Venous Ulcer and Wound Management in Relation to Palliative Care - Essay Example

Literature review: Venous Ulcer and Wound Management in Relation to Palliative Care Wound management in palliative care presents enumerable challenges in the health care system, patients, and families. It requires nursing skills and critical thinking, and poses a dilemma amongst the health care workers and patients. However, proper wound management, palliation, and comfort provides hope to patients and their families (Grey, et al, 2006; Simon, et al, 2004 and McDonald, 2006). In palliative care, an effective communication skill of nurses plays an important function in supporting patients and their families. It is their main goal to provide the finest quality of life for these patients. Hence, wound management in palliative patients should be holistic and must address complicated issues in wound management setting (Naylor, 2005; Chaplin, 2004; Sieggreen, 2005). Venous ulcer is defined as leg tissue breakdown caused by sustained venous hypertension secondary to chronic deep, superficial, and perforator venous insufficiency (Sieggreen, 2005; Grey, 2006). Vessel wall damage and fluid loss is caused by high venous pressure in the capillary beds causing soft tissue oedema. Red blood cells that follow tissue fluid escape releases hemosiderin, producing the characteristic brown skin staining. The soft tissue fibrosis caused by chronic fluid deposition makes the leg more vulnerable to trauma and less receptive to cellular oxygen transport. Fluid accumulation and maximal stretching causes tissue oozing that opens to develop into a sore and eventually, to venous ulcer (Simon, et al, 2004; Sieggreen, 2005; Baumgartner, et al, 2005; McDonald, et al, 2006). The risk factors for venous insufficiency are: varicose veins, history of leg swelling and blood clots in deep vein, prolonged sitting or standing, hypertension, multiple pregnancies, previous surgeries, injuries, obesity, increasing age, and immobility. Characteristic signs and symptoms of venous leg ulcer are observed above or around medial malleolus. It is painless unless infected, associated with swollen and aching, surrounded by mottled brown or black staining, dry, itchy, and reddened skin. Fifty percent of which is associated with varicose veins, and also lipodermatosclerosis, lymphoedema, papillomatosis, fissuring, and oozing (Simon, et al, 2004; Sieggreen, 2005; Baumgartner, et al, 2005; McDonald, et al, 2006). The three main categories of wounds in palliative patients are malignant wounds, pressure ulcers, and wounds that result from vascular disease of the lower limb. In palliative care, to improve the quality of life of the patient, wound management must be holistic. Hence, the following key elements must be considered: (1) comprehensive assessment which include the personal perspective of the patient towards his/her condition, history of illness and wound treatment, the general physical condition, symptoms, functional abilities, examination, diagnosis, patients’ understanding of his illness, future prospects and his personal wishes, concerns, and priorities. (2) Assessment of the family which includes their structure, function, and concern. (3) Discussion and goal identification to help enhance the quality of life of the patient. For a better outcome, the following principles of wound management must be applied: (1) Comprehensive assessment of the site, type, grade, and dimension of the wound as well as wound characteristics, levels of exudates, bleeding, malodour, pain and the surrounding skin condition. (2) Identification and management of the contributing factors such as unrelieved pressure. (3) Identification of the objective in wound management, and the appropriate selection of intervention (Chaplin, 2004; Naylor, 2005; Schim, et al, 2005; Langemo, et al, 2007; McDonald, et al, 2006). A holistic approach in wound management should include the prevention of wound development and deterioration, correction of the underlying cause, control of wound - related symptoms, utilize patient self - assessment, provision of psychosocial support, and promotion of independence and quality of life of the patient (Anonymous, 2003; Chaplin, 2004; Simon, et al, 2004; Naylor, 2005; Sieggreen, 2005; Schim, et al, 2005; Baumgartner, 2005; Grey, et al, 2006; McDonald, et al, 2006; Langemo, 2007; Richards, et al; 2007). Goals of treatment in palliative wound care must be geared towards pain, odour, exudates, bleeding, and infection reduction as well as control of symptoms and provision of comfort (McDonald and Lesage, 2006; Naylor, 2005). The decisions in wound management must be balance and should meet the priorities of the patients. Nurses must be able to identify priorities and must achieve the objective identified from comprehensive wound assessment (Chaplin, et al, 2004). Chaplin added that palliative care should integrate psychological, social, and spiritual approach to help patient live as healthy as possible until the time of his death (cited from WHO, 2002). Palliative wound care must not only stop in the hospital premise but rather, outpatient and community based care should also continue to provide independence and quality life to patients. To improve patient care and healing of the ulcer, emphasis must be geared towards education, training, and compression system development. For an effective wound management in palliative care, a nurse should focus on four layer compression bandaging, leg elevation, improvement of nutrition and mobility, obesity control, and skin grafting and venous surgery in selective patients (Simon, et al, 2004; Naylor, 2005). However, among the aforementioned management, compression remains to be the mainstay in wound management. The complexities in palliative care that nurses can face are: multiple symptoms, cachexia and anorexia, psychological and social impact, significant changes of the patient, and impact of the wound to the family. Langemo, et al (2007) noted that the integrative palliative care concepts with chronic wound management strategies honours the wishes of the patient at the end of his life, and keeps him as comfortable as possible. In conclusion, wound management in palliative care poses great challenges to nurses who need to combine their skills in patient assessment, communication, and decision making strategies. To achieve an approach to care that is holistic person - centred, key components in palliative care must be combined with wound management principles. In palliative care, the complexity of the nature of wound can be resolved by systematic and person - centred approach of care. Hence, achievement of best quality of life can be provided by the nurses to the patients and their families by combining an effective communication and decision making skills (Chaplin, 2004; Naylor, 2005; Schim, et al, 2005). Reference Anonymous. (2003). The challenges of wound management in palliative care. British Journal of Nursing, 12(11), S4. Ashfield, T. (2005). The use of topical opioids to relieve pressure ulcer pain. Nursing Standard, 19(45), 90 - 92. Baumgartner, I., Schainfield, R., and Graziani, L. (2005). Management of Peripheral Vascular Disease. Annual Review of Medicine, 56(2005), 249 - 72. Chaplin, J. (2004). Wound Management in Palliative Care. Nursing Standard, 19(1), 39 -42. Grey, J., Harding, K., and Enoch, S. (2006). Venous and Arterial Leg Ulcers. BMJ, 332(3537), 347 -350. Langemo, D., Anderson, J., and Hanson, D. (2007). Understanding Palliative Wound Care. Retrieved March 4, 2006, from www.nursing2007.com. McDonald, A. and Lesage, P. (2006). Palliative management of pressure ulcers and malignant wounds in patients with advanced illness. Journal of Palliative Medicine, 9(2), 285 -295. Naylor, W. (2005). A guide to wound management in palliative care. International Journal of Palliative Nursing, 11(11), 573 - 579. Richards, A., Kelechi, T., and Hennessy, W. (2007). Risk factors and wound management for palliative care patients. Journal of Hospice and Palliative Nursing, 9(4), 179- 181. Schim, S. and Cullen, B. (2005). Wound Care at the End of Life. Nursing Clinics of North America, 40(2005), 281 294. Siegreen, M. (2005). Lower extremity arterial and venous ulcers. Nursing Clinics in North America, 40(2005), 391 - 410. Simon, D., Dix, F., McCollum, C. (2004). Management of Venous Leg Ulcers, BMJ, 328(1), 1358 - 1362. Read More