What is the best approach for managing decubitus (pressure) ulcers in hospice patients?

Management of Decubitus Ulcers in Hospice Patients

High protein nutritional supplementation combined with proper positioning, pressure redistribution, and appropriate wound dressings based on exudate level is the best approach for managing pressure ulcers in hospice patients. 1, 2

Nutritional Management

• Protein supplementation: High protein oral nutritional supplements (30% energy from protein) significantly reduce pressure ulcer development and improve healing 1

  • Recommended protein intake: 1.2-1.5 g/kg/day 2
  • Supplements containing micronutrients involved in wound healing (zinc, arginine, carotenoids, vitamins A, C, and E) may improve healing 1

• Evidence strength: Meta-analysis of four randomized controlled trials showed oral nutritional supplementation was associated with significantly lower incidence of pressure ulcer development (odds ratio 0.75; 95% CI 0.62–0.89) 1

Pressure Relief and Positioning

• Frequent repositioning: Change position every 2-4 hours to prevent further tissue damage 2
• Pressure redistribution: Use pressure-redistributing foam mattresses to prevent breakdown and reduce pain 1
  • Economic evidence supports early prevention of pressure ulcers using these specialized mattresses 1
  • Consider reclining chairs instead of gurney beds when appropriate 1
• Proper positioning: Ensure optimal blood circulation to pressure areas 1

Wound Care

Assessment and Documentation

• Document wound characteristics including size, depth, exudate level, and presence of necrotic tissue 2
• Evaluate for signs of infection (spreading cellulitis, systemic signs) 1, 2
• Reassess within 3 days of initial identification 2

Wound Dressing Selection

Based on exudate level:

• Minimal exudate: Hydrocolloid dressings 2
• Moderate exudate: Foam dressings 2
• Infected wounds: Non-occlusive dressings that allow drainage 2

Debridement and Infection Management

• Surgical debridement: Necessary to remove all necrotic tissue 1, 2
• Antibiotic therapy: For infected pressure ulcers with:
  • Spreading cellulitis
  • Systemic signs of infection
  • Target both Gram-positive and Gram-negative facultative organisms and anaerobes 1
  • Consider MRSA coverage in high-prevalence settings (>20% MRSA in local isolates) 1, 2

Special Considerations for Hospice Patients

• Goal-oriented care: Focus on symptom management and comfort rather than complete healing 3

• Palliative wound care priorities:

  • Control pain
  • Manage infection, odor, bleeding, and exudate
  • Maintain quality of life for patient and caregiver 3

• Family caregiver support: Educate caregivers about pressure ulcer care, acknowledging potential barriers such as:

  • Fear of causing pain
  • Guilt when new pressure ulcers develop
  • Discomfort with unpleasant wound characteristics 4

Common Pitfalls to Avoid

• Delaying treatment of infected ulcers increases risk of complications 2
• Relying solely on antimicrobial dressings is not recommended for routine wound management 2
• Neglecting nutritional status can impair healing potential 1, 2
• Overlooking the psychological impact on patients and caregivers 4

By implementing this comprehensive approach to pressure ulcer management in hospice patients, caregivers can help minimize discomfort and maintain dignity while providing appropriate palliative care.