By Mark Vance, RN WCC

Challenges in Wound Care at End of Life

Non-healing woundsEscharOdorCaregiver supportEnvironmentNutrition and hydrationSupply management and understanding of

productsComorbidities

What Are the Challenges?

Assessment of Wound1. Location, type, and cause of wound2. Drainage3. Wound base4. Staging of wound, or determining partial

thickness vs. full thickness5. Surrounding skin6. Odor7. Pain

Building a Plan to Meet These Challenges

Assessment of Client and Caregiver Wishes1. What does client want? Aggressive care vs.

conservative care2. What are caregivers able to do in helping

hospice nurses and patient?3. What are caregivers willing to do?4. What type of environment are you dealing

with?5. What resources do you have?

Building a Plan to Meet Challenges

Assessment of Wound Potential for Healing

1. What time frame does client have? Days, weeks, or months?

2. Severity of wound, to include size of wound, type of wound, slough and eschar in wound.

3. Patient wants vs. needs 4. Available supplies

Building a Plan to Meet Challenges

Patient Centered Goals

1. Build trust and rapport with patient2. Understand impact of wound to patient and

caregivers3. Education on wound healing or decline and

outcome of wound4. Negotiate treatment plan, what works for

patient vs. best practice

Building a Plan to Meet Challenges

Types of Wounds and How They Develop Pressure ulcers caused by improper turning,

poor nutrition, less than ideal support surface Surgical wounds typically caused by infection,

poor nutrition, fragile skin Tumors caused by cancer Skin tears typically caused by falls or bumping

into furniture. Stasis ulcers caused by venous or arterial

insufficiency Radiation burns caused by radiation therapy

Understanding Wounds

1. Hemostasis: coagulation, clot formation, release growth factors

2. Inflammatory phase: leakage of plasma, neutrophils and macrophages

3. Proliferative phase: reformation of tissue4. Maturation phase: can take up to 1 year to

complete.

Phases of Wound Healing

Acute wounds are defined as disruptions in the integrity of the skin and underlying tissues that progress through the healing process in a timely and uneventful manner. The acute surgical wound is an example of a healthy wound in which healing can be maximized.

A chronic wound is a wound that does not heal in an orderly set of stages and in a predictable amount of time the way most wounds do; wounds that do not heal within three months are often considered chronic. Chronic wounds seem to be detained in one or more of the phases of wound healing.

Acute Wounds and Chronic Wounds

Type of wound and location Measurements to include length, width,

depth and tunneling or undermining Wound base; type of tissue, include

percentages Wound drainage and odor Periwound Age of wound Ability of wound to heal Nutrition

Wound Assessment

Build goals for careFind appropriate care for woundsMeet client and caregiver needs and wantsProvide comfort and supportFocus on managing vs. healing wound

So Now What Do We Do?

Wound Product Categories

Transparent Film

Hydrocolloid

Hydrogel

Calcium Alginate

Hydrofiber; Aquacel

Collagen

Foam

Antimicrobial dressings

Gauze

Transparent Film(Tegaderm)

Description: Polyurethane with porous adhesive layer

Indications:Primary &

Secondary dressingStage 1 & II ulcersNon-draining

Advantages:Ready wound

inspectionWater tightPrevents or reduces

frictionChange every 5-7

days Disadvantages:

Non-absorptiveMay adhere to woundNon-absorptive

Hydrocolloid(Duoderm CGF)

Description: Hydrophilic colloid particles bound to polyurethane foam

Indications:Stage I to IV ulcersPartial & full thicknessNecrotic woundsPreventive for high-

risk friction areasSecondary dressing or

under taping procedures

Advantages:Facilitate autolytic

debridementImpermeableConformableAbsorptive, minimal

to moderate drainageDisadvantages:

May be hard to remove

Shears off easilyNot recommended

for heavy drainage

Hydrogel(Curasol/wound gel)

Description: Water or glycerin based sheet or gel. Available with silver (SilvaSorb Gel)

Indications:Stage II to IV ulcersPartial & full

thicknessPainful woundsRadiation-damaged

tissueDermabrasion

Advantages:Non-adherentRehydrates wound bedReduces wound painCan use with topical

medsDisadvantages:

May require secondary dressing

Surrounding skin maceration

Not for heavy drainage

Calcium Alginate(Curasorb/Sorbsan)

Description: Nonwoven composite of fibers from calcium-sodium alginate (seaweed)

Indications:Partial & full

thickness Moderate to heavy

drainageStage III or IV ulcersDehisced woundsSinus tracts, tunnels,

or cavitiesInfected wounds

Advantages:Absorbent &

nonocclusiveTrauma-free removalUse with infected

woundsReduces change

frequencySheets & ropes

availableDisadvantages:

Not with dry eschar, burns, heavy bleeding

Need secondary dressing

May produce odorPossible bed damage

Hydrofiber(Aquacel)

Description: Sodium carboxymethylcellulose that interacts with wound exudate. Also in silver

Indications:Partial to full-

thicknessModerate to heavy

drainageDonor sitesDehisced woundsStage III to IV ulcersSinus tracts, tunnels,

or cavities

Advantages:Highly absorptiveTrauma-free removal

Disadvantages:Not with dry eschar,

non-exudating wounds, 3rd degree burns, or heavy bleeding

Requires secondary dressing to secure

Composites(All dress, viasorb, stratasorb)

Description: Combination of 2 distinct products made as a single dressing; may include absorptive layer, foam, hydrocolloid.

Indications:Partial to full thicknessStage I to IV ulcersMinimal to heavy

drainageSurgical incisions

Advantages:Facilitates autolytic

debridementConformableMultiples shapes and

sizesEasy to apply and removeMost have adhesive

borderDisadvantages:

Adhesive border may limit use on fragile skin

Wound damage if not properly used & monitored

Collagen(Fibercol, Promogran matrix, Silver Prisma

matrix)

Description: Major body protein; stimulates cellular migration & contributes to new tissue development & wound debridement

Indications:Partial and full

thicknessStage III & some IV

ulcersDermal ulcersDonor sitesSurgical wounds

Advantages:Absorbent, nonadherentForms biodegradable gelConforms wellUse with topical agentsChange every 1-3 daysUse for minor slough

Disadvantages:Not for 3rd degree burnsNot for necrotic woundsNeeds secondary dressing

Foams

Description: A hydrophilic, polyurethane film coated foam, non occlusive nonadherent absorptive

Indications:Partial to full

thicknessMinimal to heavy

drainageStage II to IV ulcersSurgical woundsUlcersInfected & non

infected wounds

Advantages:NonadherentTrauma-free removalAbsorbs min to heavy Easy to apply and

removeChange every 3-5

daysDisadvantages:

Not for non-draining or dry eschar

Second dressing to secure

May macerate surrounding skin if not changed

Silver DressingsDescription: Immediate and

sustained release of ionic silver; effective barrier to bacterial penetration

Indications:All wounds except: Stage

I ulcer, 3rd degree burns, and non-draining

Infected woundsHighly colonized woundsOver grafts or skin

substitutesUnder compression

AdvantagesInhibits growth of

bacteria, especially antibiotic-resistant strains

Effective up to 7 daysDisadvantages

Secondary dressing required

Incompatible with oil-based products

Possible sensitivity to silver

Hydrofera Blue

Iodoflex and iodosorb

Charcoal dressings

Wound fillers

Various tapes and ways to secure dressings

Specialty Dressings

If wound is too moist, then soak up drainage. If wound is too dry, then moisturize it. Use the right product for the right wound.Meet patient’s needs, not your own.

Basic Premise of Wound Care

Now let’s look at some pictures and decide on

wound care.

Arterial/Diabetic

Arterial Wounds

Necrotic/ Unstageable

Necrotic/Unstageable

Necrotic/Unstageable

Stage 3 Pressure Ulcer

Stage 4 Pressure Ulcer

Venous Leg Wound

Diabetic Foot Wound

Stage 2 Pressure Ulcer

Stage 2 Pressure Ulcer

Necrotic Eschar Wound

Any Questions????

References

Bryant, Ruth A., and Denise P. Nix. Acute & Chronic Wounds: Current Management Concepts. St. Louis, MO: Elsevier/Mosby, 2012. Print.

Collier, Kyna Setsor, Bridget McCrate Protus, Connie L. Bohn, and Jason M. Kimbrel. Wound Care at End of Life: A Guide for Hospice Professionals. Montgomery: HospiScript Sevices, 2013. Print.

Morgan, Nancy, and Donna Sardina. Skin and Wound Mangement Course: Seminar Workbook. Stevensville: Wound Care Education Institute, 2012. Print.