The document discusses pressure ulcers, including their definition, risk factors, stages, and case studies of management. It defines pressure ulcers as localized skin or tissue damage caused by prolonged pressure over bony areas. It outlines four stages of pressure ulcers based on depth of tissue damage. Two case studies are presented showing management of pressure ulcers through regular wound assessment, dressing changes, and multidisciplinary care including nutrition and physical therapy support. Prevention strategies emphasized include skin inspection, repositioning, and use of pressure-relieving surfaces.

1. Don’t Let the SORES grow on them
Wound Management
Orange Valley Nursing Home
(Marsiling)

2. CONFIDENTIAL
• Pressure Ulcer or Pressure Injury is defined as an area of
localized damage to the skin, muscle, and/or unrelieved
pressure, usually over bony prominences and an external
surface for a prolonged period of time (MOH, 2001).
• It is common among elderly patients who have reduced
activity or become immobile.
• It can present a serious health problem if it becomes infected
or reach an advanced stage.
• Preventing pressure injury requires care and attention and
recognizing the signs is very important.
November 18
2
What is pressure ulcer?
© 2014 Orange Valley Nursing Homes Pte Ltd

3. CONFIDENTIALNovember 18
3
What is pressure ulcer?
© 2014 Orange Valley Nursing Homes Pte Ltd
• Pressure ulcer / pressure injury is a localised injury to the
skin and/or underlying tissue over a bony prominence, as
a result of pressure, or pressure with shear and friction.

4. CONFIDENTIALNovember 18
4
Potential Pressure Ulcer areas

5. CONFIDENTIALNovember 18
5
Anatomy of the skin

6. CONFIDENTIAL
• Intact skin
• Non-Blanchable redness
at localised area
• Over bony prominence
• Darker pigmented skin
tone may not have visible
blanching
November 18
6
Stages of Pressure Ulcer – Stage 1

7. CONFIDENTIAL
• Colour may differ from
surrounding
• Area may be painful
• Firm
• Warmer / cooler than
surrounding tissue
November 18
7
Stages of Pressure Ulcer – Stage 1

8. CONFIDENTIALNovember 18
8
Stages of Pressure Ulcer – Stage 1

9. CONFIDENTIAL
• Partial thickness loss of
dermis
• Superficial layer
• Shiny / Dry Shallow ulcer
• Red pink wound bed
• No slough
November 18
9
Stages of Pressure Ulcer – Stage 2

10. CONFIDENTIALNovember 18
10
Stages of Pressure Ulcer – Stage 2

11. CONFIDENTIAL
• Full thickness tissue loss
• Subcutaneous fat may be visible
• Bone / Tendon / Muscle not
visible
• Slough may be present
• Slough does not obscure depth
of tissue loss
• Undermining & Tunneling
November 18
11
Stages of Pressure Ulcer – Stage 3

12. CONFIDENTIALNovember 18
12
Stages of Pressure Ulcer – Stage 3

13. CONFIDENTIAL
• Full thickness tissue loss
• Exposed bone, muscle, tendon
• Exposed bone / tendon is
directly visible
• Slough / Eschar present on
parts of wound bed
• Undermining / Tunneling
• Looks like a “Crater’’
November 18
13
Stages of Pressure Ulcer – Stage 4

14. CONFIDENTIALNovember 18
14
Stages of Pressure Ulcer – Stage 4

15. CONFIDENTIAL
• Full thickness tissue loss
• Base of ulcer is covered by
slough (yellow, tan, gray, green,
brown or eschar) in wound bed
• True stage cannot be
determined – Until sufficient
slough / eschar is removed
from wound bed
November 18
15
Stages of Pressure Ulcer – Unstageable

16. CONFIDENTIALNovember 18
16
Stages of Pressure Ulcer – Unstageable

17. CONFIDENTIALNovember 18
17
Types of Wound
Granulating Epithelizing

18. CONFIDENTIALNovember 18
18
Types of Wound
Sloughy Infected / Critically Colonised

19. CONFIDENTIALNovember 18
19
Types of Wound
Fungating Necrotic

20. CONFIDENTIAL
• Age
• Mental Status
• Incontinence
• Pain
• Support Surfaces
• Skin color / skin changes
• Poor mobility / poor immobility
• Poor nutrition status
• Compromised blood flow
• Neuropathy / compromised sensation
November 18
20
Predisposing Factors
© 2018, Wound Source

21. CONFIDENTIAL
• Mr. A, 94 years old, male, was admitted to Orange Valley
Nursing Home in Marsiling on June 2018
• Ex-smoker, bedbound, uncommunicative, NGT
• Past Medical History:
- Hypertension
- Old lacunar infarcts
- Abdominal aortic and bilateral artery aneurysm
- Metastatic prostate cancer
- Mild dementia
November 18
21
Case Study 1

22. CONFIDENTIAL
• Multiple pressure ulcers due
to prolonged immobility
• Came in on 18/6/2018 with
vascular wound on his left
foot, Unstageable
• Wound is 90% sloughy /
necrotic, 10% granulating
• Wound size: 6 cm x 4 cm
November 18
22
Case Study 1
June 2018

23. CONFIDENTIALNovember 18
23
Case Study 1
July 2018
Size: 5 cm x 4 cm
90% sloughy/necrotic, 10% granulating
August 2018
Size: 4.5 cm x 4 cm
60% granulating, 40% slough

24. CONFIDENTIALNovember 18
24
Case Study 1
September 2018
Size: 3.5 cm x 2 cm
70% granulating, 30% slough
October 2018
Size: 3 cm x 2 cm
100% granulating

25. CONFIDENTIALNovember 18
25
Case Study 1
Latest Wound as of Nov 2018
• 100% granulating
• Size: 1.5 cm x 1 cm (almost
closing)

26. CONFIDENTIAL
• Mr. B, 90 years old, male, was admitted to Orange Valley
Nursing Home in Marsiling on April 2017
• Bedbound, uncommunicative, ADL dependent, NGT
• Past Medical History:
- Cervical spondylosis
- Bilateral renal cyst
- BPH s/p TURP
- Parkinson’s disease
- Hypertension
- TIA 2011
November 18
26
Case Study 2

27. CONFIDENTIAL
• Issue prior admission to OV:
Fever secondary to infected
sacral sore
• Admitted with sacral wound
Stage 4 (25/4/17)
• Wound size of 10 cm x 7 cm
• Wound be: 60% granulating,
40% sloughy/necrotic
• Surrounding skin is
macerated
• Large amount of exudates
November 18
27
Case Study 1

28. CONFIDENTIALNovember 18
28
Case Study 2
September 2017
Size: 5.9 cm x 4 cm
90% granulating, 10% sloughy
December 2017
Size: 3.9 cm x 3 cm
100% granulating

29. CONFIDENTIALNovember 18
29
Case Study 2
February 2018
Size: 3.3 cm x 2 cm
100% granulating
August 2018
Size: 2.8 cm x 1.8 cm
100% granulating

30. CONFIDENTIALNovember 18
30
Case Study 2
Latest Wound as of Nov 2018
• 100% granulating
• Size: 1.2 cm x 1 cm

31. CONFIDENTIAL
• Braden scale assessment upon admission and at regular
intervals
• Daily skin assessment / inspection to all residents.
 Usage of topical moisturiser / barrier cream
 Improve activity or mobility status
 Cleanse skin at time of soiling
 Hourly – two hourly changing of position
 Basic range of motion exercise on bedbound
 Provide pressure relieving mattress for at risks
November 18
31
Pressure Ulcer Prevention and Management

32. CONFIDENTIAL
• Photo taking of all wounds
during admission and or when noted with early
signs of developing pressure injury.
• Wound rounds were conducted by wound team to
assess the wounds on each level – focusing from
complex and infected wounds to simple wounds.
• Daily wound measurement every after wound dressing.
• Diligent review and documentation on wound progress.
• Monthly discussion by branch wound team on all
wounds and residents at risk.
November 18
32
Pressure Ulcer Prevention and Management

33. CONFIDENTIAL
• Multi-disciplinary approach on wound management:
 Referral to dietician to improve nutritional status –
monthly or more frequent review by RD.
 Referral to doctor on any skin abnormalities and or
changes on wounds for further intervention – close
follow up on identified cases.
 Referral to PT for mobility interventions.
• Staff education and training – competency on proper
assessment and monitoring of wounds, wound dressing
• Education for residents and their family members.
November 18
33
Pressure Ulcer Prevention and Management

34. Thank You!