Chronic Wounds: Palliative Management for the Frail Population—PART II
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Chronic Wounds in the Frail Population
This section will review specific wounds most often seen among frail elderly that may have gradually become recalcitrant and nonresponsive to treatment regimes.
Pressure ulcers. Definition. Of all the chronic wound categories included in this document, pressure ulcers have the least satisfactory definition, which may account for the broad application of this term to ulcers having different etiologic factors. The definition of a pressure ulcer, according to the Pressure Ulcers in Adults: Prediction and Prevention is “…any lesion caused by unrelieved pressure resulting in damage of underlying tissue.”21 These ulcers usually occur over bony prominences and are classified based on depth of penetration through soft tissue layers to bone. Pressure ulcers are virtually the only type of wound that are solely attributed to external forces: pressure, shear, friction, and maceration.
Assessment. The presence of a pressure ulcer on a frail elderly person demands a comprehensive assessment of the entire patient to determine what factors and underlying diseases may have contributed to that ulcer’s occurrence. Pressure ulcers, theoretically, should always be considered healable, since external forces can generally be controlled. However, pressure ulcers among the frail population present some unique challenges.
The relationship between frailty and pressure ulcers is linked by significant commonalities in the core definition of frailty and key etiologic influences for pressure ulcers. Impaired mobility and abnormal nutrition form the cornerstone that defines frailty. Not surprisingly, these same factors are associated with the development of pressure ulcers.
Physical appearance. Pressure ulcers have a wide range of shapes and depth but can generally be confined to breakdown observed over bony prominences that have been exposed to some degree of pressure and probably other physical forces. The wound’s edges and its shape provide clues as to the influencing factors that initiated the skin breakdown. An oblong wound with a pocket of undermined tissue is most likely caused by a combination of pressure and shearing forces. This type of pressure ulcer is found most commonly over the sacral and ischial prominences. Wounds that form from blisters, with immune system or chemical irritant etiologies ruled out, are most likely caused by pressure and friction forces. Pressure ulcers that present with only a small opening to the skin and may drain foul smelling exudates are referred to as closed ulcers. These ulcers are formed through exposure to excessive pressure that has damaged the deep soft tissue before the epidermal layer. Another common pressure ulcer is one that is completely covered with eschar, often found on the heel. It is important to rule out other etiologic influences, such as peripheral vascular disease, before making the determination a wound is solely caused by pressure.
The wound bed of a pressure ulcer is also subject to a wide range of appearances. Exposure to excessive amounts of moisture and chemical irritation, such urine and/or fecal matter, will cause a pressure ulcer’s wound bed to become heavily contaminated while also weakening the surrounding intact skin.
Comorbidities. The occurrence of pressure ulcers is often accompanied by underlying medical conditions that predispose a patient to this type of ulcer. Clinical conditions that are the primary risk factors for developing pressure ulcers include continuous urinary incontinence or chronic voiding dysfunction, chronic bowel incontinence, paraplegia, quadriplegia, sepsis, and the illnesses and conditions listed above under Nonhealing Chronic Wounds.
Disease management treatments that contribute to pressure ulcer risk include steroid therapy, radiation therapy, chemotherapy, renal dialysis, and head elevation the majority of the day.
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