Individual chosen palliative case scenario
Ms A 70 year old lady, single, Resident of XYZ Nursing Home for 20 years since she had developed a MCA (Middle cerebral artery) infarct stroke, became bedbound, and developed right hemiplegia. She is functional status ECOG 4 (Eastern Cooperative Oncology Group), which means she is completely disabled; unable to do any selfcare; totally confined to bed.
Has medical history of right breast cancer diagnosed 25 years ago. Advanced care planning that she had done was for best supportive care and not for rehospitalization. She is medifunded financially and has only one sibling who visits her regularly in Nursing home.
She is complicated by right breast fungating wound and also was found to at risk of developing buttock excoriation (incontinence- associated dermatitis). I am the palliative nurse from Homecare service assigned to Ms A and will be exploring critically analysing and translating evidenced-based knowledge into practice for the care of Ms A. The NH staff also requested for me to educate them how to prevent IAD and how to manage fungating wound in general.
Following are the outline of my assignment
Importance of skin care in palliative settings
Skin constitutes the largest organ of our human body (Westwood, 2014). Maintaining and improving skin integrity has been widely practiced but little is known about its evidence and latest updates. According to Lichterfeld et al.(2015), patients who are very sick or chronically ill, and those who have immobility, or bladder/bowel incontinence, they are very susceptible for many skin conditions like pressure sores, incontinence associated dermatitis,dry skin, fungal rashes etc. Ms A is a classic example. In a multiprevalence study done by Hahnel et al.(2017), there is high incidence of skin conditions in aged nursing home residents and reduced their quality of life. In another study conducted by Haley et al.(2011)- findings showed quality of life improves with good skin care. Following, I will be critically exploring and going through evidence based articles focusing on skin care for Ms A condition.
Different skin conditions evident in Ms A case. There are 2 main types.
Exploration and Analysis of Different treatment and management based on literature reviews for these conditions.
(a)Fungating breast wound-Locally advanced, metastatic or recurrent cancer may extend into the skin, changes its integrity, and results chronic, poorly healing, and fungating wounds. Closure of these wounds is difficult and in many cases impossible, which causes significant distress for patients, families and the caregiving teams.
Moreover, they are a constant reminder (vision, smell, discharge) of disease progression. Frequent complications of these wounds are bleeding, infections, and sepsis.
The patients suffer from pain, functional impairment, the presence of an open, discharging wound, and very often from odours due to necrosis and microbial contamination. Palliative care directly addresses the needs of the patients and their relatives in such distressing situations. Principles of care are to be defined according to the goals of palliative care in general.
If cure is not fleasible, the primary goal is shifted towards providing the best comfort and quality of life possible despite the presence of the ulcerating wounds. Thus, local wound management and symptom control become the major focus of the multidimensional approach integrating physical, psychological, social, and spiritual issues (Merz et al.,2011).
Merz et al.(2011) gave us valuable information on management of fungating wounds. Firstly it is essential to do a assessment and documentation of the wound. Dressings recommended include less bulky wound products, have non adherent properties and high absorbent capacity.
Silver-impregnated wound dressings help to reduce microbial growth and therefore odours.
A very efficient way to bind secretions and odours is the use of activated charcoal.
Crushed tablets of activated charcoal (as used for diarrhoea treatment) can be packed into compresses or other appropriate tissues and applied to the top layer of the dressing
Direct contamination of the wound with the charcoal has to be avoided. For odours, topical metronidazole, oral administerd chorophyll and medical honey have shown benefits.
In another A Double-Blinded, Randomized, Clinical Trial done by Villela-Castro,Gouveia Santos, & Woo (2018), comparing the efficacy between
is a common antiseptic agent used in contact lens
cleaning solutions, mouthwash, skin disinfectant solutions, and
wound dressings. It has a board antimicrobial activity against
gram-negative and gram-positive fungi, spores, yeasts, and
in ordor management. Results showed Both PHMB and metronidazole signifi cantly reduced odor in malodorous MWs within 4 days. Neither solution was found to be more effective than the other in the magnitude of odor reduction.
As for local necrosis- minor debridement by professionals can be considered. If prognosis is short, leaving the dead tissue in place and in a dry wound environment is recommended.
For bleeding wound-
Woo,Krasner,Kennedy,Wardle, & Moir (2015) showed -Repeated application and removal of adhesive tapes and dressingspull the skin surface from the epithelial cells, and this can precipitate skin damage by stripping away the stratum corneum. Dressing-related trauma is associated with wound enlargement,increased exudate, bleeding, pain, inflammation, and anxiety. Dressings with silicone adhesive are the least likely to cause maceration and skin damage with repeated application. To protect periwound skin, a number of sealants, barriers, and protectants, such as wipes, sprays, gels, and liquid roll-ons, are useful on the periwound skin.
According to Merz et al.(2011),silicone wound contact dressing is preferred to prevent bleeding. In cases of minor bleeding-topical adrenaline diluted in 1:1000 can be used but restrictively as it can cause tissue necrosis. Topical tranxemic acids can also be crushed and applied.In few suitable cases, radiation therapy can be effective. In cases of massive bleeding, dark towels and linens and preparing families and caregivers should be done. Sedation is not necessary in massive bleeding as patient dies within sec to minutes.
Akbulut,Yagmur, Gumus, Babur & Can (2014) studied case reports showed the efficacy and safety of alternative medical applications as a complementary or alternative method to modern medical treatments remain unknown. However if there is no risk of the alternative application causing harm to the patient or reducing the efficacy of the primary evidence-based therapy, it may be used to increase the patient’s sense of well-being.
(b)Incontinence Associated Dermatitis
Incontinence-associated dermatitis (IAD) is a class of irritant dermatitis that develops from constant exposure to urine or liquid stool (McNichol,Ayello,Phearman,Pezzella, ; Culver,2018). Based on the literature reviews conducted by McNichol et al. (2018)- Incontience associated dermatitis is a very common problem among patients who have bowel/urinary incontinenece like Ms A. From a total of 105 literatures that were identified and reviewed by McNichol et al. (2018) – these the valuable information are found valuable and effective:
*One top reason for the development of IAD was the use of soap, water and wash cloth.
The skin contains a normal flora of organisms that are kept in check when skin pH remains within the usual acid mantle range.When skin pH moves into the alkaline level, pathogenic bacteria counts rise.
Repeated exposure to urine and/or feces can lead to changes in skin pH from the normal acidic pH of 4 to 6 to an alkaline pH. Using alkaline soaps can also raise the skin’s pH.
Once the skin pH is raised into the alkaline range, the skin
lipids are modified, leaving the skin vulnerable to damage.
Aging skin developed a 20% loss in dermal thickness (“paper-thin” skin). Aging skin also include a flattening of the dermal-epidermal junction and
surface pH that is less acidic. This is evident in Ms A who is 70 year old.
*The researchers believed that it is important for clinicians to have a clear standard way to translate this knowledge into everyday practice. For years, care bundles and mnemonics have enabled clinicians to remember key components of care interventions.
A quick and easy-to-remember mnemonic such as ACT can be readily used by the healthcare provider or caregiver.
The A represented for assess; C represented cleanse skin, correct cause, and contain incontinence ;and T represented treat vulnerable and/or damaged skin and avoidtraumatic skin injury. Please refer to appendix for more details (McNichol et al.2018).
*Skin assessments should provide guidance and assist clinicians in determining the care plan for prevention and healing of IAD-damaged skin.
*There are three essential components to the process of care: cleansing ,moisturizing, and protecting the skin.
Products with fewer ingredients (dyes, fragrances, preservatives)are preferred to avoid skin reactions.
Therefore, it is crucial that clinicians know the composition of the products they use for skin care.
*Moisturizing. This is the second step. Moisturizers function to repair the barrier integrity of the epidermis, enhance retention of water content, and reduce transepidermal water loss. Moisturizers have varying formulas but willcontain either emollients, humectants, or occlusives. Emollients smooth the skin surface with the addition of lipids. Humectants attractwater to the stratumcorneum. Occlusives provide a barrier to the skin from exposure to stool and/or urine.
The last step of a defined skin care regimen for prevention and treatment of IAD is skin protection. Skin protectants served as moisture barriers. They should provide a barrier to the skin from irritants such as urine, stool, and excess moisture. Several types of skin protectants are available, including products with petrolatum, zinc, dimethicone, and liquid acrylates. These products come in form of creams, lotions, ointments, pastes, or films. These products provide different degrees of barrier function, and it can be a task to decide which is the best product to use in individual patient circumstances because of a general lack of evidence. The use of a skin barrier cream to skin care protocol caused increased hydration of the stratum corneum, decreased skin pH, and decreased the magnitude of erythema in patients in a long-term-care institutions in Japan. Application of zinc oxide cream, which resulted in better treatment of IAD in adult hospitalized patients in the Philippines.
Despite the evidence on which product or products to use for
IAD is inconclusive, one must observe for the ingredients in the products to determine product selection for a specific patient’s
condition. Most of the skin barrier products applied for both prevention and treatment contain one or more of the following: petrolatum, zinc oxide, dimethicone, and acrylateterpolymer. Petrolatum (petroleum jelly) constitues a common foundation for many ointments.
Petrolatum being transparent, forms an occlusive barrier, and increases skin hydration. Zinc oxide comes in an opaque or clear cream or paste. Dimethicone, a silicone-based product, is also transparent, nonocclusive, and moisturizing.
Acrylate terpolymer ,a liquid film-forming acrylate and does not need removal or reapplication with each episode of incontinence.
Newer, long-lasting barriers such as those in the cyanoacrylate class are found to keep their barrier function
after repeated contact with urine, feces, and dual incontinence and the subsequent cleansing of the skin for several days.
Cleansing with higher-pH soaps and cleansers, when done with cleansing techniques that consist rough scrubbing with terry cloth, loofa, and other materials, can result injury to the skin. Futhermore these methods affect the lipid layer of protection in the skin’s make-up, allowing portals of entry for bacteria between cells. It is found that massage and vigorous rubbing of the skin with a harshwashcloth are more likely to result in skin/cellular damage and tissue inflammation than to promote beneficial outcomes associated with massage (such as increased tissue blood flow) Consequently,it is suggested that cleansing be performed using soft cloths to reduce or limit the potential for injury, particularly in fragile and vulnerable areas such as the perineum.
Education was provided to all shifts of nursing staff. It was conducted over a 3- to 4-day period in an effort to initiate the new program and standard of practice to all staff concurrently. A clearly defined algorithm for treatment and prevention was
derived for IAD care. Standard use of the term “incontinence associated
dermatitis” was adopted and stated within the nursing department standards and practice for the institution.
Unit-based skin champions were then tasked to disseminate this information with
other nursing staff at both unit meetings and at the bedside.
All new nursing staff were given education on IAD and the standard
of practice at the institution-wide orientation.
As with the introduction of any new change, there
were some challenges posed to change that required repeated education to all nursing staff, including nursing assistants.
Skin care champions became naturally the essential players in maintaining the change in practice at the forefront of daily care. A “Save Our Skin” education program was conducted twice a year for both nurses and nursing assistants.
Informational flyers were distributed frequently to the wards.
Information about the skin care products was placed in the unit’s
tool kits for easy access. The same information is also put on the
skin care committee’s intranet site. In later years, online competency
presentations on skin care have been developed and
presented for annual review by all inpatient nursing staff.
*Barriers to Treatment discussed in this article
Administrators have restricted access to
incontinence cleansers, moisturizers, moisture barriers, and soft
bathing cloths during “off” shifts and weekends in an effort to
control overuse and contain costs. Insufficient amount of
the necessary supplies at the bedside, in the bathroom, or on the
nightstand of the person with incontinence means a easy replacement
will be made, whether that be in favour of an abrasive cloth, an
alkaline soap, an inadequate moisture barrier, or the omission
of an evidence-based step. Direct care providers need easy
access to products with demonstrated efficacy. Guidance from
professional organizations is needed to direct consumers toward
efficacious product ingredients to deliver predictable results.
This literature review was well conducted as literature review of substantial numbers of related literature was being made.
I believed the findings of this review are generalizable with modification to my work setting and recommendation for Ms A.
In 2017, Bliss et al. used cohort design to find out the incidence of IAD in older (aged ?65 years) nursing home residents.
Bliss et al used a sample of 10,713 residents in 448 nursing homes situated in 28 states and all 9 United States Census divisions.
The cohort consisted nursing home residents who were continent or usually continent of urine and/or feces on the first full MDS record,
were free of IAD per POs at admission, and developed incontinence (urinary, fecal, or dual) during their nursing home stay per MDS or PO records.
Subsequent development of incontinence and IAD was determined by documentation.
Outcome of the study showed the occurence of IAD was 5.5%. Significant predictors of IAD were not given preventive interventions for IAD, presence of a perineal pressure injury, these patients had greater functional disabilities in activities of daily living, more skin perfusion problems, and lesser cognitive deficits.
Preventing and managing IAD is an important part of nursing practice and findings of this study confirmed the value of the nurse in the nursing home setting. The predictors of IAD identified in this study assist nurses in developing the focus of education for nursing home staff and in planning their consultation services.
For example, nurses can employ the research-based evidence of this study to help nursing homes in identifying residents at risk for IAD to
reduce their morbidity and improve their health outcomes. They emphasize the need for timely healing of perineal pressure injuries.
In all, early identification of patients who are at risk and preventive measures should be offered early.
Translation of evidenced based knowledge into pratcice of basic care
– Use of the products which has shown evidence can be used for Ms A.
– Tutorials on common skin conditions, its assessment, management and documentation should be conducted.
– Work group on how to prevent pressure sore & IAD formation. Monitoring of incidences and KPI
– Getting ready available items for daily use.
– Communication with family and patients on these issues
– Skin Care Campaigns and Champions
In summary, ongoing assessment of patient skin should form a daily routine in a palliative care nurse. Early identification of patient who are at risk or have the problem helps with early prevention and treatment strategies. These can greatly improve patients’ comfort and quality of life.