Palliative care sao paulo - 21/09/2012


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Palliative care sao paulo - 21/09/2012

  1. 1. Skin & Wound care forPatients Receiving Palliativecare Professor Carol Dealey, Birmingham, UK International Pressure Ulcer Guidelines
  2. 2. Acknowledgements Part of this paper is based on the SCALE Statements and part is based on a joint paper that I presented with Diane Langemo at the 11th National NPUAP Conference in Washington DC in 2009. International Pressure Ulcer Guidelines
  3. 3. “The skin is essentially a window into the healthof the body, and if read correctly, can provide agreat deal of insight into what is happeninginside the body.” (Sibbald et al, 2009) International Pressure Ulcer Guidelines
  4. 4. Palliative Care It is estimated that about 300 million individuals, or 3% of the world’s population need palliative and end-of- life care each year (Singer & Bowman, 2002). International Pressure Ulcer Guidelines
  5. 5. Guideline Development Palliative care, according to the World Health Organization (1989), is focused on managing and controlling patient’s symptoms while promoting the best quality-of-life for both the patient and family, while neither hastening nor prolonging death. Moderately sufficient informed clinical consensus exists to support pressure ulcer management in an individual receiving palliative care, despite the ethically understandable absence of randomized controlled trials comparing approaches in human subjects International Pressure Ulcer Guidelines
  6. 6. SCALE: Skin Changes at Life’s End A series of consensus statements developed by an international panel Freely available from I include some I think useful here International Pressure Ulcer Guidelines
  7. 7. Statement 1 Physiological changes that occur as a result of the dying process may affect the skin and soft tissues and may manifest as observable changes in:  skin colour  Skin turgor  Skin integrity  Localised pain They can be unavoidable despite best possible care International Pressure Ulcer Guidelines
  8. 8. Statement 4 Skin changes at life’s end are a reflection of compromised skin:  Reduced soft tissue perfusion  Decreased tolerance to external insults  Impaired removal of metabolic wastes International Pressure Ulcer Guidelines
  9. 9. Statement 7 A total skin assessment should be performed regularly and document all areas of concern consistent with the wishes and condition of the patient. Although the main concern will be the bony prominences, other skin damage may be present such as bruising, mottling of the skin or skin tears International Pressure Ulcer Guidelines
  10. 10. Moving on to the commonest problem: Pressure Ulcers International Pressure Ulcer Guidelines
  11. 11. The rest of this paper is based on theInternational Pressure Ulcer Guidelines (NPUAP/EPUAP, 2009) International Pressure Ulcer Guidelines
  12. 12. Prevention of Pressure Ulcers Ideally PU should be prevented in all palliative care patients, but it must be accepted that it is not always possible This section of the presentation identifies specific prevention guideline statements that should be utilised when caring for these patients This is not to say that other statements are not also important……… International Pressure Ulcer Guidelines
  13. 13. Risk Assessment General Health Status (Strength of Evidence B)  A number of epidemiological studies have used measures indicating general health status relevant to the population under study, and these have emerged in multivariable modelling as predictive of pressure ulcer development. Examples include:  number of activity of daily living dependencies  do not resuscitate status  APACHE score  lymphopenia  confusion/mental status International Pressure Ulcer Guidelines
  14. 14. Psychosocial Assessment Consider the care setting of the patient and the implications for care delivery Identify the wishes of the individual and family members Identify individual’s problems, not the healthcare giver’s problems International Pressure Ulcer Guidelines
  15. 15. Repositioning Repositioning frequency will be influenced by the individual (SOE = C) and the support surface in use (SOE = A).  Repositioning frequency will be determined by:  the individual’s tissue tolerance,  their level of activity and mobility,  their general medical condition,  the overall treatment objectives  assessment of the individual’s skin condition.  (SOE = C). International Pressure Ulcer Guidelines
  16. 16. Skin Integrity Undertake regular skin inspection of the bony prominences for signs of redness in individuals identified as being at risk of pressure ulceration. The frequency of inspection may need to be increased in response to any deterioration in overall condition. (SOE = C) Inspect the skin over bony prominences for early indications of pressure damage (redness) each time an immobile individual is turned or repositioned. Do not turn the individual onto a body surface that is still reddened from a previous episode of pressure loading (SOE = C) International Pressure Ulcer Guidelines
  17. 17. Skin Care Use skin emollients to hydrate dry skin in order to reduce risk of pressure damage (SOE = B)  A study of risk factors in 286 hospitalised patients with limited mobility used multivariate analysis to identify significant factors for pressure damage. They found dry skin to be a significant and independent risk factor (Allman et al, 1995). The most appropriate emollient has yet to be determined. International Pressure Ulcer Guidelines
  18. 18. Nutrition Provide nutritional support to each individual with both nutritional risk and pressure ulcer risk, following the nutritional cycle:  Nutritional assessment  Estimation of nutritional requirements  Compare nutrient intake with estimated requirements  Identification of a feeding route  Monitoring of nutritional outcome  Reassessment of nutritional status when there is a change in the individual’s condition. International Pressure Ulcer Guidelines
  19. 19.  Reassessment of nutritional status when there is a change in the individual’s condition.  Individuals may need different forms of nutritional management during the course of their illness. Furthermore, this nutritional management needs to be properly managed and may need to be provided in different settings as their clinical status changes. Clinical processes can only be effectively implemented if there is a robust infrastructure. The clinical team needs to understand the different elements involved in effective service provision and this also depends on bringing together many disciplines including catering/food service, finance and senior management. (Stratton et al., 2003) International Pressure Ulcer Guidelines
  20. 20.  Nutritional management of individuals with inadequate nutritional intake and pressure ulcer risk, who are also receiving palliative care or end of life care, has to take into account their prognostic profile. Moreover it has to meet especially the individual’s wishes and preferences.  Family members may also wish to be involved in planning nutritional management International Pressure Ulcer Guidelines
  21. 21. Individualising Care Palliative care and end of life care is not a ‘one size fits all’ system. It needs to be tailor-made to the individual Sometimes we have to accept that we will not be ‘permitted’ to provide all the care that we would wish International Pressure Ulcer Guidelines
  22. 22. Pressure Ulcer Treatment The palliative care individual, with body systems shutting down, generally lacks the physiological resources for closure/healing of PU to occur. The goal may be to maintain or enhance PU status, rather than healing. As death nears, the skin may be first organ to be compromised and “fail”, with other systems following the downward spiral. International Pressure Ulcer Guidelines
  23. 23. Pressure Ulcer Assessment Regular PU assessment provides information on PU status & alerts staff to need for treatment change. Assess location, size, depth, undermining, tunneling, pain, edema, tissue present (e.g.necrotic, slough, eschar, granulation, epithelialization), & exudate & odor. Wound monitoring is important to continue to meet goals of comfort & reduction in wound pain & symptoms such as odor & exudate. PU may ↓ as death approaches & condition worsens. As physical condition deteriorates, less frequent assessment may minimize pain & discomfort. International Pressure Ulcer Guidelines
  24. 24. Pressure Ulcer Management Set treatment goals consistent with the values and goals of the individual, while considering the family input. (SOE = C) Assess impact of PU on quality of life of patient and family. (SOE = C) Set a goal to enhance quality of life, even if the pressure ulcer cannot/does not lead to closure/healing. (SOE = C) International Pressure Ulcer Guidelines
  25. 25. Pressure Ulcer Management The treatment plan will vary according to the specific requirements of the individual patient. The next few slides provide some general guidance which can be adapted to specific patient need International Pressure Ulcer Guidelines
  26. 26. Pressure Ulcer Management –Dressing Change Manage the PU and periwound area on a regular basis. (SOE = C)  Cleanse wound with each dressing change using potable water, Normal Saline, or a non-cytotoxic cleanser, minimizing trauma to the wound and to help control odor. (SOE = B)  Use a dressing that maintains a moist wound healing environment and is comfortable to the individual. (SOE = B)  Use dressings that can be left in place for longer time periods to promote comfort related to PU. (SOE = B)  Protect the periwound skin with a skin protectant/barrier or dressing. (SOE = C) International Pressure Ulcer Guidelines
  27. 27. Pressure Ulcer Management -Debridement  Debride ulcer of devitalized tissue to control infection and odor. (SOE = B)  Use conservative, non-surgical (autolytic) debridement of necrotic tissue as appropriate. (SOE = B)  Avoid sharp debridement with fragile tissue that bleeds easily. (SOE = C) International Pressure Ulcer Guidelines
  28. 28. Pressure Ulcer Management -Infection  Assess PU for signs of infection; ↑pain; friable, edematous, pale, dusky granulation tissue; foul odor & wound breakdown; pocketing at base; or delayed healing. (SOE = B)  Antibiotics may be required to control infection (SOE = C)  Use an antimicrobial dressing, or a polyurethane foam or a hydrogel or alginate dressing. (SOE = B)  Choose a dressing that can absorb the amount of exudate present, control odor, keep periwound skin dry, and prevent dessication of ulcer. (SOE=C) International Pressure Ulcer Guidelines
  29. 29. Pressure Ulcer Management - Odor Odor results from bacterial overgrowth & necrotic tissue. Malodorous wounds are often polymicrobic, with anerobes & aerobes. PU odor can be very disturbing to patient, contributing to significant feelings of embarrassment &/or depression, isolation, & poor QOL. Assess pt and ulcer, with focus on co-morbid conditions, nutritional status, cause of ulcer, presence of necrotic tissue, presence & type of exudate & odor, psychosocial implications, etc. (SOE = C) International Pressure Ulcer Guidelines
  30. 30. Pressure Ulcer Management Control wound odor  Cleanse ulcer & remove devitalized tissue. (SOE=C)  Use metronidazole to effectively control PU odor. (SOE=C)  Use honey to help control odor. (SOE = C)  Use external odor absorbers for the room (e.g. activated charcoal, kitty litter, vinegar, vanilla, coffee beans, burning candle, pot pouri). (SOE = C) International Pressure Ulcer Guidelines
  31. 31. Pressure Ulcer Pain Management Perform a routine PU pain assessment. (SOE = B) Assess PU procedural & non-procedural pain initially, weekly, & with each dressing change. (SOE = C) Provide a systematic treatment for PU pain. (SOE = C)  If consistent with treatment plan, provide opioids &/or non- steroidal anti-inflammatory drugs 30 min before dressing change or procedure & afterwards. International Pressure Ulcer Guidelines
  32. 32. Pressure Ulcer Pain Management  Ibuprofen impregnated dressings may help decrease PU pain in adults.  OTC lidocaine preparations help ↓PU pain.  Diamorhine hydrogel is effective analgesic treatment for open PU in palliative care individual.  Provide local topical treatment for PU pain.  Select extended wear time dressings to ↓pain associated with frequent dressing changes. International Pressure Ulcer Guidelines
  33. 33. Pressure Ulcer Pain Management Encourage individuals to request a time out during a procedure that causes pain. (SOE = C)  For a patient with PU pain, music, relaxation, position changes, meditation, guided imagery, and TENs are sometimes beneficial . (SOE = C)  Self-hypnosis, healing touch, progressive relaxation, & electrothermal therapy are reported to be of benefit to treat chronic neuropathic pain. (SOE = C) International Pressure Ulcer Guidelines
  34. 34. Pressure Ulcer Pain Management Anxiety is influenced both physiologically and psychologically. Anxiety can be somewhat ameliorated by talking with the patient about their PU related pain, providing a detailed explanation of each procedure, answering questions, allowing active participation, pacing the procedure to pt’s preference, & allowing time outs as needed (Smith et al., 1997) International Pressure Ulcer Guidelines
  35. 35. Conclusions Pressure ulcers can add to a patient’s burden and distress at end of life It is not always possible to prevent PU as the skin may ‘fail’ Existing PU should be managed by symptom amelioration to improve QoL Treatment plans should always recognise the wishes and goals of the individual and family members. International Pressure Ulcer Guidelines
  36. 36. In doing so… We can hope that our patients have a peaceful and comfortable death International Pressure Ulcer Guidelines
  37. 37. Any Questions? International Pressure Ulcer Guidelines