Skin Care

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SG Pall eBook
SG Pall eBook
Nursing Care for the Palliative Care Patient
Skin Care

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Introduction

Patients receiving palliative care often face skin problems, as a result of advanced disease and declining physical state.
Nursing aspects consist of ensuring good skin care, preventing and managing skin breakdown and its associated symptoms, as well as addressing the psychosocial impact of wounds on patients and families.

Good Skin Care

The aim of good skin care is to maintain skin integrity through consistent care, coupled with skill and knowledge in the use of skin products:

Gentle skin cleansers (QV Gentle wash, Secura Moisturizing Cleanser, Conveen EasiCleanse) instead of soap which can cause dry skin
Moisturizers for dry skin
Barrier products (Cavilon, Conveen, Secura Protective Cream) to protect skin from excoriating body fluids

Wound Care

General wound classification & treatment

Necrotic (Black)/Sloughy (Yellow)	Infected (Green)
Aim: Debride/Rehydrate Consider autolytic debridement (hydrogels, hydrocolloids) or surgical/sharp debridement If debridement is not appropriate, protect peri‐wound area and leave exposed if dry or use simple dressing to protect	Aim: Debride/Treat infection/Manage odour/exudates Debride dead tissue that harbours bacteria Consider antimicrobial dressings For exudates: alginates, hydrofibers, foams For odour: antimicrobial dressings, odour‐control products
Granulating (Red)	Epithelializing (Pink)
Aim: Promote/Protect granulating tissue Semi-occlusive, non-gauze dressings: hydrocolloids, foams For bleeding: Alginates, hydrofibres	Aim: Protect epithelial tissue Low-adherent moisture conserving primary dressings: foams, hydrocolloids

Wound dressing types

Dressing Types & Products	Description
Films (e.g. Tegaderm, Opsite)	Provides transparent primary wound cover with a range of fluid‐handling capacities.
Non‐adherents (e.g. Primapore, Melolin, Mepore pro)	Allows removal without causing trauma, pain or damaging delicate new tissue around wound margin.
Foams (e.g. Allevyn Non-Adhesive, Mepilex)	Super absorbent particles embedded within dressing that enhance absorption of exudates. Suitable for moderate to heavily exuding wounds.
Hydrocolloids (e.g. Wafers – Duoderm CGF, Duoderm thin, Versiva; Powder – Comfeel; Paste – Duoderm paste, Comfeel paste)	Contains gel‐forming agents and provides effective occlusion. Requires change every 3‐5days. Does not cause trauma on removal. Useful for clean granulating, superficial wounds, with low to medium exudates.
Hydrogels (e.g. Duoderm hydroactive gel, Intrasite gel)	Transparent aqueous gels. Promotes rapid debridement by facilitating rehydration and autolysis of dead tissue in dry, sloughy or necrotic wounds. Requires change every 3 days. Not suitable for heavily-exuding wound.
Hydrofibres (e.g. Aquacel)	Absorbs and interacts with wound exudates to form a soft gel that traps bacteria. Conforms to wound contours, prevents peri-wound maceration whilst providing a microenvironment. Not useful in bleeding, dry and necrotic wounds.
Alginates (e.g. Algisite M, Urgosorb, Kaltostat, Seasorb)	Derived from seaweed. Maintains a moist microenvironment that promotes healing and granulation. Also has haemostatic effect. Useful for moderate to heavily exudating wound and to arrest superficial bleeding.
Anti‐microbials (e.g. Cademoxer Iodine – Iodosorb paste, Iodosorb powder; Silver dressings – Acticoat Absorbent, Acticoat, Algisite Ag, UrgoCell Ag, Mepilex Ag, Aquacel Ag)	Controls bacterial burden and prevents microbial continuum in wound beds. Iodine: controls surface bacteria on a wound while facilitating debridement. Silver: broad spectrum of activity against gram‐negative, gram‐positive microorganisms, yeast and fungi.
Odour Control Products (e.g. Carbo Flex)	Utilises activated charcoal which absorbs odour and exudates. Usually indicated for malodorous wounds.

Malignant Fungating Wounds

Malignant fungating wounds arise when cancer cells infiltrate and proliferate within the skin, resulting in loss of tissue viability and development of a nodular/ulcerated wound.
Bacterial colonization is common, leading to malodour and exudates.
Unless they can be treated with anti-cancer treatments, wound healing is very unlikely.
Generally have major negative physical and psychosocial impact on patients and families.
Overall goal of treatment is to promote comfort, prevent isolation and maintain quality of life, through:
- Minimizing pain and trauma
- Controlling malodour, exudates and bleeding
- Maintaining integrity of peri-wound area
- Considering cosmetic appearance in the choice of dressing regime

Malignant fungating wound care

Moisten wound dressings before removal if they stick to wound base
Gently irrigate with normal saline

For painful wounds:

Administer prescribed analgesia before commencing dressing.
Use non-adherent dressings (e.g. Mepilex). Do not allow wound to dry out as it will lead to increased pain/bleeding on removal.
Minimize frequency of dressing changes to reduce pain and discomfort, if appropriate.
Review baseline pain control and dosage of analgesia given prior to wound dressing to reduce wound pain.

For moderate to highly exudating wounds:

Use absorbent dressings (e.g. alginate, hydrofibre, foam dressings, with secondary absorbent pad (e.g. gamgee).
Stoma appliance or wound manager may be considered for very highly exudative wounds with small openings.

For bleeding wounds:

Preventive measures such as use of non-adherent dressings and cleansing by irrigation rather than swabbing. Prepare dark towels if large amount of bleeding is anticipated.
Use alginate dressings (e.g. kaltostat).
Consider topical measures (e.g. adrenaline 1:1000 or Tranexamic acid) to bleeding points.
Consider palliative radiation therapy.

For malodorous wounds:

Use topical antimicrobial (e.g. Silver dressings or Metronidazole powder) to wound bed.
Consider odour control products (e.g. charcoal).
Occlusive dressings should only be used if surrounding skin is healthy.
Consider environmental agents (e.g. room deodorisers, aromatherapy oils).
Protect peri-wound area with suitable barrier product (e.g. Cavilon cream), before securing dressing.

Pressure Ulcers

The key to good pressure ulcer management is prevention, if possible.

Pressure injury prevention measures:

Regular assessment and skin inspection (especially pressure areas)
Keep skin clean and dry, cleanse promptly following incontinence episodes and protect skin with barrier product
Do not massage or vigorously rub skin at risk of pressure ulcers
Consider skin moisturizer to hydrate dry skin
Consider prophylactic foam dressings to bony prominences in high risk patients
Maximise nutrition, consider dietician referral if necessary
Frequency repositioning, avoid pressure on areas with existing erythema
Use of assistive devices and proper lifting techniques to minimize injury caused by shearing
Use pressure relieving devices (e.g. alternating pressure mattress)
Caregiver education on pressure ulcer prevention

Stages of Pressure injury

Stage I: Non-blanchable Erythema: Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin..
Stage II: Partial Thickness Skin Loss Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister.
Stage III: Full Thickness Skin Loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible.
Stage IV: Full Thickness Tissue Loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible.
Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar
Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin.

Pressure Ulcer Treatment

Set treatment goals consistent with patient/family’s goals of care.
Initial assessment and reassessment of wound at each dressing change.
Assess for pain and institute pain management strategies as needed.
Select wound dressing based on:
- Ability to keep wound bed moist
- Bacterial burden
- Presence of wound odour
- Nature and volume of exudate
- Condition of wound tissue & peri-wound skin
- Wound size, depth, location
- Presence of tunnelling/ undermining
- Goals of care
Protect peri-wound area.
Educate patient and family regarding skin changes and plan of care.

References

Burd A, Wong KC, Kumta SM. Aggressive surgical palliation for advanced girdle tumours. Indian Journal of Plastic Surgery : Official Publication of the Association of Plastic Surgeons of India. 2012;45(1):16-21. doi:10.4103/0970-0358.96571. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3385388/figure/F3/. Accessed July 12, 2017.
Grocott P, Gethin G, Probst S. Skin Problems in palliative care. In: Cherny IN, Fallon M, Kaasa S, Portenoy KR, Currow CD,ed. Oxford Textbook of Palliative Medicine. 5th ed. New York, NY: Oxford University Press; 2015:715-723.
Merims S, Lotem M. Skin problems in oncology. In: Cherny IN, Fallon M, Kaasa S, Portenoy KR, Currow CD,ed. Oxford Textbook of Palliative Medicine. 5th ed. New York, NY: Oxford University Press; 2015:930-939.
NPIAP (2016) – Pressure Injury Stages Retrieved from https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf
Nursing Care for the Palliative Patient. In: Division of Palliative Medicine Handbook. 5^th ed. Singapore, SG: Division of Palliative Medicine, National Cancer Centre Singapore; 2016:29-33.
Naylor W. Symptom control in the management of fungating wounds. World Wide Wounds. 2002. http://www.worldwidewounds.com/2002/march/Naylor/Symptom-Control-Fungating-Wounds.html. Published February, 2002. Accessed July, 2017.
National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Perth, Australia: Cambridge Media; 2009.