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Wound Management
- 1. Don’t Let theSORES grow on them Wound Management Orange Valley Nursing Home (Marsiling)
- 2. CONFIDENTIAL • Pressure Ulceror 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 ispressure 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 PressureUlcer areas
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- 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 maydiffer 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 ofPressure Ulcer – Stage 1
- 9. CONFIDENTIAL • Partial thicknessloss 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 ofPressure Ulcer – Stage 2
- 11. CONFIDENTIAL • Full thicknesstissue 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 ofPressure Ulcer – Stage 3
- 13. CONFIDENTIAL • Full thicknesstissue 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 ofPressure Ulcer – Stage 4
- 15. CONFIDENTIAL • Full thicknesstissue 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 ofPressure Ulcer – Unstageable
- 17. CONFIDENTIALNovember 18 17 Types ofWound Granulating Epithelizing
- 18. CONFIDENTIALNovember 18 18 Types ofWound Sloughy Infected / Critically Colonised
- 19. CONFIDENTIALNovember 18 19 Types ofWound Fungating Necrotic
- 20. CONFIDENTIAL • Age • MentalStatus • 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 pressureulcers 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 Study1 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 Study1 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 Study1 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 prioradmission 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 Study2 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 Study2 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 Study2 Latest Wound as of Nov 2018 • 100% granulating • Size: 1.2 cm x 1 cm
- 31. CONFIDENTIAL • Braden scaleassessment 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 takingof 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 approachon 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
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