Chuck Tilley MS, ANP-BC, ACHPN, CWOCN

Discuss the concept of skin failure in the chronically ill and in terminally ill hospice patients and the development of Kennedy Terminal Ulcers

Describe various position statements regarding avoidable vs. unavoidable pressure ulcers

Discuss the use of some traditional pressure ulcer prevention and treatment strategies: are they evidence-based?

Review a typical hospice patient’s course of treatment and identify best practices used and/or missed opportunities to utilize evidence-based strategies

First used in the literature by La Puma 1991

“An event in which the skin and underlying tissue die due to hypoperfusion that occurs concurrent with severe dysfunction or failure of other organ systems”.

(Langemo & Brown, 2005)

Pathophysiology: “As a body shunts blood and nutrients to vital

organs such as the heart, lungs, and kidneys, it shunts blood away from the periphery or the skin”

“Damaged tissue loses its tolerance to

pressure and trauma and cannot assimilate nutrients causing more tissue damage and, ultimately, necrosis”

(Goode & Allman, 1989)

“Skin and underlying tissue die d/t hypoperfusion concurrent with an ongoing, chronic disease state”

Elderly, DM, HF, CKD, MS, ALS, Paraplegics, Quadriplegics, AIDS

Combination of age-related declines and chronic co-morbidities accelerate loss in

functioning (Langemo &

Brown, 2005)

“Skin and underlying tissue die d/t hypoperfusion concurrent with end of life”

(Brown, 2003)

“62.5% of pressure ulcers in hospice patients occurred in the 2 weeks before death”

(Brown, 2003)

Occurrence of skin failure, like any other organ system failure, should be used to establish goals of care and future treatment

(Langemo & Brown, 2005)

Characteristics: Pear, butterfly or horseshoe shaped Usually develops on the sacrum Color may be red, yellow, purple or black Skin is almost always intact and looks at times

almost like a black blood blister Borders of the ulcer are usually irregular Sudden onset. Starts out larger than other

pressure ulcers, usually more superficial initially, and develops rapidly in size and depth

Treatment for a Kennedy Terminal Ulcer is the same as if would be for any other pressure ulcer

Tends to be a geriatric phenomenon. Reported frequently in hospice patients

Patients have a history of dying within 8-24 hours of development

(Schank, 2009)

(Schank, 2009)

Centers for Medicare and Medicaid (2004)

Avoidable Unavoidable….facility did not do one or more:

• evaluate the resident’s clinical condition and pressure ulcer risk factors

• define/implement interventions consistent with resident needs, goals, and recognized standards of practice

• monitor and evaluate the impact of the interventions

• revise the interventions as appropriate

….even though the facility:

• had evaluated the resident’s clinical condition and pressure ulcer risk factors

• defined/implemented interventions consistent with resident needs, goals, and recognized standards of practice

• monitored and evaluated the impact of the interventions

• revised the interventions as appropriate

Wound, Ostomy, and Continence Nurses Society, 2009

• Published a position paper in 2009 ; “There are clinical circumstances in which a pressure ulcer is unavoidable”

•The presence of pressure ulcers can suggest an overall deterioration in the medical condition (included in hospice criteria) (Langemo et al., 2006; Witkowski et al., 2000)

• In the case of palliative care, pressure ulcer prevention may be displaced by the greater need for comfort and the family’s need for support. Many pressure ulcer interventions may be inappropriate if the measures cause intractable pain or undue family burden near end of life (Brink, Smith, & Linkewich, 2006; Reifsnyder & Magee, 2005)

Skin Changes At Life’s End, 2008• Some skin changes, including pressure ulcers, at end of life are unpreventable• SCALE is a reflection of compromised skin (reduced soft-tissue perfusion, decreased tolerance to external insults, and impaired removal of metabolic wastes• Risk factors, symptoms, and signs associated with SCALE may include suboptimal nutrition, including loss of appetite, weight loss, cachexia and wasting, low serum albumin/prealbumin levels, and low hemoglobin, as well as dehydration. • Expectations around the patient’s end-of-life goals and concerns should be communicated among members of the interprofessional team and the patient’s circle of care

Case: 82yo female with a history of NIDDM, HTN, CKD Stage III, HLD, Vascular Dementia and weight loss of 20lbs over 5 months admitted to a hospice residence with a L

Trochanteric Stage III pressure ulcer s/p 1 week stay at a local hospital

for a fall at home with surgical pinning of R hip

Advance Directives: DNR/DNI/DNH, HCA: husband, HCP states she doesn’t want artificial

nutrition/hydration: no tube feeds, IV fluids/TPN

Functional: A & Ox1, bedbound, total care for all ADLs, incontinent

of B & B, eats 25-50% of most meals (NAS, NCS diet),

frequently spits out meds, egg crate mattress, uses adult

diapers and soap and water to manage incontinence

Pain: Moans and calls out with facial grimacing when

turned- especially onto R hip: turns self onto left

side where she appears comfortablePE: Dry flaky skin, poor turgor, oral mucosa

slightly moist, cachectic, temporal wasting, observed intermittently coughing after meals,

incontinent of urine Q2H, stools at least twice dailyVS: 132/86 98-88-20 FS range: 244-288 BMI: 18. 1Braden Score: 9 Labs: Albumin 2.0

Orders: Advance Directive: DNR/DNI/DNH Diet: NCS, NAS Pureed consistency Aspiration precautions, Nutrition consult Activity: Bedrest, T & P Q2H VS: Routine Weights: Weekly Wound Care: Hydrocolloid L Hip Q72H Meds: MVI 1 po daily, Zinc 220mg po daily, Vitamin C 500mg po BID, Lisinopril 10mg po daily, Metphormin 500mg po BID, Metoprolol 25mg po BID, Tylenol 650mg po/PR Q6H PRN Therapy: Swallow evaluation for diet

recommendations

Course: Developed Aspiration PNA with deterioration in VS (profound hypotension) and neurological function. Developed a sacral Kennedy Terminal Ulcer which was found on Day 19. L Trochanteric wound deteriorated to a Stage IV pressure ulcer with periwound Incontinence Associated Dermatitis (IAD). Day 21 patient expired.

BMI: 17 Functional: Despite being changed every two

hours she is frequently found wet (incontinence care with adult diapers and soap and water), despite T & P she continued to migrate to L Trochanter for comfort, egg crate mattress,

Orders (Day 19): Wound Care: Hydrocolloid Q72H to both wounds Meds: Vitamin C 500mg po BID, MVI 1 po daily, Zinc 225mg po daily,

Augmentin 875mg po BID x10D, Roxanol 5mg po/sl Q2H PRN

pain/tachypnea/dyspnea Diet: NPO except meds Incontinence Care: Attends, soap and

water Oxygen: O2 2L NC humidified

WOCN developed a Guideline For Prevention and Management of Pressure Ulcers first published in 2003 then updated in 2010

Examined the evidence surrounding pressure ulcer prevention and treatment with recommendations based on an extensive literature review with over 300 articles reviewed

Level A: Two or more supporting RCTs of at least 10 humans with pressure ulcers, a meta-analysis of RTCs, or a Cochrane Systematic Review of RCTs

Level B: One or more supporting controlled trials of at least 10 humans with pressure ulcers or two or miore supporting non-randomized trials of at least 10 humans with pressure ulcers

Level C: Two supporting case series of at least 10 humans with pressure ulcers or expert opinion

Risk Identification: Use of a valid and reliable risk assessment tool is

recommended (Level of Evidence = B) Risk assessment should be performed upon entry to a

health care setting, and repeated on a regularly scheduled basis, or when there is a significant change in the individual’s condition. (Level of Evidence = C) (WOCN, 2010)

The Braden, the Norton and Waterlow PU risk assessment scales have been found valid for the prediction of PU risk in a variety of health care settings and in multiple countries

Hospice is identified as an appropriate unit to administer the Braden Scale (Bolton, 2007)

Nutrition: Routine Vitamin C & Zinc supplementation Vitamin C: “The use of Vitamin C and Vitamin A supplementation remains unproven”. (Gray & Whitney, 2003; Gray, 2003) Zinc: “There is no evidence to conclude that routine administration of supplemental zinc will promote healing of pressure ulcers. In fact, doses of zinc

greater than 40mg per day may effect copper levels with possible anemia” (NPUAP/EPUAP, 2009)

Turning and positioning: Q2HRepositioning and turn; regularly and

frequently (Level of Evidence C) (WOCN, 2010)The frequency of repositioning is

unknown and lacks scientific evidence

(Moore & Cowman, 2009; Pieper, 2007)

Dressing Selection: Hydrocolloids Studied more than any other dressing Recommended Stage II and IIIs with minimal depth (NPUAP/EPUAP, 2009) May be undermined by urine or stool

and can aggravate wounds/IAD etc.

Support Surfaces: Egg Crate Mattress Pressure redistributing surfaces are

recommended for individuals with full thickness or ulcers that involve multiple turning surfaces

(Nix, 2007) For patients with a large stage III or IV

pressure ulcers or ulcers on multiple turning surfaces; a low-air-loss or air-fluidized surface may be indicated. (Level of Evidence B)

(WOCN, 2010)

Incontinence Care: Soap and Water/ Adult Diapers

Use of soap is discouraged as it is more alkaline and causes skin irritation

Consider using briefs when out of bed and underpads when in bed to minimize moisture and heat trapping

pH-balanced perineal skin cleanser and barrier ointments are recommended for incontinence care

Indwelling Foley: Indicated for stage III-IV pressure ulcers

(WOCN, 2011)

Did we:▪ Evaluate risk factors?▪ Follow established standards of practice?▪ Consider patient’s goals of care?▪ Monitor, evaluate and revise interventions?

Was the deterioration of the L Trochanteric pressure ulcer avoidable or unavoidable?

Was the Kennedy Terminal Ulcer avoidable or unavoidable?

Bolton, L. (2007). Which pressure ulcer risk assessment scales are valid for use in the clinical setting? Journal of Wound, Ostomy and Continence Nursing, 34(4 ). 368-381.

Brown, G. (2003). Long-term outcomes of full thickness pressure ulcers: healing and mortality. Ostomy Wound Management, 49, 42-50.

Centers for Medicare and Medicaid Services. (2004). Guidance to surveyors for long term care facilities (CMS Manual Pub. 100-07 state Operations). Washington, DC: Author. Retrieved November 1, 2012 from http://www.cms.hhs.gov/transmittals/Downloads/R4SOM.pdf

Goode, P. S. & Allman, R. M. (2003). The prevention and management of pressure ulcers. Medical Clinics of North America, 1989, 1511-24

Gray, M (2003). Does oral zinc supplementation promote healing of chronic wounds? Journal of Wound, Ostomy and Continence Nursing, 31(4): 157-60.

Gray, M., & Whitney, J.D. (2003). Does vitamin C supplementation promote pressure ulcer healing? Journal of Wound, Ostomy and Continence Nursing, 30: 245-249.

La Puma, L. (1991). The ethics of pressure ulcers. Decubitus, 4, 43-4.

Langemo, D., & Brown, G. (2006). Skin fails too: Acute, chronic, and end-stage skin failure. Advances In Skin & Wound Care, 19, 206-211.

Kennedy, L. Kennedy Terminal Ulcer (2004, August 14). Retrieved November, 11 2012 from http://kennedyterminalulcer.com/index.html

Krasner, D. (1995). The chronic wound pain experience: A conceptual model. Ostomy Wound Management, 41, 20-29.

Moore, Z., & Cowman, S. (2009). Repositioning for treating pressure ulcers. Cochrane Data base of Systematic Reviews, 2, CD006898

Mortimer, P.S. (1998). Management of skin problems: Medical aspects. In D. Hanks & N. MacDonald (Eds.), Oxford Textbook of Palliative Medicine (2nd ed., pp. 617-27). Oxford: Oxford University Press.

National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel (NPUAP/EPUAP). (2009). Prevention and treatment of pressure ulcers: Clinical practice guideline. Washington, D.C.: National Pressure Ulcer Advisory Panel

Nix, D. (2007). Support Surfaces (2007). In R. Bryant and D. Nix (Eds.), Acute and Chronic Wounds: Current Management Concepts, 3rd ed. St. Louis, MO: Mosby Elsevier.

Pieper, B. (2007). Mechanical forces: Pressure, shear and friction. In R. Bryant and D. Nix (Eds.), Acute and Chronic Wounds: Current Management Concepts, 3rd ed. pp. 205-235. St. Louis, MO: Mosby Elsevier.

Schank, J. (2009). Kennedy Terminal Ulcer: The “Ah-Ha!” moment and diagnosis. Ostomy Wound Management, 15;55(9): 40-4.

Sibbald, G., Krasner, D., Lutz, J. (2011). Tip the SCALE toward quality end-of-life skin care. Nursing Management, 42(3): 24-32.

Wound, Ostomy and Continence Nurses Society. (2007). The WOCN image library [Image database]. Retrieved from http://images.wocn.org

Wound, Ostomy and Continence Nurses Society. (2009). Position paper: Avoidable versus unavoidable pressure ulcers. Glenview, IL: Author

Wound, Ostomy and Continence Nurses Society. (2010). Guideline For Prevention and Management of Pressure Ulcers. Glenview, IL: Author

Wound, Ostomy and Continence Nurses Society. (2011). Incontinence Associated Dermatitis (IAD): Best Practice for Clinicians. Mount Laurel, NJ: Author