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Palliative Care

Pressure Ulcer Management in Palliative Care

Prevention and management of skin and subcutaneous tissue injury caused by prolonged pressure or shear, common in patients with limited mobility.

Also known as: Bed Sore Management, Decubitus Ulcer Care

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Referral and warning signs

When to refer

Need for surgical debridement. Complex wounds requiring specialist wound care input. Need for skin grafting/flaps (usually not appropriate in end-of-life care). Suspected osteomyelitis.

Red flags

  • Signs of sepsis (fever, tachycardia, hypotension, confusion).
  • Rapidly spreading cellulitis.
  • Exposure of bone or tendon in the wound base.
  • Significant tissue necrosis requiring extensive debridement.
  • Failure to improve despite appropriate management.

Signs and symptoms

  • Stage I: Non-blanchable erythema of intact skin.
  • Stage II: Partial-thickness skin loss (abrasion, blister, shallow crater).
  • Stage III: Full-thickness skin loss involving damage/necrosis of subcutaneous tissue.
  • Stage IV: Full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures.
  • Unstageable: Full-thickness loss where base is covered by slough/eschar.
  • Pain at the ulcer site.
  • Signs of infection (increased redness, warmth, swelling, purulent discharge, odour).

Risk factors

  • Immobility.
  • Poor nutritional status.
  • Incontinence (moisture).
  • Reduced sensory perception.
  • Friction and shear forces.
  • Advanced age.
  • Chronic illness (diabetes, vascular disease).

Diagnosis

Clinical assessment

Regular skin inspection, especially over bony prominences (sacrum, heels, hips, elbows, shoulders). Identify and stage any ulcers found. Assess wound characteristics (size, depth, exudate, tissue type - granulation/slough/necrotic, surrounding skin condition). Assess for signs of infection.

Investigations

  • Wound swab for culture and sensitivity if clinical signs of infection present.
  • Blood tests (CBC, CRP) if systemic infection suspected.
  • Imaging (X-ray, MRI) only if osteomyelitis suspected beneath a deep ulcer.

Diagnostic criteria

Clinical assessment and staging based on visual inspection.

Management

Non-pharmacological management

  • Prevention:
  • - Frequent repositioning (e.g., every 2 hours if bedbound, more often if chairbound).
  • - Use of pressure-relieving surfaces (specialized mattresses, cushions).
  • - Optimize nutrition and hydration (consider prognosis).
  • - Keep skin clean and dry; use barrier creams if incontinent.
  • - Minimize friction and shear (use lifting sheets, avoid dragging).
  • - Regular skin inspection.
  • Treatment:
  • - Debridement of necrotic tissue/slough (surgical, enzymatic, autolytic - depending on resources and goals of care).
  • - Wound Cleansing: Use normal saline (0.9% NaCl).
  • - Dressings: Choose based on wound stage, exudate level, presence of infection, goals. (e.g., hydrocolloids, foams, alginates, hydrogels). Aim to maintain a moist wound environment.
  • - Manage exudate.
  • - Protect surrounding skin.
  • - Encourage mobility/position changes as much as possible.

Pharmacological treatment

  • Pain Management: Assess and treat wound-related pain (systemic analgesics, topical agents).
  • Topical Metronidazole: Powder or gel applied to wound for odour control.
  • Systemic Antibiotics: Only if signs of spreading cellulitis or systemic infection (sepsis). Treat based on likely organisms and culture results (if available). See UCG section 22.1.3 for cellulitis.

Monitoring

Regularly assess wound healing progress (size, tissue type, exudate). Monitor surrounding skin integrity. Assess pain control. Monitor for signs of infection.

Complications

  • Pain.
  • Local infection (cellulitis).
  • Systemic infection (sepsis).
  • Osteomyelitis (infection of underlying bone).
  • Delayed wound healing.
  • Increased caregiver burden.
  • Reduced quality of life.

Prevention

  • Risk assessment.
  • Regular repositioning schedule.
  • Use of pressure-reducing devices.
  • Skin care and hygiene.
  • Nutritional support (where appropriate).

Patient education

  • (Primarily for Caregivers):
  • Importance of regular turning/position changes.
  • How to inspect the skin for early signs.
  • Keeping skin clean and dry.
  • Proper lifting techniques (avoid dragging).
  • Importance of nutrition/hydration (if appropriate).
  • Basic wound care/dressing changes if applicable.
  • When to report concerns (signs of infection, worsening ulcer).

Uganda-specific notes

Access to specialized mattresses and advanced dressings is limited. Focus on frequent repositioning, basic skin hygiene, adequate padding, simple saline cleansing, and locally available dressings. Metronidazole for odour is a practical intervention. Early involvement of caregivers is crucial.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 13, Section 13.2.3

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