Promoting Skin Integrity in End of Life Care

Part 1

Tracey McKenzieHead of Tissue Viability Services

TSDFT

• To Understand the Extrinsic Factors of Pressure Ulcer (PU) development

• To understand the Intrinsic factors of PU development

• To understand SCALE/Kennedy & 3:30 ulceration

• To be able to identify Grades of pressure damage

About 300 million individuals, or 3% of the world’s population, need palliative or end-of-life care each year.

The skin is the largest organ of the body and in many patients at the end of life the skin fails along with other organs.

Skin failure is due to hypoperfusion and is seen alongside severe dysfunction, or failure, of other organs.

Whilst it has been acknowledged that PU’s can be unavoidable for those patients at the end of their lives it is still of paramount importance to try to prevent avoidable pressure damage from occurring.

To that end then basic principles of Pressure Ulcer Prevention still apply and must be implemented for all patients.

Please turn round and, for one minute,

kneel in your chair – think about what is

happening to the tissue between the chair

and your knees.

Pressure:

A pressure ulcer will develop if the capillary blood flow to the skin and the underlying tissue is obstructed over a sufficient period of time.

Please put your knuckle on the

arm of your chair or table. Keeping

the knuckle in place rock the skin

backwards and forwards- think

about the trauma this will be

causing to the blood vessels etc.

Shear:Shearing forces will only exist if pressure is also present. The outer layers of the skin remain static while deeper layers move causing discolouration at the skin’s surface.

Please rub your wrists together for thirty

seconds (I will time you!)

What do you think is happening to the

surface of your skin?

Friction: Friction damage occurs when the epidermal layer of the skin is damaged from rubbing against external surfaces, e.g. bed linen, prosthetic device or footwear.

Moisture: Slight amounts of moisture can lead to an increased risk of developing pressure ulcers. Moisture macerates the skin and decreases it’s strength.

• Risk mobility or immobility

• Sensory impairment

• Acute illness

• Level of consciousness

• Extremes of age

• Circulatory problems

• Severe chronic or terminal illness

• Previous history of pressure damage

• Malnutrition and dehydration

• Incontinence

Equipment/Device related

• Inappropriate use of specialised

equipment and poor manual handling

technique

• Enforced immobilisation

• Traction or splints

• Waiting times

• A and E, theatre, X ray

• Medication:

• Sedatives

• Steroids

• Anti-inflammatory medication

• Cytotoxic drugs

• Chair

• Wrong height

• Lack of pressure relieving cushion

In 1 study (Hanson et al, 1991), the majority of PU’s in a hospice sample occurred in the 2 weeks before death although this was not unexpected as body systems physiologically begin to shut down 10 to 14 days prior to death.

Pressure ulcers occurring just before death (2-3 days) were described by Karen Kennedy-Evans 1989) and coined the ‘Kennedy Terminal Ulcer’ although these are now referred to as SCALE ulcers.

These ulcers usually have a sudden onset and present on the sacrum.They can be shaped like a pear, butterfly or horseshoe.It can have the colours of red, yellow, black or purple.The borders of the ulcer are usually irregular.

These ulcers usually start out as a blister, or a Grade II, and can rapidly progresses to a Grade III or a Grade IV.

In the beginning it can look much like an abrasion. It can start as a red/purple area then turn to yellow and then black.

One theory is as people are approaching the dying process the internal organs begin to slow down and go into what is thought of as multi-organ failure. This is where all the organs start to slow down and not function as efficiently as previously.

No particular symptomatology may be detected except the skin over bony prominences starts to show effect of pressure in a shorter time frame. Where as turning a patient every two hours may be enough in somewhat of a normal situation it now may cause superficial tissue damage.

Many professionals concur that pressure

ulcers occurring at the end of life are often not preventable and that efforts to prevent them are complicated.

Because of the patient’s frail condition many professionals also agree that it may be impossible to eradicate PU’s in the terminally ill because of the multiple risk factors and

comorbid conditions.

The Byron Health Centre in the USA presented the 3:30 syndrome as a subdivision of the SCALE Ulcer.

These areas presents a little differently as they occur in a much shorter period of time

These areas of tissue damage look like a speck of dirt but on closer examination are small spots beneath the skins surface.

These can look like suspected deep tissue injuries. As the hours progress it becomes larger and can in a matter of hours become almost the size of a ten pence piece.

The usual story is the patient had no discoloration/skin damage evident on rising but at 3:30 PM, when the patient returned to bed, the skin showed blackened discoloration.

The life expectancy of the 3:30 syndrome presentation of these patients was within 8-24 hours.

(Thus the name: 3:30 syndrome).

IF IT’S PINK

PRESS

IT!

Please ensure you document all areas

checked as:

BLANCHING or NON-BLANCHING as

appropriate…..this tells us there is blood

supply to that area

DO NOT use the word INTACT as Grade 4

(EPUAP) damage can be Intact!

The European Pressure Ulcer Advisory Panel (EPUAP) is the recognised Grading tool for the UK.

The Grades of pressure damage are:

Grade 1

Grade 2

Grade 3

Deep Tissue Injury (DTI)

Grade 4

Definition:

Non-blanching erythema of intact skin.

Discoloration of the skin, warmth, oedema,

induration or hardness may also be used as

indicators, particularly on individuals with

darker skin.

Definition:

Partial thickness skin loss involving

epidermis, dermis, or both. The ulcer is

superficial and presents clinically as an

abrasion or blister.

Definition:

Full thickness skin loss involving damage /

necrosis of subcutaneous tissue that may

extend down to, but not through,

underlying fascia.

Definition:

Deep tissue injuries (DTI) are purple or

maroon areas of intact skin or blood-filled

blisters caused by damage to the underlying

soft tissues. It is common for a thin blister to

form over the surface of the dark wound

bed, and the wound may further evolve to

become covered by thin eschar.

Definition:

Extensive destruction, tissue necrosis, or

damage to muscle, bone, or supporting

structures with or without full thickness

skin loss.