10.1 (11.1) Skin problems in palliative care

Question 1

What are three goals of wound management in PC

Answer 1

◆ management of underlying CAUSE of the wound

◆ management of the wound and peri-wound SKIN (TIME)

◆ management of wound-related ISSUES (DOPPI: discharge, odour, Pruritus, pain, infection)

Question 2

Name 3 types of wounds with potential for complete healing

Name 3 that have not shown healing outcomes

Answer 2

Healing:
1. Pressure ulcers grade I/II
2. Diabetic and venous ulcers
3. Skin tears

Likely to be non-healing:
1. Deep pressure ulcers
2. Arterial wounds
3. Malignant wounds

Question 3

Name 3 non-medical consequences for patients living with wounds

Answer 3

1. Wound exudate/odour leads to loss of self-confidence
2. QOL
3. Social isolation

Question 4

List four types of wounds that people in palliative care might experience.

Answer 4

◆ pressure ulcers*
◆ moisture lesions
◆ skin tears*
◆ dry irritated skin*
◆ malignant fungating wounds*
◆ fistulae*
◆ blistering skin conditions, for example, epidermolysis bullosa, bullous pemphigoid.

Question 5

List four common symptoms/issues associated with wounds that need to be managed

Answer 5

management of odour, exudate, bleeding, pain, and the maintenance of an intact dressing system

FA: doppi
Discharge - including bleeding
Odor
Pruritus
Pain
Infection

Question 6

List three wound assessment scales*

Answer 6

1. Toronto Symptom Assessment System for Wounds
2. the Schulz Malignant Fungating Wound Assessment Tool
3. the Wound Symptoms Self-Assessment Chart (WOSSAC)
4. the TELER System
5. Hopkins Wound Assessment Tool

Question 7

Wound assessment tools assess what core five symptoms

Answer 7

odour, pain, bleeding, exudate, itching

FS: DOPPI

Question 8

List four general factors that contribute to skin weakness in advanced illness

Answer 8

1. Performance status
2. ageing (sarcopenia)
3. Chronic disease and multiple co-morbidities
4. iatrogenic (i.e. systemic glucocorticoid use)

Question 9

List four basic actions of good skin care

Answer 9

Good skin care aims to maintain and replenish the skin by:
1. cleansing (soap/water can be drying)
2. moisturizing (lotion»ointment)
3. protecting (barrier products)
4. Hydrating

Question 10

List four general principles of management of pressure ulcers

Answer 10

Treat cause:
◆ pressure relief and management of any friction or shear forces
◆ continence and fistula management

Treat symptoms:
◆ good skin care

Treat complications:
◆ wound complication management (DOPPI)

Question 11

List three practical tools for preventing skin damage from urine and stool

Answer 11

disposable pads

close fitting underwear, self seal nappies

urinary catheter

anal or stoma bag

fecal management systems (tube inserted into rectum and drains into bag)

Question 12

List 4 pathomechanisms of fungating malignant wounds

Answer 12

A combination of:
1. Tumour growth
2. Anaerobic bacteria growth due to hypoxia -> infection
2. Loss of local blood supply
3. Loss of tissue viability

Question 13

What is the rationale for WBP (wound bed preparation)

List the 4 components of WBP via the TIME acronym

Answer 13

If healing is the goal, wound bed needs to be free of bacteria and harmful enzymes. If palliation is the goal, same approach reduces odour, exudate, damage to peri-would skin. (FS: manage DOPPI)

“TIME”
1. Tissue management
2. Infection and inflammation management
3. Moisture balance
4. Edge of wound (how this advances inward to cover broken area)

Question 14

List four types of wound debridement (and example) that can be used to remove necrotic tissue from a wound

Answer 14

Autolytic debridement: hydrogel dressings

Biological debridement: larval therapy

Chemical debridement: iodine, medical grade honey

Surgical and sharp (doctor) debridement: scalpel, scissors, forceps by trained tissue viability nurse or surgeon

Enzymatic debridement: collagenase agents

Mechanical debridement: ultrasound and water irrigation devices

FS: ABCDE + M

Question 15

List three circumstances when scab formation is preferred to wound healing (scab formation is encouraged with astringents such as potassium permanganate)

Answer 15

head and neck wound

life expectant short

multiple wounds over body

Question 16

List 4 options for management of wound exudate

Answer 16

1. Electrochemotherapy
2. Skin barriers*
3. Hydrocolloids*
4. 2 layer permeable vented dressings
5. Drainage bags*
6. Negative pressure therapy*

Question 17

List four interventions to treat underlying causes of malignant fungating wounds

Answer 17

surgery
radiotherapy
Chemo or immunotherapy
photodynamic therapy

Question 18

List three contributors to wound exudate

Answer 18

Dead tissue - exudate production is also attributed to bacterial enzymes (proteases) and their role in the autolytic processes of tissue breakdown and liquefaction

local oedema

lymphoedema

Question 19

List two contributors to wound odor

Answer 19

bacteria

dead tissue

Question 20

Beside use of medications, list 2 methods for managing cutaneous pruritic irritation from wounds

Answer 20

1. Transcutaneous electrical nerve stimulation (TENS)
2. Select personal clothing/bed linen that wicks away heat and moisture

Question 21

List four methods of managing wound odor

Answer 21

Tx odor:
- topical: metronidazole, charcoal, aloe vera, and honey
- silver dressing

Tx source:
- debride dead tissue
- systemic abx (less desirable due to abx resistance, side effects, or ineffective if lack of blood supply to wound)

Question 22

Managing minor bleeding from a fungating wound:

• list 3 dressing management
• list 3 procedures
• list 3 medications

Answer 22

Dressing management 
◆ dressing application (decrease frequency) and removal techniques (wet dressing with NS before removal)
◆ maintenance of humidity at the wound/dressing interface
◆ cleaning techniques (gentle wound cleaning)

Procedures: 
- cautery  (Gen surg)
- radiotherapy (rad)
- electrochemotherapy 
- Surgical haemostatic sponges 

Medications: 
- apply adrenaline 1:1000 
- Sucralfate suspension
- Oral and topical TXA
- Glue embolization

Question 23

List three roles of dressings in the management of wound infection

Answer 23

◆ to contain the infection and prevent contamination to and from the wound
◆ to keep anti-microbial agents in contact with the wound
◆ to contain exudate and odour

FS: DOI of DOPPI

Question 24

List three types of tissue you might encounter in a wound

Answer 24

Necrotic tissue - debride

Granulation tissue - protect and promote

Epithelializing tissue - protect