulcers heal in several month to years. Larger stage 4 pressure ulcers can take longer to heal, and the presence of infection, undermining, or tunnelling will also delay healing. Residents with poor nutritional status or multiple chronic medical conditions may also have delayed healing of their stage 4 pressure ulcers.

What is the difference between stage 3 and stage 4 pressure ulcers?

Stage 3 pressure ulcers result from an injury that causes the loss of all skin layers, exposing underlying subcutaneous fat, but muscle, tendon, or bone is not exposed. Stage 4 pressure ulcers result from full loss of all skin layers and tissue with exposed muscle, tenson, or bone.

What role do CNAs play in preventing pressure ulcers?

CNAs play an essential role in preventing pressure ulcers by repositioning at risk residents and alerting nursing staff to any skin changes as well as worsening of pressure ulcers. CNAs can also ensure that residents receive adequate nutrition and hydration.

How can leadership support better pressure ulcer outcomes?

Facility leadership can play a role in creating a culture that prioritizes skin integrity. Leadership should ensure that policies and procedures are in place for resident screenings that determine pressure ulcer risk as well as regular skin assessments. Leadership should also ensure that success stories and improvement in pressure ulcer rates are highlighted.

What complications should staff monitor for during treatment?

Staff should monitor stage 4 pressure ulcers during treatment for worsening of the wound (i.e., the wound becomes deeper or larger) or for signs of infection (the resident develops a fever, exudate drains from the wound, or the skin surrounding the wound becomes red or warm). Staff should urgently contact a medical provider if the stage 4 pressure ulcer worsens or if infection of the wound or underlying bone (osteomyelitis) is suspected