WOU N D & SKI N C AR E
Assessing wounds in palliative care By Rita C. Bergevin, MSN, RN-BC, CWCN
PALLIATIVE WOUND CARE emphasizes patient comfort, symptom relief, and preservation of dignity and self-esteem in patients for whom complete wound healing measures are inappropriate. These patients are typically terminally ill (6- to 12-month life expectancy) and may have disseminated cancer or other conditions with significant comorbidities that preclude aggressive or prolonged treatments.1,2 The goals of palliative wound care are to prevent or manage complications and help the patient attain the maximum level of functioning with activities of daily living. This article addresses how to provide the best care for bleeding, odor, pain, exudate, and skin breakdown in patients with unhealable wounds. Bleeding Wound bleeding may be related to friable cutaneous tissue with reduced fibroblast activity. Any friction or minor trauma from removal of wound dressings that adhere to the wound surface may provoke bleeding from this fragile tissue.3 Immediately apply direct pressure and ice packs to control bleeding. Applying ferric subsulfate solution, a topical hemostatic agent, may allow hemostasis.2,4 Other strategies include applying gauze saturated with a combination of topical epinephrine (1:1,000), oxidized cellulose, and collagen.2 Another option is to apply a calcium alginate dressing; its absorbent, nonadherent, biodegradable fibers derived from seaweed have excellent hemostatic potential.5 Silver nitrate may be useful as a sclerosing agent.6
Nonadhesive absorbent dressings are recommended to limit moisture, which is contraindicated in nonhealing wounds, and prevent traumatic dressing removal, which helps decrease pain and bleeding. Nonabsorbent gauze, such as hydrogel or vaseline-impregnated gauze, and semi-permeable foam dressings may be used for dry wounds. Another strategy is to apply protective barrier films to skin surrounding the wound using atraumatic tape and mesh netting to affix dressings to help avoid unnecessary trauma during dressing removal. Odor An unpleasant odor can be caused by infection and necrotic tissue. Wound bacteria are predominantly anaerobic along with certain Gram-negative aerobic organisms, such as pseudomonas. In a mix of anaerobic and aerobic organisms, either type can cause odor.7 Metronidazole is highly effective in reducing the load of anaerobic bacteria in the wound, thus decreasing unpleasant odors.8 Topical metronidazole is available as a gel and a cream. Alternatively, gauze can be soaked with I.V. metronidazole solution and applied as a compress, or tablets can be ground up and sprinkled onto the wound surface. Topical metronidazole has been used in combination with calcium alginate or foam dressings.9 Other topical antimicrobials include gentamicin sulfate cream, bacitracin/neomycin/polymyxin B sulfate, and topical silver sulfadiazine. Antiseptics such as povidone-iodine and
chlorhexidine can also be used to help treat infection.8 An activated charcoal dressing can control odor by filtering out the chemicals that cause odor and absorbing bacteria. Charcoal dressings are more effective if they can be sealed around the wound edges, and they can be combined with topical metronidazole. Application of manuka honey, chloromycetin solution, or topical wound deodorizer may also aid in odor control. Putting cat litter or baking soda under the wound bed may also help to reduce odor.2 Be sure to assess the wound for evidence of a Candida infection, which may cause the odor. This type of fungal infection causes raised red lesions that extend around the wound margin, often accompanied by odor, burning, and pruritus. Topical nystatin or clotrimazole cream may be effective to combat this infection.10 Gentle removal of exudate and debris from the wound base can help reduce odor. Surgical debridement isn’t indicated because of the risk of bleeding. Gently irrigate the wound with 0.9% sodium chloride solution and use a commercial wound cleanser with surfactant.11 Hydrogel dressings can also help with gentle debridement because they soften the necrotic tissue. Pain Wound pain can be nociceptive, neuropathic, or a combination. Nonsteroidal anti-inflammatory drugs (NSAIDs) should be initiated as first-line therapy and administered on a regular, rather than
68 l Nursing2014 l August
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
www.Nursing2014.com
as-needed, schedule to maintain a constant serum drug level. An opioid such as hydrocodone combined with an NSAID or used as a single agent should be used as a next step. Morphine may be the drug of choice for severe pain because it can be administered by different routes and is easily titrated.7 Dressing changes often trigger wound-related pain. Pain may also be related to irritation of periwound skin by adhesive tapes and dressings. The use of nonadherent interfaces such as silicone, zinc oxide/ petroleum, acrylates, and hydrocolloid is helpful.8 Pain from dressing removal may be alleviated by applying topical opioids or lidocaine.2 A contact dermatitis may result from damage by wound effluent; topical steroids are useful in this situation. Infection must always be considered when assessing a painful wound and handled appropriately. Exudate Inflammation that may be associated with infection promotes exudate. Excessive moisture creates an ideal wound environment for bacterial proliferation, especially when the patient is immunocompromised. Avoid hydrating gels and moistureretentive dressings such as hydrocolloids because they have limited absorption capabilities.12 Two-layer, permeable vented dressings may be ideal because the perforated nonadherent layer protects the wound surface while allowing passage of exudate to an absorbent layer.9 Wound drainage bags are indicated for high-volume drainage. These products include attached skin barriers, flexible adhesive surfaces, and an access window over the site. Negative pressure wound therapy may help to contain exudate and reduce the need for painful dressing changes. www.Nursing2014.com
Skin breakdown Frequently documented in patients with nonhealing wounds, breakdown of periwound skin is related to numerous factors, including malnutrition, poor general physical condition, decreased fluid intake, poor tissue perfusion, decreased mobility, impaired removal of metabolic wastes, impaired immune status, altered sensation, and radiation damage in patients who’ve undergone radiation therapy. Pressure ulcers are aggravated by urinary and fecal incontinence, friction, and traumatic dressing changes.13,14 Strategies to prevent skin breakdown are moisture barrier ointment and moisture barrier paste and skin sealants. Skin sealants protect the skin from maceration. It has limited ability to protect the skin from enzymes. Moisture barrier ointment is helpful and effective with high volume output or diarrhea.2 Moisture barrier paste should be used to protect the skin against high output effluent. It’s important to note that mineral oil can be used to facilitate removal of the paste—the skin shouldn’t be scrubbed to remove the paste. Two more important factors to prevent skin breakdown are adequate hydration and nutrition. Several factors can affect skin hydration: humidity, removal of sebum, and age. Application of emollients to the skin replaces lost sebum and water when humidity is low. The daily application of moisturizing lotions has been found to be advantageous.2 Adequate nutrition at the end of life isn’t always attainable. So, providing small frequent meals or nutritional protein supplements when possible may aid in avoiding skin breakdown.13
Appropriate wound care is based on the needs and healthcare goals of the patient and family and can often lead to improved outcomes even in advanced cases. The goals of palliative wound care are preventing complications and relieving symptoms in order to maintain the patient’s comfort and preserve dignity, self-esteem, and quality of life. ■ REFERENCES 1. World Health Organization. Cancer Pain Relief: With a Guide to Opioid Availability. 2nd ed. Geneva, Switzerland: World Health Organization; 1996. 2. Bryant R, Dix D. Acute and Chronic Wounds: Current Management Concepts. 4th ed. St. Louis, MO: Mosby, Inc.; 2012:505-513. 3. Alexander S. Malignant fungating wounds: key symptoms and psychosocial issues. J Wound Care. 2009;18(8):325-329. 4. AstriGyn. Prescribing information. 2004. http:// www.coopersurgical.com/Documents/33961-DFU. pdf. 5. Hess CT. Clinical Guide to Skin and Wound Care. 7th ed. Philadelphia, PA: Lippincott, Williams & Wilkins; 2012. 6. Harris DG, Noble SI. Management of terminal hemorrhage in patients with advanced cancer: a systematic literature review. J Pain Symptom Manage. 2009;38(6):913-927. 7. Emanuel L, Librach S. Lawrence Palliative Care: Core Skills and Clinical Competencies. 2nd ed. St Louis, Mo: Elsevier; 2011. 8. Woo KY, Sibbald RG. Local wound care for malignant and palliative wounds. Adv Skin Wound Care. 2010;23(9):417-428. 9. National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. Prevention and Treatment of Pressure Ulcers: Clinical Guidelines. Washington, DC: National Pressure Ulcer Advisory Panel; 2009. 10. Alavi A, Woo K, Sibbald RG. Common nail disorders and fungal infections. Adv Skin Wound Care. 2007;20(6):346-359. 11. Seaman S. Management of malignant fungating wounds in advanced cancer. Semin Oncol Nurs. 2006; 22(3):185-193. 12. Woo KY. Meeting the challenges of woundassociated pain: anticipatory pain, anxiety, stress, and wound healing. Ostomy Wound Manage. 2008;54(9):10-12. 13. Langemo D. General principles and approaches to wound prevention and care at end of life: an overview. Ostomy Wound Manage. 2012;58(5):24-34. 14. Stephen Haynes J. An overview of caring for those with palliative wounds. Br J Community Nurs. 2008;13(12):S24, S26, S28, passim. At the Decker School of Nursing in Binghampton, N.Y., Rita C. Bergevin is a clinical associate professor. The author has disclosed that she has no financial relationships related to this article. DOI-10.1097/01.NURSE.0000451541.13898.fb
August l Nursing2014 l 69
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Assessing wounds in palliative care By Rita C. Bergevin, MSN, RN-BC, CWCN
PALLIATIVE WOUND CARE emphasizes patient comfort, symptom relief, and preservation of dignity and self-esteem in patients for whom complete wound healing measures are inappropriate. These patients are typically terminally ill (6- to 12-month life expectancy) and may have disseminated cancer or other conditions with significant comorbidities that preclude aggressive or prolonged treatments.1,2 The goals of palliative wound care are to prevent or manage complications and help the patient attain the maximum level of functioning with activities of daily living. This article addresses how to provide the best care for bleeding, odor, pain, exudate, and skin breakdown in patients with unhealable wounds. Bleeding Wound bleeding may be related to friable cutaneous tissue with reduced fibroblast activity. Any friction or minor trauma from removal of wound dressings that adhere to the wound surface may provoke bleeding from this fragile tissue.3 Immediately apply direct pressure and ice packs to control bleeding. Applying ferric subsulfate solution, a topical hemostatic agent, may allow hemostasis.2,4 Other strategies include applying gauze saturated with a combination of topical epinephrine (1:1,000), oxidized cellulose, and collagen.2 Another option is to apply a calcium alginate dressing; its absorbent, nonadherent, biodegradable fibers derived from seaweed have excellent hemostatic potential.5 Silver nitrate may be useful as a sclerosing agent.6
Nonadhesive absorbent dressings are recommended to limit moisture, which is contraindicated in nonhealing wounds, and prevent traumatic dressing removal, which helps decrease pain and bleeding. Nonabsorbent gauze, such as hydrogel or vaseline-impregnated gauze, and semi-permeable foam dressings may be used for dry wounds. Another strategy is to apply protective barrier films to skin surrounding the wound using atraumatic tape and mesh netting to affix dressings to help avoid unnecessary trauma during dressing removal. Odor An unpleasant odor can be caused by infection and necrotic tissue. Wound bacteria are predominantly anaerobic along with certain Gram-negative aerobic organisms, such as pseudomonas. In a mix of anaerobic and aerobic organisms, either type can cause odor.7 Metronidazole is highly effective in reducing the load of anaerobic bacteria in the wound, thus decreasing unpleasant odors.8 Topical metronidazole is available as a gel and a cream. Alternatively, gauze can be soaked with I.V. metronidazole solution and applied as a compress, or tablets can be ground up and sprinkled onto the wound surface. Topical metronidazole has been used in combination with calcium alginate or foam dressings.9 Other topical antimicrobials include gentamicin sulfate cream, bacitracin/neomycin/polymyxin B sulfate, and topical silver sulfadiazine. Antiseptics such as povidone-iodine and
chlorhexidine can also be used to help treat infection.8 An activated charcoal dressing can control odor by filtering out the chemicals that cause odor and absorbing bacteria. Charcoal dressings are more effective if they can be sealed around the wound edges, and they can be combined with topical metronidazole. Application of manuka honey, chloromycetin solution, or topical wound deodorizer may also aid in odor control. Putting cat litter or baking soda under the wound bed may also help to reduce odor.2 Be sure to assess the wound for evidence of a Candida infection, which may cause the odor. This type of fungal infection causes raised red lesions that extend around the wound margin, often accompanied by odor, burning, and pruritus. Topical nystatin or clotrimazole cream may be effective to combat this infection.10 Gentle removal of exudate and debris from the wound base can help reduce odor. Surgical debridement isn’t indicated because of the risk of bleeding. Gently irrigate the wound with 0.9% sodium chloride solution and use a commercial wound cleanser with surfactant.11 Hydrogel dressings can also help with gentle debridement because they soften the necrotic tissue. Pain Wound pain can be nociceptive, neuropathic, or a combination. Nonsteroidal anti-inflammatory drugs (NSAIDs) should be initiated as first-line therapy and administered on a regular, rather than
68 l Nursing2014 l August
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
www.Nursing2014.com
as-needed, schedule to maintain a constant serum drug level. An opioid such as hydrocodone combined with an NSAID or used as a single agent should be used as a next step. Morphine may be the drug of choice for severe pain because it can be administered by different routes and is easily titrated.7 Dressing changes often trigger wound-related pain. Pain may also be related to irritation of periwound skin by adhesive tapes and dressings. The use of nonadherent interfaces such as silicone, zinc oxide/ petroleum, acrylates, and hydrocolloid is helpful.8 Pain from dressing removal may be alleviated by applying topical opioids or lidocaine.2 A contact dermatitis may result from damage by wound effluent; topical steroids are useful in this situation. Infection must always be considered when assessing a painful wound and handled appropriately. Exudate Inflammation that may be associated with infection promotes exudate. Excessive moisture creates an ideal wound environment for bacterial proliferation, especially when the patient is immunocompromised. Avoid hydrating gels and moistureretentive dressings such as hydrocolloids because they have limited absorption capabilities.12 Two-layer, permeable vented dressings may be ideal because the perforated nonadherent layer protects the wound surface while allowing passage of exudate to an absorbent layer.9 Wound drainage bags are indicated for high-volume drainage. These products include attached skin barriers, flexible adhesive surfaces, and an access window over the site. Negative pressure wound therapy may help to contain exudate and reduce the need for painful dressing changes. www.Nursing2014.com
Skin breakdown Frequently documented in patients with nonhealing wounds, breakdown of periwound skin is related to numerous factors, including malnutrition, poor general physical condition, decreased fluid intake, poor tissue perfusion, decreased mobility, impaired removal of metabolic wastes, impaired immune status, altered sensation, and radiation damage in patients who’ve undergone radiation therapy. Pressure ulcers are aggravated by urinary and fecal incontinence, friction, and traumatic dressing changes.13,14 Strategies to prevent skin breakdown are moisture barrier ointment and moisture barrier paste and skin sealants. Skin sealants protect the skin from maceration. It has limited ability to protect the skin from enzymes. Moisture barrier ointment is helpful and effective with high volume output or diarrhea.2 Moisture barrier paste should be used to protect the skin against high output effluent. It’s important to note that mineral oil can be used to facilitate removal of the paste—the skin shouldn’t be scrubbed to remove the paste. Two more important factors to prevent skin breakdown are adequate hydration and nutrition. Several factors can affect skin hydration: humidity, removal of sebum, and age. Application of emollients to the skin replaces lost sebum and water when humidity is low. The daily application of moisturizing lotions has been found to be advantageous.2 Adequate nutrition at the end of life isn’t always attainable. So, providing small frequent meals or nutritional protein supplements when possible may aid in avoiding skin breakdown.13
Appropriate wound care is based on the needs and healthcare goals of the patient and family and can often lead to improved outcomes even in advanced cases. The goals of palliative wound care are preventing complications and relieving symptoms in order to maintain the patient’s comfort and preserve dignity, self-esteem, and quality of life. ■ REFERENCES 1. World Health Organization. Cancer Pain Relief: With a Guide to Opioid Availability. 2nd ed. Geneva, Switzerland: World Health Organization; 1996. 2. Bryant R, Dix D. Acute and Chronic Wounds: Current Management Concepts. 4th ed. St. Louis, MO: Mosby, Inc.; 2012:505-513. 3. Alexander S. Malignant fungating wounds: key symptoms and psychosocial issues. J Wound Care. 2009;18(8):325-329. 4. AstriGyn. Prescribing information. 2004. http:// www.coopersurgical.com/Documents/33961-DFU. pdf. 5. Hess CT. Clinical Guide to Skin and Wound Care. 7th ed. Philadelphia, PA: Lippincott, Williams & Wilkins; 2012. 6. Harris DG, Noble SI. Management of terminal hemorrhage in patients with advanced cancer: a systematic literature review. J Pain Symptom Manage. 2009;38(6):913-927. 7. Emanuel L, Librach S. Lawrence Palliative Care: Core Skills and Clinical Competencies. 2nd ed. St Louis, Mo: Elsevier; 2011. 8. Woo KY, Sibbald RG. Local wound care for malignant and palliative wounds. Adv Skin Wound Care. 2010;23(9):417-428. 9. National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. Prevention and Treatment of Pressure Ulcers: Clinical Guidelines. Washington, DC: National Pressure Ulcer Advisory Panel; 2009. 10. Alavi A, Woo K, Sibbald RG. Common nail disorders and fungal infections. Adv Skin Wound Care. 2007;20(6):346-359. 11. Seaman S. Management of malignant fungating wounds in advanced cancer. Semin Oncol Nurs. 2006; 22(3):185-193. 12. Woo KY. Meeting the challenges of woundassociated pain: anticipatory pain, anxiety, stress, and wound healing. Ostomy Wound Manage. 2008;54(9):10-12. 13. Langemo D. General principles and approaches to wound prevention and care at end of life: an overview. Ostomy Wound Manage. 2012;58(5):24-34. 14. Stephen Haynes J. An overview of caring for those with palliative wounds. Br J Community Nurs. 2008;13(12):S24, S26, S28, passim. At the Decker School of Nursing in Binghampton, N.Y., Rita C. Bergevin is a clinical associate professor. The author has disclosed that she has no financial relationships related to this article. DOI-10.1097/01.NURSE.0000451541.13898.fb
August l Nursing2014 l 69
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
