wound care for terminally ill patient

1、 Wound CareBest Practice GuidelinesVITAS Healthcare CorporationGoalTo educate healthcare professionals on effective wound care protocols, in order to ensure optimal care for our terminally ill patients.Objectives Identify preventative measures Describe risk factors contributing to skin impairment De

2、scribe the parameters of wound assessment including staging of wounds Describe wound types and tissues Describe care planning considerations and the selection of appropriate interventions Prevention Inspect skin Moisture control Proper positioning and transfer techniques Nutrition Avoid pressure on

3、heels and bony prominences Use of positioning devices Monitor and documentRisk Assessment Alterations in mobility Level of incontinence Nutritional status Alteration in sensation or response to discomfort Co-morbid conditions Medications that delay healing Decreased blood flow to lower extremities w

4、hen ulceration is presentContributing Factors1 Assessment and DocumentationLocationStage and SizePeriwound UnderminingTunnelingExudateColor of wound bedNecrotic TissueGranulation TissueEffectiveness of TreatmentAssessment and DocumentationWound and Risk Assessment every visitDocumentation on Wound A

5、ssessment Form every 7 days when 1 or more pressure ulcer existsPhysician assessment and documentation on Physician Wounds Care Assessment toolPressure Ulcer Staging2Care Planning.Overall strategy and scope of the treatment plan depends on patients condition, prognosis, and reversibility of the woun

6、d.Appropriate Goals Prevent complications or the deterioration of an existing wound Prevent additional skin breakdown Minimize harmful effects of the wound on the patients overall condition Promote wound healingInterventionsDressing considerations should include: Patients condition and prognosis Car

7、egiver ability Ease and continuity of use Ability to maintain moisture balance Frequency of change Pain Management1) Medicate the resident prior to dressing changes2) Some treatment regimes may be uncomfortable for the resident 3) Provide maintenance doses of medication for those patients who have p

8、ain. 4) Adjuvant therapy may be appropriate5) Consider non-medicinal approaches Types of Wounds3 Pressure Ulcers Arterial Insufficiency Diabetic Ulcers Venous Insufficiency Surgical Wounds Tumors Palliative Wound Care for the Imminent PatientThink: Comfort Quality of LifeTreatment Choices: Keep Curr

9、ent Treatment Irrigation, Cover with DuoDERM Thin or Bioclusive Dressing Irrigation, Silvadene, Cover with Gauze (if infection is suspected) Basic Elements of Wound Care Cleanse Debris from the Wound Possible Debridement Absorb Excess Exudate Promote Granulation and Epithelialization When Appropriat

10、e Possibly Treat Infections Minimize Discomfort Wet to Dry DressingsIndicated for Mechanical Debridement ONLY Causes Injury to New Tissue Growth Is Painful Predisposes Wound to Infection Becomes a Foreign Body Delays Healing Time Frequency Goal is to minimize the frequency of dressing change Daily d

11、ressing changes increase chances of infection and disrupts the healing of tissue Optimal wear time is 3-7 days Decrease Frequency of Dressing ChangesInterventions:Patients At-Risk or Stage I Assess “Risk for Breakdown” Utilize skin creams and lotions for dry skin Utilize barrier products as needed t

12、o minimize irritation from incontinence Reposition frequently Encourage fluids as tolerated and appropriate Use pillows in bed for positioningCleansing Wounds. Remove Wound Debris Sustain Moist Environment Soften Necrotic Tissue Debride the Wound Reduce the Risk of Bacterial Contamination and Infect

13、ion Reduce OdorGoals & Treatment Guidelines Dry to Minimal Exudate Moderate Exudate Copious ExudateInterventions Stage IGOALS:Maintain skin integritySkin to remain clean and odor freeProtect and moisturize skinTREATMENTS:Preferred agents (dry skin)Aloe Vesta skin creamPreferred agents (at risk f

14、or breakdown due to incontinence/pressure)Aloe Vesta protective ointmentDermarite Perigaurd barrier ointmentInterventions Stage II, III, IVDry to Minimal ExudateGOALS:Minimize dressing changesMaintain moist environmentPrevent infectionPrevent additional skin breakdownTREATMENTS:Preferred agents:Hydr

15、ofiber (Aquacel)ViscopasteHydrocolloid (DuoDERM Extra Thin)Follow product guidelines for frequency of dressing change InterventionsStage II, III, IVModerate ExudateGOALS:Minimize dressing changesMaintain moist environmentPrevent infectionPrevent additional skin breakdownTREATMENTS:Preferred Agents:H

16、ydrofiber (Aquacel)Hydrocolloid (DuoDERM Signal)Follow product guidelines for frequency of dressing changeInterventionsStage II, III, IVCopious ExudateGOALS:Minimize dressing changesManage ExudatePrevent infectionPrevent additional skin breakdownTREATMENTS:Preferred Agents:Hydrofiber (Aquacel)Hydroc

17、olloid (DuoDERM Signal)Follow product guidelines for frequency of dressing changeInterventionsNecrotic Tissue in Ulcer BedFungating LesionsInfected WoundsSkin TearsGangrenous WoundsDiabetic UlcersInterventionsNecrotic Tissue in Ulcer Bed Mechanical Debridement Autolytic Debridement Sharp or Surgical

18、 Debridement* Enzymatic or Biochemical Debridement* Biological Debridement*Requires ApprovalInterventionsNecrotic Tissue in Ulcer Bed Prior to debridement interventions, assess whether it will enhance wound healing or promote infection or cause undue pain. Do NOT institute aggressive debridement if

19、the patient is within days/week of death, or if the eschar is stable, dry, non-draining, and wound is not infected. For Intact black heel relieve pressure no dressing or debridement if opens then refer to necrotic treatments.InterventionsFungating LesionGoals:Removal of exudateOdor controlPain contr

20、olNon-Pharmacological measures to control odor include:Oil of WintergreenCharcoal briquettes or Coffee groundsDryer SheetsTreatments:Preferred AgentsNon-Adherent Gauze Dressing (Telfa)Zinc Oxide Paste (Viscopaste)Activated Charcoal Dressing (Carboflex)Atropine solution may be used to control bleedin

21、gMetrogel cream can be used to control odorInterventionsInfected WoundsDiagnosis of wound infection:Swab Cultures not recommendedBased on clinical signs (fever, increased pain, friable granulation tissue, foul odor)Tissue culture or biopsy is not optimal for the hospice patient.Treatments:Preferred

22、agents:Hydrofiber (Aquacel Ag)Silvadene ointment and non-sterile gauzeDO NOT USE:Providine IodineIodophorDakins solutionHydrogen peroxideAcetic AcidInterventionsSkin TearsGoals: Prevent infectionHealingPrevent further injuryMinimize dressing change frequency Treatments: Preferred Agents:Non-Sterile

23、Gauze Transparent Film (Opsite)InterventionsIschemic (Gangrenous) WoundsDraining wounds Cover with Telfa or gauze and wrap with KerlixNo drainage Cover with gauze and Kerlix Change QD and PRNVenous Stasis or Diabetic UlcersDraining wounds Cover with Telfa or Adaptic with a Kerlix wrap changed QD Cleanse with normal saline using bulb syringeNon-draining wounds Cover with gauze and wrap with Kerlix Apply tape to the Kerlix to prevent further injury to surrounding skin Change QD Support SurfacesComfort and Shea