Palliative care sao paulo - 21/09/2012

Skin & Wound care for
Patients Receiving Palliative
care

Professor Carol Dealey,
Birmingham, UK

International Pressure Ulcer Guidelines

Acknowledgements

 Part of this paper is based on the SCALE
Statements and part is based on a joint
paper that I presented with Diane Langemo
at the 11th National NPUAP Conference in
Washington DC in 2009.


“The skin is essentially a window into the health
of the body, and if read correctly, can provide a
great deal of insight into what is happening
inside the body.” (Sibbald et al, 2009)


Palliative Care

 It is estimated that about 300 million
individuals, or 3% of the world’s
population need palliative and end-of-
life care each year (Singer & Bowman, 2002).


Guideline Development
 Palliative care, according to the World Health
Organization (1989), is focused on managing and
controlling patient’s symptoms while promoting the
best quality-of-life for both the patient and family,
while neither hastening nor prolonging death.

 Moderately sufficient informed clinical consensus
exists to support pressure ulcer management in an
individual receiving palliative care, despite the
ethically understandable absence of randomized
controlled trials comparing approaches in human
subjects


SCALE: Skin Changes at Life’s End
 A series of consensus
statements developed by
an international panel

 Freely available from
www.woundsresearch.com

 I include some I think
useful here

Statement 1
 Physiological changes that occur as a result
of the dying process may affect the skin and
soft tissues and may manifest as observable
changes in:
 skin colour
 Skin turgor
 Skin integrity
 Localised pain

 They can be unavoidable despite best
possible care

Statement 4

 Skin changes at life’s end are a reflection of
compromised skin:
 Reduced soft tissue perfusion
 Decreased tolerance to external insults
 Impaired removal of metabolic wastes


Statement 7
 A total skin assessment should be performed
regularly and document all areas of concern
consistent with the wishes and condition of
the patient.
 Although the main concern will be the bony
prominences, other skin damage may be
present such as bruising, mottling of the skin
or skin tears


Moving on to the commonest problem: Pressure Ulcers


The rest of this paper is based on the
(NPUAP/EPUAP, 2009)


Prevention of Pressure Ulcers
 Ideally PU should be prevented in all palliative care
patients, but it must be accepted that it is not always
possible

 This section of the presentation identifies specific
prevention guideline statements that should be
utilised when caring for these patients

 This is not to say that other statements are not also
important………


Risk Assessment
 General Health Status (Strength of Evidence B)
 A number of epidemiological studies have used
measures indicating general health status
relevant to the population under study, and
these have emerged in multivariable modelling
as predictive of pressure ulcer development.
Examples include:
 number of activity of daily living dependencies
 do not resuscitate status
 APACHE score
 lymphopenia
 confusion/mental status


Psychosocial Assessment

 Consider the care setting of the patient and the
implications for care delivery

 Identify the wishes of the individual and family
members

 Identify individual’s problems, not the healthcare
giver’s problems


Repositioning

 Repositioning frequency will be influenced by
the individual (SOE = C) and the support
surface in use (SOE = A).
 Repositioning frequency will be determined by:
 the individual’s tissue tolerance,
 their level of activity and mobility,
 their general medical condition,
 the overall treatment objectives
 assessment of the individual’s skin condition.
 (SOE = C).


Skin Integrity
 Undertake regular skin inspection of the bony
prominences for signs of redness in individuals
identified as being at risk of pressure ulceration.
The frequency of inspection may need to be
increased in response to any deterioration in
overall condition. (SOE = C)
 Inspect the skin over bony prominences for early
indications of pressure damage (redness) each
time an immobile individual is turned or
repositioned. Do not turn the individual onto a body
surface that is still reddened from a previous
episode of pressure loading (SOE = C)

Skin Care

 Use skin emollients to hydrate dry skin in order to
reduce risk of pressure damage (SOE = B)
 A study of risk factors in 286 hospitalised patients
with limited mobility used multivariate analysis to
identify significant factors for pressure damage. They
found dry skin to be a significant and independent
risk factor (Allman et al, 1995). The most appropriate
emollient has yet to be determined.


Nutrition
 Provide nutritional support to each individual with both
nutritional risk and pressure ulcer risk, following the
nutritional cycle:
 Nutritional assessment
 Estimation of nutritional requirements
 Compare nutrient intake with estimated
requirements
 Identification of a feeding route
 Monitoring of nutritional outcome
 Reassessment of nutritional status when there is a
change in the individual’s condition.


 Reassessment of nutritional status when there is
a change in the individual’s condition.
 Individuals may need different forms of nutritional
management during the course of their illness. Furthermore,
this nutritional management needs to be properly managed
and may need to be provided in different settings as their
clinical status changes. Clinical processes can only be
effectively implemented if there is a robust infrastructure.
The clinical team needs to understand the different elements
involved in effective service provision and this also depends
on bringing together many disciplines including catering/food
service, finance and senior management. (Stratton et al.,
2003)


 Nutritional management of individuals with
inadequate nutritional intake and pressure ulcer
risk, who are also receiving palliative care or end
of life care, has to take into account their
prognostic profile. Moreover it has to meet
especially the individual’s wishes and preferences.
 Family members may also wish to be involved in planning
nutritional management


Individualising Care

 Palliative care and end of life care is not a ‘one size
fits all’ system.

 It needs to be tailor-made to the individual

 Sometimes we have to accept that we will not be
‘permitted’ to provide all the care that we would wish


Pressure Ulcer Treatment

 The palliative care individual, with body systems
shutting down, generally lacks the physiological
resources for closure/healing of PU to occur. The
goal may be to maintain or enhance PU status, rather
than healing. As death nears, the skin may be first
organ to be compromised and “fail”, with other
systems following the downward spiral.


Pressure Ulcer Assessment
 Regular PU assessment provides information on PU
status & alerts staff to need for treatment change.
 Assess location, size, depth, undermining, tunneling,
pain, edema, tissue present (e.g.necrotic, slough,
eschar, granulation, epithelialization), & exudate &
odor.
 Wound monitoring is important to continue to meet
goals of comfort & reduction in wound pain &
symptoms such as odor & exudate.
 PU may ↓ as death approaches & condition worsens.
As physical condition deteriorates, less frequent
assessment may minimize pain & discomfort.


Pressure Ulcer Management
 Set treatment goals consistent with the values and
goals of the individual, while considering the family
input. (SOE = C)

 Assess impact of PU on quality of life of patient and
family. (SOE = C)

 Set a goal to enhance quality of life, even if the
pressure ulcer cannot/does not lead to
closure/healing. (SOE = C)



 The treatment plan will vary according to the specific
requirements of the individual patient.

 The next few slides provide some general guidance
which can be adapted to specific patient need


Pressure Ulcer Management –
Dressing Change
 Manage the PU and periwound area on a regular
basis. (SOE = C)
 Cleanse wound with each dressing change using potable
water, Normal Saline, or a non-cytotoxic cleanser,
minimizing trauma to the wound and to help control odor.
(SOE = B)
 Use a dressing that maintains a moist wound healing
environment and is comfortable to the individual. (SOE = B)
 Use dressings that can be left in place for longer time
periods to promote comfort related to PU. (SOE = B)
 Protect the periwound skin with a skin protectant/barrier or
dressing. (SOE = C)


Pressure Ulcer Management -
Debridement

 Debride ulcer of devitalized tissue to control
infection and odor. (SOE = B)

 Use conservative, non-surgical (autolytic)
debridement of necrotic tissue as appropriate.
(SOE = B)

 Avoid sharp debridement with fragile tissue that
bleeds easily. (SOE = C)


Pressure Ulcer Management -
Infection
 Assess PU for signs of infection; ↑pain; friable,
edematous, pale, dusky granulation tissue; foul odor &
wound breakdown; pocketing at base; or delayed
healing. (SOE = B)
 Antibiotics may be required to control infection (SOE =
C)
 Use an antimicrobial dressing, or a polyurethane
foam or a hydrogel or alginate dressing. (SOE =
B)
 Choose a dressing that can absorb the amount of
exudate present, control odor, keep periwound
skin dry, and prevent dessication of ulcer.
(SOE=C)

Pressure Ulcer Management - Odor
 Odor results from bacterial overgrowth & necrotic
tissue. Malodorous wounds are often polymicrobic,
with anerobes & aerobes. PU odor can be very
disturbing to patient, contributing to significant
feelings of embarrassment &/or depression, isolation,
& poor QOL.
 Assess pt and ulcer, with focus on co-morbid
conditions, nutritional status, cause of ulcer,
presence of necrotic tissue, presence & type of
exudate & odor, psychosocial implications, etc. (SOE
= C)


 Control wound odor
 Cleanse ulcer & remove devitalized tissue. (SOE=C)

 Use metronidazole to effectively control PU odor. (SOE=C)

 Use honey to help control odor. (SOE = C)

 Use external odor absorbers for the room (e.g. activated
charcoal, kitty litter, vinegar, vanilla, coffee beans, burning
candle, pot pouri). (SOE = C)


Pressure Ulcer Pain Management
 Perform a routine PU pain assessment. (SOE = B)

 Assess PU procedural & non-procedural pain initially, weekly, &
with each dressing change. (SOE = C)

 Provide a systematic treatment for PU pain. (SOE = C)

 If consistent with treatment plan, provide opioids &/or non-
steroidal anti-inflammatory drugs 30 min before dressing
change or procedure & afterwards.


 Ibuprofen impregnated dressings may help
decrease PU pain in adults.
 OTC lidocaine preparations help ↓PU pain.
 Diamorhine hydrogel is effective analgesic
treatment for open PU in palliative care
individual.
 Provide local topical treatment for PU pain.
 Select extended wear time dressings to ↓pain
associated with frequent dressing changes.


 Encourage individuals to request a time out during a procedure
that causes pain. (SOE = C)

 For a patient with PU pain, music, relaxation, position
changes, meditation, guided imagery, and TENs are
sometimes beneficial . (SOE = C)

 Self-hypnosis, healing touch, progressive relaxation, &
electrothermal therapy are reported to be of benefit to treat
chronic neuropathic pain. (SOE = C)



 Anxiety is influenced both physiologically and
psychologically. Anxiety can be somewhat
ameliorated by talking with the patient about their PU
related pain, providing a detailed explanation of each
procedure, answering questions, allowing active
participation, pacing the procedure to pt’s preference,
& allowing time outs as needed (Smith et al., 1997)


Conclusions
 Pressure ulcers can add to a patient’s burden
and distress at end of life
 It is not always possible to prevent PU as the
skin may ‘fail’
 Existing PU should be managed by symptom
amelioration to improve QoL
 Treatment plans should always recognise the
wishes and goals of the individual and family
members.


In doing so…

 We can hope that our patients have a
peaceful and comfortable death


Any Questions?


Palliative care sao paulo - 21/09/2012

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