SWM Module 21: Wound Care — Palliative Considerations Flashcards

A holistic approach that addresses the physical, psychological, and spiritual needs of patients and families or caregivers.

Focuses on comfort care.

Palliative wound

To give back control of patients’ lives and facilitate the highest level of independence, dignity, and comfort possible. The focus of care must shift from doing what is best for the wound to what is best for the patient

• Stabilizing current wounds
• Preventing the development of new ones when possible
• Preventing infection
• Managing symptoms to enhance patient comfort and well-being
• Promoting healing when feasible
• Preventing further wound breakdown through off-loading and positioning

Patient-Centered Care

Symptom Managment

Holistic Approach

Interdisciplinary

Adaptability

Focus on Comfort

H Hemorrhage

O Odor control

P Pain

P Pruritus

E Exudate

S Superficial infection

• Direct Pressure: Apply firm, direct pressure for at least 5 minutes without interruption to allow clot formation.
• Elevation: Elevate the affected extremity above heart level to help reduce blood flow and slow bleeding.
• Calcium Alginate: Promotes hemostasis by absorbing blood and supporting clot formation.
• Avoid Cytotoxic Agents: Solutions like Dakin’s can interfere with clotting and delay hemostasis

• Silver Nitrate Sticks: Chemically cauterize the bleeding site, providing localized hemostasis.
• Hemostatic Agents: Gelfoam® sterile sponges or products like WoundSeal® powder create a physical barrier to support clot formation.

Gently remove exudate and debris to reduce bacterial load and odor. Hypochlorous acid wound cleansers are safe and effective for reducing bacteria (Patel & Cox-Hayley, 2019).

Gentle mechanical debridement with saline moistened gauze to remove necrotic tissue.

• Metronidazole gel (0.75 to 0.80%) applied directly to the wound once daily for 5 to 7 days is effective in controlling anaerobic bacteria (Bryant & Nix, 2024).
• Metronidazole tablets may also be crushed and applied to the wound; however, this practice is based on case reports rather than high-level evidence (Bryant & Nix, 2024).
• Systemic Metronidazole can be used if there is evidence of deep tissue infection causing foul odor. It can be administered per IV or orally, instead of or in addition to topical metronidazole (Patel & Cox-Hayley, 2019).

Note: Metronidazole use for wound odor is off-label, as its FDA-approved indications are rosacea and bacterial vaginal infections.

• Cadexomer iodine reduces bacterial counts, controls odor, and absorbs exudate, making it ideal for when both odor management and exudate absorption are required.
• Medical grade honey has antimicrobial benefits and there is some evidence that it may be effective in the management of odor as well as wound pain (Patel & Cox-Hayley, 2019).
• Silver dressings release silver ions when they come in contact with wound exudate to reduce bacterial load by killing a wide range of bacteria. Several dressing types are available for moderate to heavy exudating wounds.
• Hydrofera blue dressings contain methylene blue and gentian violet, which are antimicrobials that reduce bioburden and odor associated with the byproducts of bacteria. The foam structure of these dressings absorbs moderate to heavy exudating wounds.

Contain methylene blue and gentian violet, which are antimicrobials that reduce bioburden and odor associated with the byproducts of bacteria. The foam structure of these dressings absorbs moderate to heavy exudating wounds.

Release silver ions when they come in contact with wound exudate to reduce bacterial load by killing a wide range of bacteria. Several dressing types are available for moderate to heavy exudating wounds.

Has antimicrobial benefits and there is some evidence that it may be effective in the management of odor as well as wound pain.

Reduces bacterial counts, controls odor, and absorbs exudate, making it ideal for when both odor management and exudate absorption are required.

• Yogurt or Buttermilk: Patel and Cox-Hayley (2019) suggest applying yogurt or buttermilk to the wound for 15 minutes after cleaning to reduce wound odor by lowering pH, though evidence is limited.
• Essential Oils: Some essential oils have been identified as exerting antimicrobial activity, with minimal cytotoxicity activity (Akhmetova et al., 2016).
• Sugar: Sugar is quickly diluted after application, so frequent reapplication may be necessary to maintain effectiveness and prevent bacterial resistance. To help retain diluted sugar in the wound, a paste made from petroleum jelly and glycerin can be used to reduce sugar washout from the wound bed (Akhmetova et al., 2016).

Suggest applying to the wound for 15 minutes after cleaning to reduce wound odor by lowering pH, though evidence is limited.

Some have been identified as exerting antimicrobial activity, with minimal cytotoxicity activity (Akhmetova et al., 2016).

Quickly diluted after application, so frequent reapplication may be necessary to maintain effectiveness and prevent bacterial resistance. To help retain diluted sugar in the wound, a paste made from petroleum jelly and glycerin can be used to reduce sugar washout from the wound bed.

Absorb odor; some absorb exudate, but their effectiveness diminishes when wet.

• Lidocaine (Lidoderm®): Available as gels, creams, or patches, lidocaine provides numbing to the area, reducing pain sensation
• Capsaicin (Qutenza®): Derived from chili peppers, reduces pain signal intensity when applied as an ointment
• Diclofenac (Voltaren®): A topical non-steroidal anti-inflammatory drug (NSAID) that can help reduce inflammation and pain at the wound site

Provides numbing to area, reducing pain sensation

Reduces pain signal intensity when applied as an ointment

A topical non-steroidal anti-inflammatory drug (NSAID) that can help reduce inflammation and pain at the wound site

• Acetaminophen (Tylenol®): Often used for mild to moderate pain, it has fewer gastrointestinal side effects but should be used cautiously in patients with liver dysfunction.
• Non-Steroidal Anti-Inflammatories (NSAIDs): Medications such as ibuprofen (Motrin®) and naproxen (Aleve®), are effective for pain that involves inflammation but should be used with caution in patients with kidney issues or gastrointestinal risks.
• Opioids: Medications such as morphine (MS Contin®), oxycodone (OxyContin®), and fentanyl (Actiq®) may be required for moderate to severe pain.

May be required for moderate to severe pain.

Often used for mild to moderate pain, it has fewer gastrointestinal side effects but should be used cautiously in patients with liver dysfunction.

Medications such as ibuprofen (Motrin^®) and naproxen (Aleve^®), are effective for pain that involves inflammation but should be used with caution in patients with kidney issues or gastrointestinal risks.

Tricyclic Antidepressants (TCAs)

Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)

Duloxetine (Cymbalta^®) and venlafaxine (Effexor^®) relieve neuropathic and musculoskeletal pain but may cause nausea, dizziness, and insomnia.

Amitriptyline (Elavil^®) and nortriptyline (Pamelor^®) increase serotonin and norepinephrine, helping ease neuropathic pain (e.g., diabetic neuropathy). Side effects include dry mouth, constipation, and drowsiness.

• Gabapentin (Neurontin^®) and Pregabalin (Lyrica^®): Reduce excitatory neurotransmitter release to manage neuropathic pain. The side effects are drowsiness and dizziness.

Alleviate spasms and chronic wound pain but may lead to drowsiness, dizziness, or dependency.

Reduce swelling, pressure, and pain in cases of inflammation contributing to pain.

Can help manage deep, throbbing pain in cases where cancerous wounds involve bony structures.

underlying malignancy.

• Tumor activity: Irritation of nerve endings from growing tumor
• Presence of denuded skin from excess exudate

• Increase fluid intake to maintain skin hydration.
• Apply hydrophilic lotions (e.g., Lubriderm® or Cetaphil®) after bathing while the skin is still damp to lock in moisture.
• Avoid vasodilation which can increase pruritus
  • Do not rub or scratch the area.
  • Apply cool compresses or take tepid baths.
  • Topical corticosteroids or preparations containing calamine to the area.

An uncomfortable, irritating sensation on the skin that provokes the desire to scratch. It can be localized to a small area or widespread, and range from a minor annoyance to a disabling condition that disrupts sleep and mental well-being.

malignant tumor activity, capillary permeability, or tissue autolysis

• Maceration of surrounding skin
• Saturation of dressings
• Odor
• Patient discomfort

• Absorptive dressings (e.g., foam dressings, alginates)
• Super absorptive dressings
• Negative pressure wound therapy (NPWT)
• Wound drainage pouches (ostomy pouches may work too)

To protect a sensitive and friable wound bed, use a contact layer over the wound bed that allows drainage to flow into an absorptive dressing that can be changed frequently without removing the contact layer and causing discomfort (Letizia et al., 2010; Bryant & Nix, 2024)

Infections typically present with localized redness, warmth, swelling, and sometimes increased exudate or odor.

Using an absorbent foam or alginate dressing

Lidocaine gel or cream

* Topical lidocaine provides localized pain relief with minimal systemic side effects. Antibiotics address infection; corticosteroids address inflammation, and antihistamines address pruritus.

• Medical history and wound characteristics.
• Psychosocial and emotional needs.
• Nutritional status.

To enhance the patient's quality of life while managing symptoms

* The primary goal of palliative wound care is to enhance the patient’s quality of life through symptom management, not to prioritize wound healing or aggressive treatment.

To align treatment with the patient’s goals and wishes for end-of-life care

In terminal illness, skin breakdown becomes unpreventable and untreatable as the body’s systems fail.

Moisturizing Regularly Use gentle, fragrance-free moisturizers to reduce dryness and maintain skin integrity.

Gentle Handling Minimize skin trauma by performing all care activities with caution to prevent tearing or bruising.

Pressure Management Prevent pressure injuries with regular repositioning, supportive devices (e.g., mattresses, cushions, offloading booties), and timely incontinence care.

Address Pressure Injuries Treat early signs promptly with appropriate wound care, including cleaning, dressing changes, and topical treatments for pain or infection.

Promote Hydration Encourage fluid intake when possible and use hydrating sprays or gels for additional moisture if oral hydration is limited.

Kennedy Terminal Ulcer (KTU)

A KTU is recognized for its sudden appearance and rapid progression, with the body’s functional decline during the dying process, typically manifesting in the shape of a pear, butterfly, or horseshoe and often located over the sacrum.

• Moisturizers, hydrogels, and aloe vera to soothe irritated skin
• Topical steroids may be prescribed to reduce inflammation.

Malignant fungating wounds arise when cancerous cells infiltrate the skin and surrounding blood vessels, leading to skin breakdown and wound formation. Managing these wounds can be challenging due to associated symptoms like odor, bleeding, and significant pain, along with the emotional and psychological impact on the patient.

Wound care includes gentle cleansing, non-adherent dressings, and keeping a moist wound bed. Preventing and stopping bleeding with direct pressure or hemostatic agents.

Breast cancer

• Pressure redistribution to prevent or lessen skin breakdown
• Appropriate wound dressings and dressing changes
• Meeting wound goals such as preventing infections, exudate, and odor control

The patient's comfort

Kennedy Terminal Ulcer

Absorbent foam or alginate dressing

Wound-related symptoms like odor and exudate

Lidocaine gel or creams

Assess the patient’s condition.