Wound Care for Hospice Patients

Transcription

1 Wound Care for Hospice Patients Kristen Lyn Brodrick, RN, BSN, CHPN,CWCN No financial disclosures.

2 Unique Population Patients needing hospice/palliative care are often at risk for developing multiple skin issues. The skin of dying patients can be fragile and sensitive and is subsequently at risk of being compromised from wound exudates, body fluids, pressure, and friction (Rhodes, et al). They are less mobile and at risk for pressure ulcers (PU) that often worsen or are non-healing. Cancer wounds can be painful and malodorous. Our patients deserve quality care, which includes prevention, treatment, and comfort measures (WOCN.org 2012). Hospice/Palliative nurses are often the main provider of this quality care.

3 Wound Healing Wounds heal in one of three ways: Primary healing: surgical closure ONLY. Secondary healing: granulation, contraction and epithelization. This includes pressure ulcers and skin tears. Tertiary healing is when there is a delay from injury to surgical closure. Goals of wound care can be healing or maintenance. Often maintenance is more realistic in hospice population.

4 Common wounds for Hospice patients: Pressure Ulcers (ONLY THESE ARE STAGED) In 2005, Stage 2 PU were redefined to EXCLUDE skin lesions from etiologies other than pressure. Many open wounds are still incorrectly identified using the staging system (Black, et al). Skin tears Incontinence associated dermatitis (IAD) Oncologic lesions or fungating wounds All of these wounds can be partial or full thickness.

5 Nutrition and Palliative Wound Care Nutrition has an effective role in healing wounds, but cannot prevent an individual at end of life from suffering or imminent death. (Posthauer,M) There is correlation between lower protein intake and development of pressure ulcers. No other nutritional variable was significant for predicting pressure ulcers including: total intake of calories, Vitamins A&C, zinc, iron. (Bergstrom, N and Braden, B) Enteral feedings have been found to have no effect on number or healing of pressure ulcers. (Henderson, C.T., et al) Consider patient goals, their aspiration risk, offering favorite foods, frequent sips of non caffeinated beverages.

6 Pressure Ulcers They are NOT decub, decubitus, or bedsores They are: lesions caused by compression of soft tissue between two rigid surfaces (bone internally and bed/chair etc externally) that results in ischemia. (Emory University WOCNEC). Pressure ulcers are staged 1 to 4. You cannot reverse stage a PU. Once a stage 4, always a stage 4. It would be called a healing or healed stage 4.

7 Risk Factors: Advanced age Protein-calorie malnutrition Immobility Friction and shear Exposure to moisture NPUAP (National Pressure Ulcer Advisory Panel)

8 Pressure Ulcer Prevention: Frequent turning and pressure redistribution are key interventions. A supportive surface is vital: memory foam overlay, static, APP, or low air loss mattress. Egg crate mattresses are for comfort only. They do not redistribute pressure. A Foley catheter is an option when incontinence is considered a factor.

9 Stage I Intact, non-blanchable skin.

10 Stage 2 Partial thickness loss involving epidermis and possibly dermis. Often shallow with red/pink wound bed. No slough.

11 Stage 3 Full thickness skin and tissue loss. Subcutaneous fat may be visible, but not bone, tendon, or muscle. Slough may be present but does not obscure wound bed. There may be tunneling and undermining.

12 Stage 4 Full thickness loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often there is undermining and tunneling.

13 UNSTAGEABLE Wound bed is not visible, covered by slough and/or eschar.

14 Deep Tissue Injury Purple or maroon area of intact skin or blood blister.

15 Kennedy Ulcers: Large and fast developing, often on coccyx Occur just before death Result of skin system failure Death often occurs within two weeks (Langemo, et al).

16 Kennedy Ulcer

17 HEELS: Frequent site of pressure ulcer. They should be floated AT ALL TIMES and checked often. Intact eschar should remain, as it serves as body's natural biological cover. If they open, it will be stage 3 or 4 (NPUAP).

18 Heel with intact eschar

19 Skin tears They can be either partial or full thickness. NOT STAGED (own classification system) Often occur from trauma: DME, adhesive, transfers, personal care. Transparent dressing if minimal drainage. Foam can be a good addition if drainage an issue. Dressings can remain in place for up to a week. Watch for s/s of infection.

20 Incontinence Associated Dermatitis (IAD) Incontinence associated dermatitis (IAD) develops from chronic exposure to urine or liquid stool (Gray, et al). It often occurs in skin folds. Wound bed shiny, red without slough. Periwound tissue is red, irritated, edematous. It is blotchy in appearance. Yeast is a common finding (Black, et al). You want to cleanse, moisturize and protect skin. Skin protectants serve as moisture barrier protecting the skin from exposure to irritants (urine and stool) and moisture (Black, et al.) Options include dimethicone, petrolatum, zinc oxide. Reapply after each incontinence episode. A Foley catheter may be a good temporary option.

21 IAD

22 Oncologic Lesions Oncologic lesions are solid tumors that invade soft tissue (Emory University, WOCNEC). The major issues are often pain, exudate and odor. The odor is due to tumor breakdown and anaerobic bacteria. For odor control: Flagyl gel or powder can be very helpful applied directly to wound bed. Silver dressings have bacteriostatic properties but can be expensive. Charcoal dressings. Ostomy pouch for heavily draining or malodorous wounds. Minimize dressing changes. Dressings should be nonadhesive: foam, hydrofiber, or Calcium alginate which can help bleeding from the friable tissue Premedicating before dressing changes is mandatory.

23 Basic Wound Care Concepts: debridement if indicated treat infection manage exudate or drainage fill or wick dead space keep wound bed moist and insulated protect from infection and trauma

24 Palliative wound care You are looking to maximize comfort, control exudate, minimize odor, while maintaining patient dignity. Many of these wounds will not heal before death. Most will get worse. Simpler dressings: foam, hydrofiber, alginates, hydrocolloids. Foam can be non-adhering which are good choice for oncologic lesions. Alginates have hemostatic properties which is helpful for more sanguineous drainage. Hydrocolloids can be used for autolytic debridement. Not for use on dry wounds. You can cleanse with either soap and water, saline or wound spray. Ideally dressing changes are two to three times a week. An ostomy bag can minimize exposure to MRSA wounds, control odor and/or exudate.

25 Dressings: Considerations: comfort, drainage, odor, cost, availability, complexity of dressing change Barrier Cream: IAD, Stage 1, 2 PU(shallow) Transparent dressing: Stage 1, 2 PU, skin tears, autolytic debridement, waterproof, up to 7 days depending on drainage Hydrocolloid: Partial and full thickness wounds, necrotic wounds, autolytic debridement, adhesive protection, 3-7 days depending on drainage

26 Dressings: Hydrogel: partial and full thickness wounds, painful wounds, is non-adherent, rehydrates wound bed (not for heavy drainage) SAF-gel, Hydrogel, SilvaSorb (with Ag) Foam: Partial and full thickness with minimal to heavy drainage, tunneling wounds, can be nonadherent, 3-5 days depending on drainage, not for dry eschar Allevyn, DermaFoam, Mepilex, Optifoam, Polymem. Many come with Ag

27 Calcium Alginate Partial and full thickness wounds, moderate to heavy drainage. Hemostatic properties. Tunneling wounds, sinus tracts. Available in sheets or ropes. Not for dry eschar, can desiccate wound bed if not enough drainage or if dressing not changed frequently enough. AlgiSite, Kaltostat, Maxorb Extra, Alginate, Restore

28 Hydrofiber Partial to full thickness. Moderate to heavy drainage. Tunneling wounds. Trauma free removal. Not for dry eschar or non draining wounds. Aquacel, Aquacel Ag, Aquacel Foam

29 Other considerations: SILVER (Ag) PROS: antimicrobial properties, can reduce odor and drainage by reducing bio-burden. CONS: expensive. Think about Metronidazole powder. ANTIBIOTICS May reduce drainage and pain. May be appropriate for cellulitis.

30 Debridement? It can be done at the bedside by MD or CWOCN. Not within the scope of practice for most RN's. Can help to decrease exudate and odor as well as promote healing or minimize worsening of the wound. Enzymatic debridement targets necrotic tissue but needs daily dressing changes. Transparent and hydrocolloid dressings can autolytically debride wounds that don't need sharp debridement. WET TO DRY is contraindicated and VERY painful.

31 Summary Ultimately our patient population relies on us to provide the wound care needed at end of life. The plan should be individualized and comfort based. We want to control pain and odor, maintain wound if healing not an option, and maximize quality of life. Wound care nurses can be a valuable resource in your community.

32 Sources: Baranoski, S and Ayello, E. (2008) Wound Care Essentials: Practice Principles, Second Editon. PA: Lippincott Williams and Wilkins. Bergrstrom, N., and Braden, B. A Prospective Study of Pressure Sore Risk Among Institutionalized Elderly, Journal of the American Geriatric Society 40 (8):747-58, August Black, J., Gray, M., Bliss, D, et al. (2011). MASD Part 2: Incontinence Associated Dermatitis and Intertriginous Dermatitis: A Consensus, Journal of WOCN, July/August, Emory University, WOCNEC. Wound, Ostomy, Continence Nurse Education Center. Course curriculum handout. Henderson, C.T., et al. Prolonged Tube Feeding in Long Term Care: Nutritional Status and Clinical Outcomes, Journal of the American College of Clinical Nutrition 11 (3):309-25, Hughes, R.G., Bakos, A.D., et al. Palliative Wound Care at the End of Life. Retrieved November 10,2103 from Langemo, D.K., Black, J., & National Pressure Ulcer Prevention Advisory Panel. (2010) Pressure Ulcers in Individuals receiving Palliative Care: A National Pressure Ulcer Advisory Panel White Paper, Advances in Skin & Wound Care, 23 (2), NPUPAP. National Pressure Ulcer Prevention Advisory Panel. (2009) Pressure Ulcer Prevention &Treatment, Quick Reference Guide. Photos from Google Images unless otherwise noted. Posthauer, M., Offering Supportive Nutritional Care at End of Life. Retrieved February 23, 2014 from Perspectives on Palliative Wound Care. WOCN. Org. (June 2012). Fact Sheet: How does a Wound, Ostomy, Continence Nurse Fit into your Palliative/Hospice Care Team.