General Principles and Approaches to Wound Prevention and Care at End of Life: An Overview
- 0 Comments
- 7393 reads
The assessment should include comorbid health diagnoses, medications, risk factors for tissue breakdown and nonhealing of wounds, nutritional status, results of diagnostic tests, psychosocial factors, environmental resources, and patient/family goals of care. A risk assessment for palliative care patients — the Pressure Sore Risk Assessment Scale for Palliative Care7 — was developed in a study47 of 98 Swedish hospice patients followed over 18 months. A total of 10 risk assessment tools were tested in the study, and this tool was found to be the most predictive of pressure ulcer development in this population. The three most predictive factors were physical activity, mobility, and age. Sensitivity was 100%, specificity 71%, positive predictive value 50%, and negative predictive value 100%.47
Because it is important to manage the wound and periwound on a regular basis per the individual’s wishes, the individual and the wound should be assessed, noting comorbid conditions, nutritional status, wound etiology, presence of necrotic tissue, presence and type of exudate and odor, and psychosocial implications.2,48,49
Recommendations for wound prevention and care.5 contain numerous recommendations for prevention and treatment of pressure ulcers. Most recommendations are also applicable to other wounds at end of life.
Skin integrity. In general, recommendations for maintaining skin integrity include gentle cleansing with a low-pH skin cleanser followed by the application of a moisture barrier to minimize the effects of excess moisture. As noted previously, macerated tissue is more vulnerable to injury, because it is less able to tolerate the forces of friction, shear, and pressure.50 Clinicians report that a gentle overall body massage often is appreciated in an individual at the end of life, unless contraindicated, such as by ulcer location on the body, a wound with very fragile tissue, a diagnosis of bleeding, or thrombocytopenia.
Skin emollients applied according to manufacturer’s direction are helpful in maintaining adequate skin moisture and preventing dryness.5 Minimizing the harmful effects of incontinence with skin barrier products is helpful.5 When redistributing pressure or moving the patient, the buttocks and sacral areas can be protected by using a lift sheet or an overhead trapeze.29,30,36,51 Heel pressure can be decreased by suspending the heels over a pillow while supporting the entire length of the leg or using heel protectors.5,50 Although a general guideline is to reposition an individual in bed every 2 hours or as frequently as the condition requires, one must consider that repositioning is difficult for patients with hemodynamic instability, pain, nausea or vomiting, or inability to lay in certain positions.5,10 With impaired ventilation ability at end of life, many individuals require elevation of the head of the bed. The guideline is to maintain the head of the bed at the lowest elevation possible — preferably, 30˚ or lower — to minimize friction and shear to the sacrum and buttocks.5,50 A pressure-redistributing mattress overlay or mattress that can distribute load over the contact areas of the body also may be helpful.5,50 However, clinicians should always respect that after explaining the rationale for intervention, the individual’s wishes must be taken into consideration.
Pain management. Pain and discomfort may be associated with prevention, as well as treatment of a wound, even for individuals at the end of life.