Article Title: Pressure Injury Progression and Factors Associated With Different End-Points in a Home Palliative Care Setting: A Retrospective Chart Review Study
Authors: Artico M, D’Angelo D, Piredda M, et al
Journal: J Pain Symptom...
by Holly Hovan MSN, APRN-ACNS-BC, CWOCN-AP
As wound care clinicians, one of the first steps we take after meeting our patient and assessing their wound is identifying our treatment goals. Much like managing a complex medical problem, we need to identify if our goals of care are curative or palliative. This is important with all wounds, not just those present at end of life. There are many patients with vascular disease, diabetes, or other co-morbidities that may want to take a palliative approach versus aggressive debridement or amputation. You may have heard the term, “keeping it dry and stable.” This can work at times, but as with any wound, we need to keep an eye out for signs of an active infection and determine if/when we need to further intervene. Wounds can and do resolve with a palliative approach, but it is very important to understand, and explain to our patients, the difference.
What is Palliative Wound Care?
Palliative wound care focuses on comfort, dignity, managing pain, odor, preventing infection, and taking a holistic approach to managing the wound. Although prevention of pressure injuries is always a treatment goal, even at end of life, our treatment goals and focus change in a palliative setting. Treatment choices should be based on the wound presentation… think of products that can stay in place for more than a day, manage bioburden, control odor, and help with pain (this is especially important with application and removal of dressings). In addition to the actual product that goes on or into the wound, it is important to identify other variables which impact healing: seating surface (if appropriate), bed surface, repositioning tools and tools used to prevent friction and shearing (slings, wedges, pillows), offloading of heels (think floating, heel offloading boots, foam dressings, skin barrier film), hydrating skin (emollients), protecting skin from fecal or urinary incontinence (barrier creams), managing pain (before, during and after dressing changes) and nursing staff education on the expectations and goals of a palliative pressure injury prevention and treatment program.
It is important to remember that in addition to identifying a treatment that meets the patient’s needs, we need to continue routine pressure injury prevention measures as listed above, most importantly, routine turning (every 2 hours at minimum and as needed for comfort). Other variables that are important and can impact the success of a palliative wound program include regular assessment of the wounds and updating treatments as needed; this is done best with a team approach (nursing, management/leadership, physician, dietitian, occupational therapist/physical therapist as needed). A consistent team is helpful as they get to know the patients and their needs, and are able to adjust the plan of care accordingly. Occupational therapists and physical therapists are important resources who can help with seating assessments, braces, wedges, and products to offload difficult spots such as elbows and sometimes heels.
To recap palliative wound care objectives:
1. Identify the type of wound and treatment goals (palliative vs. curative)
2. Discuss treatment options with the interdisciplinary team and patient/caregiver
3. Implement a treatment based on the principles of palliative wound care discussed above
4. Frequent (at least weekly) rounding on patients and updating treatments as needed with input from the interdisciplinary team
5. Highly important: remember to continue routine pressure injury prevention measures such as offloading, turning, appropriate seating and bed surfaces, moisture management, prevention of friction and shear, etc.
6. Continued education to nursing staff regarding expectations and treatment goals
It is important to remember that palliative wound care does not mean we give up on the wound or that we don’t provide the best treatment possible. I have seen many palliative wounds resolve in the past and continue to see them resolve. On the other hand, there are palliative wounds that do not resolve, however, are well managed so that the patient is able to have the best quality of life possible without the wound having a huge impact on their quality of life.
Continued follow-up, assessment and re-assessment, and education of nurses is key to the success of a palliative wound treatment program. As the saying goes, “there’s always more than one way to treat a wound.” This definitely holds true in the discussion of palliative wound care; the goal is to find what works best for your patient.
In future blogs, I hope to more specifically discuss treatments, especially those aimed at controlling odor and managing pain.
About the Author
Holly is a board certified gerontological nurse and advanced practice wound, ostomy, and continence nurse coordinator at The Department of Veterans Affairs Medical Center in Cleveland, Ohio. She has a passion for education, teaching, and our veterans. Holly has been practicing in WOC nursing for approximately six years. She has much experience with the long-term care population and chronic wounds as well as pressure injuries, diabetic ulcers, venous and arterial wounds, surgical wounds, radiation dermatitis, and wounds requiring advanced wound therapy for healing. Holly enjoys teaching new nurses about wound care and, most importantly, pressure injury prevention. She enjoys working with each patient to come up with an individualized plan of care based on their needs and overall medical situation. She values the importance of taking an interprofessional approach with wound care and prevention overall, and involves each member of the health care team as much as possible. She also values the significance of the support of leadership within her facility and the overall impact of great teamwork for positive outcomes.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.