General Principles and Approaches to Wound Prevention and Care at End of Life: An Overview
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Moist wound care helps prevent exposure of delicate nerve endings71-73; dry, desiccated wound beds and dressings cause pain.70
Wound infection. All chronic wounds are considered to be colonized with bacteria.74 During colonization, microorganisms are present and replicating on the wound surface; in true infection, they have invaded healthy tissue and are multiplying, producing pathophysiologic effects.74 Colonization does not constitute infection, but once the microorganisms invade healthy tissue, infection can occur.75 Individuals at the end of life usually have a compromised immune response and less able to fight the infection. Classic signs of wound infection include pain, erythema, warmth, edema, and purulent exudate.74,76,77 Bacteremia also can occur.58 When the goal for the wound is maintenance, culturing and treatment of the wound infection may not be warranted.21
Necrotic tissue and debridement. When tissues are deprived of oxygen and nutrients, they become devitalized and nonviable78 and a nidus for bacteria to thrive on.79 As bacteria colonize, necrotic material forms in the wound, promoting bacterial growth and inhibiting leukocyte phagocytosis of bacteria.78 The necrotic tissue in the wound bed becomes black and at times leathery with exposure to air or yellow/gray when exposed to moisture.69 Most distressing to the patient are the odor, drainage, and pain arising from the infection.
Odor. Wound odor can be embarrassing to the individual and lead to isolation and poor quality of life.1,14,80,81 It is important to treat the cause of the odor and the odor itself. More frequent dressing changes may be helpful, along with frequent wound irrigation to remove exudate and odor.5,14,70 Nonviable tissue can be debrided; autolytic debridement is often the least painful method for the individual.5,82 Sharp debridement is not recommended because excessive bleeding and undue pain often occur.5,9,70,82
The NPUAP-EPUAP Guidelines recommend a variety of approaches for controlling odor. Topical metronidazole can be used,2,5,40 as well as activated charcoal dressings,5,9,83-85 occlusive dressings (although not when infection is present), and frequent dressing changes.14 Cadexomer iodine5,86,87 and povidone iodine88 are effective antiseptics. Silver dressings are effective for infections and odor control. Gauze saturated with Dakin’s solution 0.25% (sodium hypochlorite) can be placed in the wound for a limited time, although it may cause some discomfort.5,88 Larvae have been used effectively in wounds with extensive necrotic tissue.89 A hyperosmotic wound environment that inhibits bacterial growth and assists in debridement may be achieved using a sugar paste and honey.90,91 Anecdotal reports of other helpful products for use in the environment surrounding the patient suggest room deodorizers, activated charcoal, kitty litter, vinegar, vanilla, coffee beans, burning candle, and potpourri.2,49,92,93
Cleansing. The wound can be cleansed at each dressing change using potable water (ie, water suitable for drinking), normal saline, or a noncytotoxic cleanser to minimize trauma to the wound and help control odor.5,49,50 The wound/ulcer should be assessed for signs of wound infection: increasing pain; friable, edematous, pale dusky granulation tissue; foul odor and wound breakdown; pocketing at base; or delayed healing.75
Nutrition. As end of life approaches, the individual may consume little in the way of fluids and food.