Wound Care for the Hospice and Palliative Patient

1. Wound Care for the Hospice and Palliative Patient Marge Mattice, RN, MSN, APNP-BC, CWON

2. DISCLOSURE • I have no financial relationships to disclose, and have no relationships with any manufacturer of wound care products of any kind. Any mention of products by name is only for the purpose of instruction and does not endorse the use of that product.

3. “But it’s just a little wound . . .” • The presence of an acute OR chronic wound can affect your patient’s : • physical well-being • psychological well-being • social interactions

4. Physical well-being • The protective barrier of the skin has been violated . . . • can be a source of infection: wound, cellulitis, osteomyelitis • can lead to sepsis and death • can interfere with daily activities • can be a source of pain

5. Psychological well-being • Patients can use denial, ignoring, and rationalizing to cope with a chronic wound • Defense mechanism may include: suppression, avoidance, withdrawal • Grieving as related to loss or alteration of body image or function • Frustration with lack of progress in healing • (Hopkins, 2001)

6. Remember . . . • Depression is NOT a “normal” part of aging! • The presence of a chronic wound in particular may well be a contributing factor to depression in you patient!!

7. Social interactions • Patient may isolate themselves from family and/or friends • Conversely, family or friends may isolate the patient by actions, words, attitudes resulting in shame, anger or embarrassment

8. Wound Healing . . .How Does it Happen??? • For centuries, a “mysterious process” –something that just (hopefully) happened! • Interventions were most likely based on the caregiver’s preference • Much more is understood now, but we still need ongoing research and study!! • (Waldrop and Doughty, 2000)

9. Wound Healing . . .A Cascade of Events • Inflammatory phase • Proliferative phase • Remodeling phase

10. What does it take to heal this wound, anyway??? • Tissue perfusion and oxygenation • Nutrition • Free of infection • Overall health-compromised by many factors • Age • Immunosuppression

11. So . . . Where do I begin??? • History • History/Previous treatment of the wound itself • Measurements • Goals

12. Patient history • Look at your patient’s list of medical problems . . .

13. It all adds up. . . • diabetes? hypertension? hypothyroid? history of chemotherapy? coronary artery disease? malnutrition? MRSA? dehydration? mental status changes? medications? • The list is endless!

14. In the palliative and hospice world . . . • Persons at the end of life are at risk for skin injury and ulcerations due to . . . • immobility • inadequate nutrition • incontinence • underlying disease processes • (Ayello and Schank, 2007)

15. A change in mindset . . .

16. Developing a plan of care and setting goals • Language is MOST important!!! • Plan of care and Goals must be PATIENT and family centered • (McManus, 2007)

17. In the palliative and hospice world . . . • concept of a “stable, non-healing wound”. . . Most of the time!!!

18. Goals . . . Specifically! • Management of pain • Management of odor • Management of bleeding • Management of exudate • Prevention of infection • (McDonald and Lesage, 2006)

19. Ehtics • Patient autonomy • Beneficence • Non-maleficence • Common good, distributive justice

20. Wound care for the palliative/hospice patient • Caring for wounds in this patient population consists of: • Care that SHOULD be provided • Care that SHOULD NOT be provided • Care that can be considered optional

21. How to sort it out . . . Let the patient tell you!!!

22. Bottom line is . . .

23. A word about prevalence • In palliative patients, the prevalence of pressure ulcers ranges from 13-47% • (Langemo, 2006) • UK hospice study-24% • (Bale et al, 1995)

24. What they found . . . • In study in the UK over two years, using focused attempts to reduce pressure ulcers, this did NOT result in a reduced occurrence!

25. The conclusion . . . • The author concluded that pressure damage at the end of life may be inevitable. • (Galvin, 2002) • “Skin Failure” • (Langemo and Brown, 2006)

26. That having been said . . .

27. Braden Score

28. A consistent way to evaluate your patient’s risk factors • Six subscales • NOT useful with the African-American and Latino populations

29. The six • Sensory perception • Skin moisture • Physical activity • Nutrition • Friction/shear • Ability to change/control body position

30. Wound Assessment

31. “How To’s” • Location-anatomic • Measurements • Wound bed • Amount of drainage • Odor • Presence of bone, tendon, muscle, adipose, slough, necrotic tissue, cartilage • Periwound skin

32. Measuring • length X width X depth • tunneling • undermining

33. Where did this wound come from? • Arterial ulcer? • Venous ulcer? • Diabetic foot ulcer (DFU)? • Neuropathic ulcer? • Pressure ulcer? • Skin tear? • Surgical? • Traumatic? • Malignant cutaneous ulcer?

34. So how can I tell arterial or venous??? • Location • Size and shape • Appearance of wound bed • Amount of exudate • Appearance of periwound skin • Type of pain

35. Location, location, location . . .

36. Arterial ulcers

39. Venous Ulcers

42. Diabetic Foot Ulcer

44. Neuropathic Ulcer

45. Pressure Ulcers

46. Stage I • Skin intact • Erythema present, non-blanchable • May have pain, burning or itching at site

47. Deep tissue injury

48. Incontinence Associated Dermatitis

49. Stage II • Partial thickness loss of skin involving dermis, epidermis • Superficial, may present as abrasion, blister or shallow crater

50. Stage III • Full thickness tissue loss • Damage , possible necrosis of SQ tissue • Can extend down to, but not through, underlying fascia • Possible undermining of ulcer