Palliative Care of Pressure Ulcers in Long-Term Care: Page 3 of 3
Malodor and Exudate
Wound odor and heavy exudates can distress patients by causing embarrassment, depression, and social isolation, leading to a poor quality of life. Odor can be controlled by properly cleaning the wound, appropriately disposing of the used dressings, adequately debriding necrotic tissue, and using antibiotic therapy and specific dressings. Topical metronidazole has been shown to be effective in reducing odor by eradicating anaerobes.7,42 Topical metronidazole gel (0.75%-0.80%) may be used directly on the wound once per day for 5 to 7 days or more often as needed, and metronidazole tablets can be crushed and placed onto the ulcer bed.2 When the primary goal is to control exudate, with a secondary goal of controlling odor, a proper dressing must be chosen that will not dry out the ulcer bed.13 Activated charcoal dressings applied to wounds significantly control odor but only if the dressing is fit as a sealed unit and if the wound is kept dry.42 There are currently no studies that assess the odor-absorbing capacity of activated charcoal dressings for pressure ulcers,20 but in other care settings, these dressings have been shown to control odor and to remove fluids and toxins that can impair healing. One randomized control trial of 120 patients showed that activated charcoal dressings were better tolerated than the hydrocolloid dressings used in a control group, even though outcomes were similar between groups.43 Healthcare providers should also be sensitive to patients who may be experiencing embarrassment or discomfort due to malodor by using other external odor-control methods, such as placing a pan of clay cat litter under the bed to absorb odors or using a jar of vinegar or coffee beans or a vanilla-scented candle to mask malodor.36
In addition to odor, if wound exudate is not controlled, it can lead to maceration, breakdown, and itching. It is important to control or eliminate wound exudates by matching dressings to the amount of exudate12; therefore, the healthcare provider should communicate with the patient in finding the appropriate comfortable dressing with maximum benefit for palliative management of the wound.13 Further, as Draper42 concluded in a comprehensive review, the development of new dressings and techniques for controlling malodor and exudate, particularly in fungating wounds, is greatly needed.
Open wounds are at risk of bacterial infection, which can delay healing and lead to other potential complications.13 Traditional signs of infection (eg, pain, erythema, edema) may be absent; thus, care providers should be alert to other signs of infection, such as serous exudate, delayed healing, discoloration of granulation tissue, malodor, wound breakdown, fever, and elevated white blood cell count.44,45 Superficial bacterial colonization of wounds is universal, and all pressure ulcers contain bacteria, but concern is warranted when the colony level reaches 105 or 106 organisms per gram.45 Experts agree that swab cultures on the wound surface should not be performed because they typically do not reflect the cause of infection.45 Rather, a more targeted laboratory work-up can help clinicians make a more accurate diagnosis, ensuring optimum treatment of infected open wounds. Testing may include swabbing for deep pus, a tissue biopsy, or a blood culture.46
Oral antibiotics, topical sulfa silverdiazine, and silver-impregnated dressings are used frequently in wound care and have all demonstrated varying degrees of efficacy in reducing bacterial burden in pressure ulcers.36,45 Due to the emergence of antibiotic resistance, the use of honey has come back into practice for the management of wounds. In a 5-week randomized clinical trial, 26 patients (total of 50 pressure ulcers at stage II or III) were treated either with honey dressing or with ethoxy-diaminoacridine plus nitrofurazone. The researchers found that the honey dressing healed pressure ulcers at approximately four times the rate of healing in the comparison group.47
Pressure ulcers can often be painful, especially in more advanced stages. In a systematic review of the literature, Gorecki and colleagues48 identified 15 studies that addressed the impact of pain on quality of life in older patients, and they concluded that pain was the most significant consequence of having a pressure ulcer and that it affected every aspect of patients’ lives. Proper pain assessment is vital to understanding its etiology.13 If pain is predictable, such as the pain associated with a debridement procedure or dressing change, it may be admissible to administer an opioid before the procedure.44 However, because pressure ulcer pain often does not respond well to systemic pain medications, localized pain management tends to be more effective and better tolerated by patients.
One randomized double-blind pilot study set out to determine the effectiveness of topical diamorphine gel on pressure ulcer pain in hospice patients.49 Pain scores improved significantly with the use of diamorphine gel over the placebo, leading to the conclusion that diamorphine gel appears to be an effective option in controlling pressure ulcer pain in palliative care patients; however, a larger study is needed to confirm these results and to assess for side effects.
A literature review by De Laat and colleagues20 led the authors to support local pain relief for patients with pressure ulcers. They found that the use of a eutectic mixture of local anesthetic cream, which consists of lidocaine and prilocaine in an oil-in-water emulsion, was effective in reducing pain caused by chronic wounds. However, lidocaine-prilocaine cream is indicated for local analgesia for normal, intact skin and has not been well studied in older adults, particularly in those with open wounds; therefore, this is an area where further clinical trials may be warranted.50
Complementary therapies may reduce anxiety and detract attention from pain caused by wounds. A review by Naylor51 identified possible therapies, including relaxation, music, massage, aromatherapy, visualization, and guided imagery. Breathing techniques, television, music, or conversation may also create distraction during painful dressing changes. However, Naylor reported that these therapies tend to be underused, inappropriately administered, and lack scientific evidence to support their efficacy. Moreover, patients are more likely to initiate these therapies rather than the healthcare provider,51 suggesting that such techniques should not be overlooked, especially in the palliative care setting.
The psychosocial effects of pressure ulcer-related odor, exudate, and pain can be severe, leading to embarrassment, chronic tiredness, self-imposed social isolation, depression, and anxiety. The literature strongly supports the need for frequent assessment and intervention to manage these adverse social effects of pressure ulcers.13,19,21,44,45,48 The NPUAP and the AHPR recommend initial and routine psychosocial assessments that consist of consultation with individual patients and their families to discuss preferences, goals, and abilities; the objective of these discussions is to promote patient adherence to the pressure ulcer treatment plan.36,38 The psychosocial assessments may evaluate mental status, learning ability, depression, polypharmacy (ie, risk of overmedication), values, lifestyle, sexuality, and culture, among other factors. Once treatment goals are set in alignment with these domains, it is important to routinely follow up with patients and arrange interventions (ie, counseling, educational resources) as necessary.
Older adults and elders residing in LTC settings represent an especially vulnerable population in which poor nutrition, immobility, loss of cognitive function, and incontinence often lead to unavoidable pressure ulcers. The aims of palliative wound care in this population include stabilization of existing wounds and prevention of new wounds, if possible. A comprehensive assessment using a multidisciplinary and holistic approach that incorporates patients’ and their family’s preferences and values will lead to individualized treatment goals. When prevention is unsuccessful or unrealistic, symptomatic management of complications should be undertaken and strive to improve patient comfort, well-being, and quality of life. Healthcare providers would be well served by integrating palliative care goals as they assess, plan, and evaluate treatment of pressure ulcers in any care setting. Further evidence-based chronic wound care research is needed that supports quality of life and encourages partnerships with patients and their families.
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