Wound Care in Hospice Settings
Mar 24, 2021
Email US
Click to Email Us
Even in the final stages of life, good wound care can contribute to physical, psychological and emotional comfort. Wounds can generate feelings of fear, aversion and suspicion of neglect. Poor wound careor lack of wound carecan be devastating to the patient and familys experience of death.
Pressure Ulcers in Hospice Patients
Pressure ulcers (bedsores) occur in more than 40 percent of hospice patients. Even with aggressive preventive measures, critically ill patients experience compromised healing response due to impacted muscle cell and immune function, among other factors. For these patients, pressure ulcer formation may be a visual biomarker that the critical illness has overwhelmed the body; skin breakdown is neither preventable nor treatable.
Family members of terminally ill patients may view pressure ulcer formation as a failure on the part of the healthcare staff caring for the patientor even as their own failing, if they are responsible for providing care. Their emotional response may lead to requests that compromise the patients comfort-focused plan of care.
However, in general, prevention and treatment should not compromise the hospice philosophy of providing comfort care. Studies show that when patients are more comfortable in one position due to advanced illness, comfort should supersede preventive measures. If hospice staff deem that routine patient turnings contribute to increased pain, turnings may be suspended.
Other Wounds Common in Hospice
Due to the wide variety of patients and conditions treated in hospice care, you may encounter an equally wide variety of wound types:
Arterial insufficiencyOften appears as ulcers with black eschar on the lower leg and foot. The skin surrounding the wound appears to be very thin, shiny and usually hairless. The foot may feel cold and appear dusky red or pale.
Diabetic ulcersTypically on the plantar surface of the foot and the second metatarsal head. They are usually painless.
Venous ulcersOccur in the so-called gaiter area, halfway up the calf and down to just below the ankle. The skin likely feels itchy and appears mottled brown or has black staining and may appear crusty. The legs may become painful with sitting.
Tumors or fungating lesionsOccur most often in cancer of the breast, but may occur with other types of cancers, including head and neck, malignant melanomas and sarcomas. The lesion may be a small crusted area or a large ulcerated area with profuse exudate and capillary bleeding. They are often disfiguring, distressing and isolating. Odor and exudate management may be a particular problem in this type of wound.
Risk Factor Assessment and Prevention
Risk assessment upon admission is crucial and must include a full body check. Pressure ulcers are caused by intrinsic and extrinsic factors, including immobilization, cognitive deficit, inability to verbalize discomfort or numbness, chronic illness, aging and poor nutrition.
Once risk factors are established, preventing wounds from occurring is the best practice. Prevention measures include, but are not limited to, inspecting the skin and monitoring for proper moisture control. Proper positioning, transfer techniques and nutrition are essential for the comfort of the patient.
Avoid pressure on the heels and bony prominences of the body, and use positioning devices whenever feasible. As always, remember to document the condition of the skin after assessment.
Staging Wounds
The following wound stages are established by the National Pressure Advisory Panel:
Stage IThe skin is intact with non-blanchable redness of a localized area. Darkly pigmented skin may not have visible blanching, but its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue.
Stage IILook for partial-thickness loss of dermis presenting as a shiny or dry shallow open ulcer with a pink wound bed, without slough or bruising. It may also present as an intact or ruptured serum-filled blister. Stage II does not describe skin tears, tape burns, perineal dermatitis, maceration or excoriation.
Stage IIIIndicates full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of the tissue loss. There may be undermining and tunneling. The depth of a stage-III pressure ulcer varies by anatomical location.
Stage IVFull-thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. This wound often includes undermining and tunneling. The depth of a stage-IV pressure ulcer varies by location. Stage-IV ulcers can extend into muscle and/or supporting structures, making osteomyelitis possible.
Deep-Tissue InjuryA purple or maroon localized area of discolored intact skin, or a blood-filled blister due to damage of the underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.
UnstageableFull-thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined.
Basic Principles of Wound Care
The first step in determining a successful wound plan of care involves establishing the patients prognosis, condition and potential for wound healing. For instance, a less aggressive approach will be necessary for someone in the final days of life, or when it is evident that healing is not realistic.
Its important to set appropriate goals based on the prognosis, condition and potential for healing. Goals for hospice patients may include:
Preventing complications of the wound, such as infection or odor
Preventing additional breakdown of the skin
Minimizing harmful effects of the wound on the patients overall condition
When developing a care plan for a patient, it is important to factor in their status and desires. Interventions should be re-evaluated every two weeks to determine whether the plan is still appropriate. A wounds failure to heal does not necessarily imply that other measures are more appropriate, or that all possible approaches should be attempted. Instead, focus on developing the best option for the patient based on their present condition and their desires.
A basic wound care plan will incorporate these elements:
Cleansing debris from the wound
Possible debridement
Absorbing excess exudate
Promoting healing
Treating infection
Minimizing discomfort
In hospice care, the pain, appearance, odor and perceived implications of wounds can be incredibly distressful for the patient and family. To stay in alignment with hospices mission of comfort care, the entire hospice team must operate with vigilance, assessing and documenting wounds and condition changes in detail, maintaining proper preventive measures and developing plans of care that consider the patients needs and desires.
By reducing the occurrence and severity of wounds and mitigating their effects, the hospice team contributes to quality of life and facilitates a peaceful death experience for both patient and family.
Submitted and Written By: Vitas Healthcare - click here for more information
Other Articles You May Like
The Respiratory System: Age-Related Changes & COPD
The respiratory system, like many of the other human systems (e.g., cardiovascular, digestive), is a wondrously complex and sophisticated arrangement of organs working together to maintain homeostasis.Contact an Office in Your AreaChronic obstructive pulmonary disease, more commonly referred to as COPD, is a health problem facing adults in the U.S. Because of its progressive nature and increased age as a leading factor, there is a greater prevalence of COPD in seniors. The good news is that many adults can easily reduce their risk of COPD through lifestyle management. COPD represents a group of lung diseases, with the two most common being emphysema and chronic bronchitis.Symptoms of COPD includeConstant coughingWheezingShortness of breathCoughing up mucusTightness in the chestResearch also suggests that there may be a link between poor air quality and COPD. The American Lung Association estimates that between 80-90% of COPD cases result from smoking. Unsurprisingly, secondhand smoke is a significant risk factor as well. Seniors should take the following steps to reduce their risk of COPD:Older adults that smoke should get support from a primary care physician and take steps to quit. There are many programs, services, and products that can help.Seniors should avoid contact with secondhand smoke whenever possible.Reducing exposure to air pollution can help relieve symptoms. Many cities issue poor air quality warnings when these warnings are in effect, seniors should limit outside activities. Seniors should avoid airborne irritants (chemicals, fumes, etc.) in the home.A healthy diet and exercise plan can improve lung function and overall health with direction from a physician.Older adults should understand the impact of aging on their respiratory system and reduce their risk of any related diseases, illnesses, or conditions.Doctors may recommend getting vaccinations for both influenza and pneumococcal pneumonia to guard against further breathing complications.Comfort Keepers Can HelpComfort Keepers elevates the human spirit for todays seniors and their families through a unique, individualized approach to care that helps seniors thrive and achieve greater wellbeing by fostering everyday positive moments, connection, and a more purposeful life no matter their age or acuity. As part of a healthcare team, an in-home caregiver can assist with activities that slow disease progression or reduce the risk for those with respiratory issues. Comfort Keepers caregivers can help by supporting physician-recommended health programs, preparing meals, encouraging prescribed physical activity, reminding seniors to take medications, and providing transportation to scheduled appointments. References:Healthline. Everything You Need to Know About Chronic Obstructive Pulmonary Disease (COPD). Web. 2018.Everyday Health. 5 Best Ways to Prevent COPD by Chris Iliades, MD. Web. 2018.Aging Care. An Overview of COPD by National Institutes of Health. Web. 2017.Unity Point Health. The Top 8 Respiratory Illnesses and Diseases. Web. 2014.American Lung Association. Lung Capacity and Aging. Web. 2017.Centers for Disease Control and Prevention. Chronic Respiratory Disease. Web. 2017.
Physical Activity for Senior Care
As seniors age, physical activities can have not only positive physical effects, but positive cognitive effects as well.Contact an Office in Your AreaIn one study, 100 nursing-home residents performed resistance exercises three times a week for 10 weeks. At the end, the exercise group could lift significantly more weight, climb more stairs, and walk faster and farther than their sedentary counterparts.Its been proven time and again that exercise is good for seniors physical and mental health. Regular exercise, even in small amounts, can improve mood, relieve stress and improve health. According to the CDC, four of the five most expensive health conditions older adults face can be prevented or managed with physical activity. But, only about 35% of adults over the age of 65 are physically active. Any senior starting a new exercise plan should consult with their physician. And, it is helpful for family and members of the care team to assist and support physical activity in any way they can. For those that are physically able to begin an exercise program, regular movement can help them live a more vibrant and healthy life. Some of the health benefits include:Improved mental health, mood and outlookPrevention, or improvement of, diseases such as diabetes, obesity, heart disease, and osteoporosisReduced pain from arthritis and minimizing its severityDecreased risk of fallsEach individual has different needs when it comes to exercise and varying health conditions that may need to be taken into consideration before beginning an exercise regimen. A health professional to determine the best approach to physical activity with senior care.There are a variety of ways to incorporate aerobic activity, strength-building exercises, stretching and balance all without leaving the comfort of home! Aerobic exercise Walking in place, dancing or aerobic routines can help get the heart rate up. These activities improve cardiovascular health and help older adults maintain a healthy weight. Strength building exercises there are many easy strength-building exercises that can help seniors build the muscles they need to do everyday activities and prevent muscle loss. And, exercises can be done with household items or using body weight, so no expensive equipment is required. Stretching Stretching before and after exercise can help prevent soreness after exercise. And, the additional benefit is improved flexibility, which is good for older adults physical health. For those looking to improve their flexibility even more, there are exercise routines available online that include yoga or stretching routines specifically for seniors.Balance exercises Balance exercises help seniors prevent falls and improve mobility. Yoga, tai chi, and other low-impact activities can all help improve balance and overall physical health.Those that need a little assistance getting started should not hesitate to reach out to their doctor, family or caregiver. It is never too late to adopt an active lifestyle! Comfort Keepers Can HelpFor seniors that need a little extra help living an active lifestyle, Comfort Keepers caregivers can help with encouragement, support and assistance with physician-prescribed exercise plans. And, caregivers can encourage overall health through meal planning, grocery shopping, meal preparation and activities. Our custom care plans focus on physical and mental health and wellness activities. Our goal is to see that clients have the means to find the joy and happiness in each day, regardless of age or acuity.To learn more about our in-home care services, contact your local Comfort Keepers location today. ReferencesCenters for Disease Control and Prevention. Adults Need More Physical Activity. Web. 2019.Health and Human Services. Facts & Statistics: Physical Activity. Web. 2017.National Council on Aging. Exercise Programs That Promote Senior Fitness. Web.Readers Digest Canada, 5 of the Best Exercises for Seniors to Build Strength, Improve Balance and Boost Heart Health. Web. Harvard Health Publishing. Exercise after age 70. Web. 2007.
Adapting Homes to Seniors' Changing Needs
More Americans are choosing to age in place. That is, they opt to stay in their homes rather than move to alternative retirement settings.But that often means they must modify their home, so it's not a danger to their safety and health when their physical abilities change.A new career field has risen to address this need: the Certified Aging-in-Place Specialist (CAPS), a program of the National Association of Home Builders. Certified individuals assess homes to identify and recommend modifications to prevent injuries from falls and other risks.According to the Centers for Disease Control (CDC), one-third of Americans age 65 and over fall each year. The CDC adds that environmental factors lead to about half of all falls that occur at home. In addition to tripping hazards and poor lighting, these factors include a lack of needed modifications, such as bathroom grab bars, handicapped showers, stair railings and ramps. The organization offers a checklist to make sure an older adult's home is as safe as possible.Home modifications help seniors maintain quality of life. They often prevent injuries that lead to a loss of independence and early admission to an assisted living or long-term care facility.The following are examples of commonly recommended modifications:Install grab bars for toilets and tubs and install a walk-in tub and/or tub seatRemove unnecessary throw rugs and fasten down rugs or floor runners to prevent slippingMove furniture to create clear walking pathsKeep objects off the floor and coil or secure cords to the wall to prevent trippingReplace doorknobs with lever door handlesApply non-slip tape on uncarpeted indoor and outdoor stepsReplace standard light switches with rocker-style switchesIncrease the width of doorways and hallways to accommodate wheelchairs and, where possible, lower sinks and countertopsMove often-used items to lower cabinets to avoid the need for step stoolsRepair or replace loose handrails and install adequate lighting in stairwaysInstall an elevator or chair liftInstall an elevated dishwasher or one with drawers for easy accessReplace old stoves with induction cooktops to help prevent burnsReplace ceramic tile floors with hardwood or vinyl for safe standingShedding Light on Home ModificationWhen modifying a home for a senior, don't forget the importance of good lighting. Seniors need two to three times as much light in order to see as well as younger people.Good lighting -- in the form of natural light -- provides seniors safety and other advantages:Sunlight provides a good dose of vitamin D, which helps the body absorb more calcium to strengthen teeth and bones. Choose window treatments that let in sunlight, without glare, to enhance the health of seniors, many of who get outside less than they used to.Daylight also improves psychological health. It lessens the energy-zapping effects of Seasonal Affective Disorder (SAD) and other forms of depression.