Monday, February 22, 2010

Care of Pressure Ulcers in Palliative Care Patients

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.

I’d like to recommend this article (full reference below) to anyone involved in the care of palliative care patients, as well as anyone who does wound care.  It is a thoughtful and well written consensus paper from the National Pressure Ulcer Advisory Panel.
The article begins by pointing out the difference in goals between palliative care patients and the usual patients with pressure ulcers (PrU).
Usual care of a PrU is designed to promote healing; however, healing or closing the ulcer in patients receiving palliative care is often improbable. Therefore, the focus of care is better directed to reduce or eliminate pain, odor, and infection and allow for an environment that can promote ulcer closure, as well as improve self-image to help prevent social isolation.
There is a significant risk of PrUs in terminally ill patients.   Many develop Stage III and IV PrUs.  Advanced age, malnutrition, immobility, friction and shear forces, and increased exposure to moisture (ie incontinence, diarrhea, etc) are common.
In 1 study, the majority of PrUs in a hospice sample occurred in the 2 weeks before death,  not unexpected as body systems physiologically begin to shut down 10 to 14 days prior to death.
For individuals who are actively dying, prevention and treatment of a PrU should be superseded by comfort needs.  This means that if it is too painful to be turned and repositioned, then those preventive activities are minimized in an effort to give comfort/pain relief.
Pressure ulcers are often unpleasant smelling wounds due to the bacteria that thrive on the wound exudates and  devitalized tissue.  We’ve agreed that it is not likely we will heal the PrU in pallitive care patients, so what can we do to decrease the smell?  The paper has these recommendations to control wound odor:
Cleanse the ulcer and periwound tissue, using care to remove devitalized tissue.
Assess the individual and the ulcer, with a focus on comorbid conditions, nutritional status, cause of ulcer, presence of necrotic tissue, presence and type of exudates and odor, psychosocial implications, and so on.
Assess the ulcer for signs of wound infection: increasing pain; friable, edematous, pale dusky granulation tissue; foul odor and wound breakdown; pocketing at base; or delayed healing.
Use antimicrobial agents as appropriate to control known infection and suspected critical colonization.
Consider use of properly diluted antiseptic solutions for limited periods of time to control odor.
Consider use of topical metronidazole to effectively control PrU odor associated with anaerobic bacteria and protozoal infections.
Consider use of dressings impregnated with antimicrobial agents (eg, silver, cadexomer iodine, medical-grade honey) to help control bacterial burden and odor.
Consider use of charcoal or activated charcoal dressings to help control odor.
Consider use of external odor absorbers for the room (eg, activated charcoal, kitty litter, vinegar, vanilla, coffee beans, burning candle, potpourri).
The article list these products and dressings as odor-controlling:
Metronidazole,  an antimicrobial agent effective against anaerobic bacteria and protozoal infections such as Trichomonas. Topical metronidazole gel (0.75%-0.80%) is frequently used directly on the wound once per day for 5 to 7 days or more often as needed.  Metronidazole tablets can be crushed and placed onto the ulcer bed.
Cadexomer Iodine, an antiseptic that allows for low-concentration release of iodine over time and promotes an acid pH that enhances the antimicrobial action of the iodine.  
Charcoal -impregnated dressings have been found to minimize wound odor. Activated charcoal attracts and binds wound odor molecules.
Dakin Solution. Odor can also be controlled using Dakin solution 0.25% (sodium hypochlorite) saturated onto gauze packing and placed into the ulcer.  Dakin solution produces its own odor and can be irritating to the respiratory system, especially if the patient is in isolation or rooms with limited ventilation. Dakin solution may cause some pain in the wound when used.
Povidone Iodine. Odor can also be controlled using povidone solution.
Silver Dressings. Silver dressings are effective in countering some infections in the wounds and thereby controlling odor.
Other Odor-Control Methods. To control odor in the room, kitty litter can be placed under the bed. Vinegar, vanilla, coffee beans, or a candle in the room are also helpful in controlling odors.   External odor absorbers in the room are effective but, at times, the smells they create can be overwhelming themselves.
Pressure Ulcers in Individuals Receiving Palliative Care: A National Pressure Ulcer Advisory Panel White Paper(C); Advances in Skin & Wound Care. 23(2):59-72, February 2010; Langemo, Diane K.; Black, Joyce; and the National Pressure Ulcer Advisory Panel

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