If you are caring for a loved one who is terminally ill, you may have noticed some changes in their skin, such as redness, blisters, or open sores. These are called pressure injuries, and they are a common and serious problem for people who are bedridden, wheelchair-bound or have limited mobility. Pressure injuries can cause pain, infection, and reduced quality of life for your loved one and you. They can also increase the cost and complexity of care. Therefore, preventing and treating pressure injuries as effectively as possible is important.
This article will provide information and guidance on preventing and managing pressure injuries in terminally ill patients. We hope this article will help you understand and cope with pressure injury prevention and management challenges in terminally ill patients. We know that caring for a loved one who is terminally ill is not easy, and we want to support you and your loved one as much as we can. Please remember that you are not alone and that many people and services can help you and your loved one.
The Role of Skin as the Largest and Potentially the First Organ to Fail in the Body
Skin is the largest organ in the body, covering about 22 square feet (2 square meters) and weighing about 8 pounds (3.6 kilograms) in an average adult. It has many functions, such as:
Protecting the body from external threats, such as temperature, sunlight, chemicals, and pathogens
Regulating body temperature, fluid balance, and electrolyte levels
Producing vitamin D, which is essential for bone health and immune function
Sensing touch, pain, pressure, and temperature
Communicating emotions, such as blushing, sweating, or goosebumps
Skin is also one of the first organs to fail in the body, especially in terminally ill patients. Skin depends on adequate blood supply, oxygen, nutrients, and waste removal to maintain integrity and function. When these factors are compromised by disease, aging, or medication, skin becomes more vulnerable to damage and breakdown. This can lead to pressure injuries, which are areas of skin and tissue damage caused by prolonged pressure or friction.
Pressure injuries are not only a consequence of skin failure but also a cause of further organ failure. This is because pressure injuries can impair the skin’s ability to protect the body from infection, dehydration, and heat loss. They can also cause inflammation, pain, and stress, which can affect the immune system, the nervous system, and the endocrine system. Therefore, preventing and treating pressure injuries can help preserve the skin’s function and the body’s overall health.
Pressure injuries can also worsen the condition and prognosis of terminally ill patients. Terminally ill patients are those who have a life-limiting illness that cannot be cured or reversed and who are expected to die within a fleeting period. These patients often have multiple and complex medical problems, such as cancer, heart failure, kidney failure, or dementia. They may also experience symptoms such as pain, nausea, fatigue, anxiety, or depression. These factors can make them more susceptible to developing pressure injuries and make it harder to heal them.
Pressure injuries can affect the quality of life, comfort, and dignity of terminally ill patients and their families. Pressure injuries can cause physical and emotional distress, such as:
Physical distress: Pressure injuries can cause pain, bleeding, infection, odor, and drainage. They can also interfere with the patient’s mobility, sleep, and hygiene. They can require frequent and intensive care, such as dressing changes, wound cleaning, and medication administration. They can also increase the risk of complications, such as sepsis, osteomyelitis, or amputation.
Emotional distress: Pressure injuries can cause anxiety, depression, anger, guilt, or shame. They can also affect the patient’s self-esteem, body image, and social relationships. They can also cause moral distress, such as feeling that the patient’s suffering is unnecessary or preventable or that their wishes and values are not respected.
Therefore, it is important to prevent and treat pressure injuries in terminally ill patients, as they can have a significant impact on their physical, emotional, and spiritual well-being. By preventing and treating pressure injuries, we can help our loved ones to live with dignity, comfort, and peace in their final days.
How to Prevent Pressure Injuries in Terminally Ill Patients?
The best way to prevent pressure injuries is to avoid or reduce the factors that cause them, such as pressure, shear, friction, moisture, and malnutrition. The following are some general principles of pressure injury prevention that apply to all terminally ill patients, regardless of their setting or condition:
Assess the patient’s risk of developing pressure injuries using a validated tool like the Braden or Norton Scale. The risk assessment should be done on admission, at regular intervals, and whenever there is a change in the patient’s condition or care plan.
Optimize the patient’s nutritional status by providing adequate calories, protein, fluids, and micronutrients, such as vitamins C and E, zinc, and copper. These nutrients are essential for skin health and wound healing. If the patient has difficulty eating or swallowing, consider using oral supplements, enteral feeding, or parenteral nutrition as appropriate. Consult a dietitian for individualized recommendations and monitoring.
Reposition the patient at least every two hours, or more frequently if needed, to relieve pressure from bony prominences, such as the sacrum, heels, hips, and elbows. Use a repositioning schedule and document the position changes. Use pillows, wedges, or foam devices to off-load pressure and prevent skin-to-skin contact. Avoid dragging or sliding the patient across the bed, which can cause shear and friction injuries. Use a draw sheet, a transfer board, or a mechanical lift to move the patient safely and gently.
Provide appropriate support surfaces for the patient, such as mattresses, overlays, cushions, or specialty beds, which can redistribute pressure, reduce shear and friction, and control moisture and temperature. Choose the support surface based on the patient’s risk level, comfort, mobility, and preference. Follow the manufacturer’s instructions for installation, maintenance, and cleaning. Check the patient’s skin regularly for signs of pressure injury or damage from the support surface.
Keep the patient’s skin clean, dry, and moisturized. Use mild, pH-balanced cleansers and avoid harsh soaps, alcohol, or antiseptics that can irritate or dry the skin. Pat the skin dry gently and avoid rubbing or scrubbing. Apply moisturizers to prevent dryness and cracking, especially on the heels and elbows. Avoid talcum powder, cornstarch, or other products that can clog the pores or create friction. Change wet or soiled clothing, bedding, or incontinence products immediately. Use barrier creams or films to protect the skin from moisture, urine, or feces.
The general principles of pressure injury prevention can be adapted to different clinical settings, such as home, hospice, or hospital, depending on the availability of resources, equipment, and personnel. The following are some specific recommendations for each setting:
Home: If the patient is cared for at home, involve the family or caregivers in the pressure injury prevention plan. Educate them on assessing the patient’s risk, providing adequate nutrition and hydration, repositioning the patient, choosing and using the support surface, and caring for the skin. Please provide them with written instructions, demonstrations, and feedback. Arrange for regular visits from a home health nurse, a wound care specialist, or a palliative care team to monitor the patient’s condition and provide guidance and support. Ensure that the patient has access to emergency services, such as 911, in case of complications or deterioration.
Hospice: If the patient is admitted to a hospice facility, coordinate the pressure injury prevention plan with the hospice staff, who are trained and experienced in palliative care. Communicate the patient’s goals, preferences, and values regarding their care and comfort. Respect the patient’s wishes and dignity and avoid interventions that may cause unnecessary pain or distress. Focus on symptom management, quality of life, and emotional and spiritual support for the patient and their family. Use a multidisciplinary approach that involves the patient, the family, the hospice staff, and other health professionals, such as a dietitian, a wound care specialist, or a chaplain.
Hospital: If the patient is hospitalized, follow the hospital’s policies and protocols for pressure injury prevention and management. Use standardized tools and documentation for risk assessment, repositioning, support surface selection, and skin care. Collaborate with other healthcare team members, such as nurses, physicians, dietitians, wound care specialists, physical therapists, and social workers, to provide comprehensive and coordinated care. Educate the patient and the family on the causes, prevention, and treatment of pressure injuries and involve them in decision-making. Prepare the patient and the family for discharge and transition to another setting, such as home or hospice, and provide them with appropriate referrals and resources.
Some population groups may have additional needs or challenges in pressure injury prevention and management, such as those with obesity, spinal cord injury, or children. The following are some guidance for these groups:
Obesity: Patients with obesity may have an increased risk of developing pressure injuries due to excess weight, reduced mobility, skin folds, and comorbidities, such as diabetes or cardiovascular disease. To prevent and manage pressure injuries in obese patients, consider the following strategies:
Use bariatric equipment, such as beds, mattresses, cushions, chairs, lifts, and scales, to accommodate the patient’s size and weight. Ensure that the equipment is properly fitted, adjusted, and maintained.
Reposition the patient more frequently, at least every hour, and use extra pillows, wedges, or foam devices to off-load pressure and separate skin folds. Check the skin folds for signs of moisture, maceration, or infection, and keep them clean and dry. Apply barrier creams or films to protect the skin from irritation or breakdown.
Provide adequate nutrition and hydration, but avoid overfeeding or underfeeding the patient. Consult a dietitian for individualized recommendations and monitoring.
Spinal cord injury: Patients with spinal cord injury may have an increased risk of developing pressure injuries due to paralysis, loss of sensation, spasticity, and autonomic dysreflexia. To prevent and manage pressure injuries in spinal cord injury patients, consider the following strategies:
Use pressure mapping, a device that measures the pressure distribution on the patient’s body, to identify high-risk areas and adjust the support surface accordingly.
Reposition the patient more frequently, at least every 15 minutes, and use a tilt table, a standing frame, or a wheelchair cushion to change the pressure points and improve blood circulation.
Provide adequate nutrition and hydration and monitor the patient’s bowel and bladder function. Use intermittent catheterization, bowel management programs, or medications to prevent urinary or fecal incontinence, which can cause skin damage and infection.
Educate the patient and the family on recognizing and managing autonomic dysreflexia. This potentially life-threatening condition occurs when the patient’s blood pressure rises due to a stimulus below the level of injury, such as a pressure injury, a full bladder, or tight clothing. Symptoms include headache, sweating, flushing, goosebumps, nasal congestion, and anxiety. Treatment includes removing the stimulus, elevating the head, and taking medications to lower blood pressure.
Children: Children may have an increased risk of developing pressure injuries due to immature skin, growth spurts, developmental delays, or congenital anomalies. To prevent and manage pressure injuries in children, consider the following strategies:
Use pediatric equipment, such as beds, mattresses, cushions, chairs, lifts, and scales, designed for children’s size and weight. Ensure that the equipment is properly fitted, adjusted, and maintained.
Reposition the child more frequently, at least every hour, and use toys, books, or games to distract and engage the child during the repositioning. Use pillows, wedges, or foam devices to off-load pressure and prevent skin-to-skin contact. Avoid using diapers, tapes, or adhesives that can cause skin damage or infection.
Provide adequate nutrition and hydration and monitor the child’s growth and development. Use growth charts, anthropometric measurements, and laboratory tests to assess the child’s nutritional status. Consult a dietitian for individualized recommendations and monitoring.
Educate the child and the family on the causes, prevention, and treatment of pressure injuries, and use age-appropriate language and materials. Involve the child in the decision-making process and respect the child’s preferences and feelings. Provide emotional and psychological support for the child and the family.
The sources of evidence and best practices for pressure injury prevention are based on the latest scientific research and clinical experience. Some of the most authoritative and comprehensive sources are:
The International Guideline: This global guideline recommends preventing and treating pressure injuries in all types of patients, settings, and conditions. It was developed by a panel of experts from various disciplines and countries and updated every four years. The latest version was published in 2019.
The ACI guideline: This local guideline recommends preventing and managing pressure injuries in palliative care settings in New South Wales, Australia. It was developed by the Agency for Clinical Innovation (ACI), a state health agency supporting innovation and healthcare improvement. The latest version was published in 2018.
We encourage you to consult these sources for more detailed, specific information and guidance on preventing and managing pressure injuries. You can also ask your healthcare providers for their advice and expertise.
Limitations of Nutrition and Exercise for the Terminally Ill
Nutrition and exercise are important for the health and well-being of everyone, but especially for people who have pressure injuries or are at risk of developing them. They can help maintain the skin’s integrity and function and promote wound healing and recovery. However, providing adequate nutrition and exercise for terminally ill patients can be challenging and sometimes impossible due to numerous factors that affect their appetite, digestion, metabolism, and mobility. This section will discuss some of these factors and their consequences.
Challenges and Barriers to Providing Adequate Nutrition and Exercise for Terminally Ill Patients
Terminally ill patients are those who have a life-limiting illness that cannot be cured or reversed and who are expected to die within a fleeting period. These patients often have multiple and complex medical problems, such as cancer, heart failure, kidney failure, or dementia. They may also experience symptoms such as pain, nausea, fatigue, anxiety, or depression. These factors can make it difficult or impossible for them to eat or exercise enough or to benefit from them. Some of the common challenges and barriers are:
Reduced appetite: Terminally ill patients may lose their appetite or interest in food due to factors such as disease progression, medication side effects, taste changes, mouth sores, or psychological distress. They may also have difficulty swallowing or chewing due to dry mouth, dental problems, or tumors. They may also have ethical or religious reasons to refuse food or fluids, such as fasting or preparing for death.
Nausea and vomiting: Terminally ill patients may experience nausea and vomiting due to factors such as disease progression, medication side effects, bowel obstruction, or increased intracranial pressure. They may also have gastroesophageal reflux, gastritis, or peptic ulcers, which can cause heartburn, indigestion, or bleeding. They may also have constipation, diarrhea, or fecal impaction, affecting their bowel function and comfort.
Fatigue and weakness: Terminally ill patients may experience fatigue and weakness due to disease progression, medication side effects, anemia, or dehydration. They may also have muscle wasting, joint stiffness, or contractures, which can limit their range of motion and strength. They may also have pain, dyspnea, or edema, which can interfere with their physical activity and endurance.
Pain and discomfort: Terminally ill patients may experience pain and discomfort due to disease progression, pressure injuries, infection, or inflammation. They may also have neuropathic pain, which is caused by nerve damage or compression and can cause burning, tingling, or shooting sensations. They may also have visceral pain, which is caused by organ dysfunction or distension and can cause cramping, bloating, or pressure sensations. They may also have emotional pain, which is caused by psychological distress and can cause sadness, anger, or fear.
Immobility and dependence: Terminally ill patients may become immobile and dependent due to factors such as disease progression, medication side effects, fatigue, weakness, or pain. They may also have cognitive impairment, such as confusion, delirium, or dementia, which can affect their awareness, memory, or judgment. They may also have sensory impairment, such as vision loss, hearing loss, or numbness, which can affect their perception, communication, or balance. They may also have social isolation, such as a lack of family, friends, or caregivers, which can affect their motivation, support, or participation.
Consequences of Malnutrition and Inactivity for Skin and Wound Healing
Malnutrition and inactivity can have severe and negative consequences for the skin and wound healing, such as:
Impaired immunity: Malnutrition and inactivity can impair the immune system, which fights infection and inflammation. This can increase the risk of developing pressure injuries or worsen the existing ones. It can also delay or prevent the wound-healing process and increase the risk of complications, such as sepsis, osteomyelitis, or amputation.
Increased inflammation: Malnutrition and inactivity can increase inflammation, the body’s response to injury or infection. This can cause pain, swelling, redness, and heat in the affected area. It can also damage healthy tissue and impair the wound-healing process. It can also affect the systemic health and well-being of the patient and cause symptoms such as fever, chills, or malaise.
Delayed tissue repair: Malnutrition and inactivity can delay tissue repair, replacing the damaged tissue with new tissue. This can affect the different phases of wound healing, such as hemostasis, inflammation, proliferation, and remodeling. It can also affect the quality and quantity of the new tissue, such as collagen, elastin, or granulation tissue. It can also affect the appearance and function of the wound, such as scar formation, contracture, or dehiscence.
Reduced blood flow: Malnutrition and inactivity can reduce the blood flow, which is the delivery of oxygen and nutrients to the tissue and the removal of waste and carbon dioxide from the tissue. This can affect the viability and function of the tissue and cause ischemia, hypoxia, or necrosis. It can also affect the wound-healing process and impair angiogenesis, which is the formation of new blood vessels. It can also affect the systemic health and well-being of the patient and cause symptoms such as pallor, cyanosis, or coldness.
Vitamins and Mineral Supplements for Pressure Injury Prevention and Healing
Vitamins and minerals are nutrients your body needs in small amounts to function properly and stay healthy. Some vitamins C, E, zinc, and copper are especially important for skin and wound healing. In this section, we will review their roles and functions, summarize the evidence and recommendations for their supplementation, provide some examples of their sources and forms, and advise you to consult with your healthcare providers before using them.
Roles and Functions of Vitamins and Minerals for Skin Health and Wound Healing
Vitamin C, vitamin E, zinc, and copper are essential for skin health and wound healing because they have the following roles and functions:
Vitamin C: Vitamin C is a water-soluble vitamin that acts as an antioxidant, protecting your cells from damage caused by free radicals. These harmful molecules can cause inflammation and aging. Vitamin C also helps your body make collagen, a protein that gives your skin strength and elasticity. Collagen is also important for wound healing, forming the framework for new tissue growth. Vitamin C also helps your body absorb iron, which carries oxygen to your cells and tissues.
Vitamin E: Vitamin E is a fat-soluble vitamin that also acts as an antioxidant, protecting your cells from damage caused by free radicals, especially in your skin and membranes. Vitamin E also helps your body regulate inflammation, a normal response to injury or infection. It can also cause pain, swelling, and delayed healing if it is too much or too long. Vitamin E also helps your skin retain moisture, preventing dryness and cracking.
Zinc: Zinc is a mineral involved in many processes in your body, such as cell growth, division, and repair. Zinc also helps your body make proteins and enzymes, which are molecules that speed up chemical reactions and perform various functions. Zinc is vital for wound healing; it helps your body form new skin, blood vessels, and scar tissue. Zinc also helps your body fight infection, as it supports your immune system, which is your body’s defense against germs and foreign substances.
Copper: Copper is a mineral that works with zinc and iron to help your body make red blood cells, which carry oxygen to your cells and tissues. Copper also helps your body produce collagen and elastin, proteins that give your skin strength and elasticity. Copper also helps your body form new blood vessels, improving blood flow and oxygen delivery to your wound. Copper also has antibacterial and anti-inflammatory properties, which can prevent infection and reduce inflammation.
Evidence and Recommendations for Vitamin and Mineral Supplementation for Pressure Injury Prevention and Healing
Vitamin and mineral supplementation can benefit pressure injury prevention and healing, especially if you have a deficiency or a higher need for them. However, the evidence and recommendations for their supplementation vary depending on the type, dose, duration, and safety of the supplement, as well as the patient’s condition, preference, and tolerance. Here are some general guidelines based on the latest research and clinical practice:
Vitamin C: The recommended daily vitamin C intake for adults is 75 mg for women and 90 mg for men. However, if you have a pressure injury or a risk of developing one, you may need more vitamin C to support your skin and wound healing. The International Guideline suggests taking 500 to 1000 mg of vitamin C daily for 8 to 12 weeks or until your wound heals. However, taking too much vitamin C can cause side effects, such as diarrhea, nausea, or kidney stones. Therefore, you should not take more than 2000 mg of vitamin C daily unless your health care provider advises otherwise.
Vitamin E: The recommended daily vitamin E intake for adults is 15 mg (or 22.4 IU) for both women and men. However, if you have a pressure injury or a risk of developing one, you may benefit from applying vitamin E topically, which means directly on your skin or wound. The International Guideline suggests applying vitamin E oil or cream once or twice daily for 2 to 4 weeks or until your wound heals. However, applying too much vitamin E can cause side effects, such as skin irritation, rash, or allergic reaction. Therefore, you should not apply more than 400 IU of vitamin E daily unless your health care provider advises otherwise.
Zinc: Adults’ recommended daily zinc intake is 8 mg for women and 11 mg for men. However, if you have a pressure injury or a risk of developing one, you may need more zinc to support your skin and wound healing. The International Guideline suggests taking 15 to 30 mg of zinc daily for 8 to 12 weeks or until your wound heals. However, taking too much zinc can cause side effects, such as nausea, vomiting, diarrhea, or copper deficiency. Therefore, you should not take more than 40 mg of zinc daily unless your health care provider advises otherwise.
Copper: The recommended daily intake of copper for adults is 0.9 mg for both women and men. However, if you have a pressure injury or a risk of developing one, you may benefit from applying copper topically, directly on your skin or wound. The International Guideline suggests applying copper sulfate or copper oxide dressing once or twice daily for 2 to 4 weeks or until your wound heals. However, too much copper can cause side effects, such as skin irritation, rash, or allergic reaction. Therefore, you should follow the manufacturer’s instructions for the copper dressing and consult your healthcare provider before using it.
Examples of Vitamin and Mineral Supplements for Terminally Ill Patients
Vitamin and mineral supplements can come in different forms, such as oral, enteral, or parenteral. The form of the supplement depends on the patient’s ability and preference to take it, as well as the availability and suitability of the supplement. Here are some examples of vitamin and mineral supplements that are available and suitable for terminally ill patients:
Oral: Oral supplements are those you swallow, such as tablets, capsules, liquids, or powders. Oral supplements are usually the easiest and cheapest way to take vitamins and minerals if you can swallow and digest them. However, oral supplements may not be absorbed well by your body, especially if you have problems with your stomach, intestines, or liver. Oral supplements may also interact with other medications or foods, so you should check with your healthcare provider before taking them. Some examples of oral supplements are:
Vitamin C: You can find vitamin C supplements in various forms, such as tablets, capsules, chewables, gummies, liquids, or powders. You can also find vitamin C combined with other nutrients, such as zinc, iron, or bioflavonoids, which may enhance its absorption and effectiveness. You can choose the form and dose of vitamin C that suits your needs and preferences, but remember not to exceed the maximum limit of 2000 mg daily.
Vitamin E: You can find vitamin E supplements in various forms, such as tablets, capsules, soft gels, liquids, or oils. You can also find vitamin E combined with other nutrients, such as selenium, which may enhance its antioxidant and anti-inflammatory properties. You can choose the form and dose of vitamin E that suits your needs and preferences, but remember not to exceed the maximum limit of 1000 mg (or 1500 IU) daily.
Zinc: You can find zinc supplements in various forms, such as tablets, capsules, lozenges, liquids, or syrups. You can also find zinc combined with other nutrients, such as vitamin C, copper, or calcium, which may enhance its absorption and effectiveness. You can choose the form and dose of zinc that suits your needs and preferences, but remember not to exceed the maximum limit of 40 mg per day.
Copper: You can find copper supplements in various forms, such as tablets, capsules, liquids, or drops. You can also find copper combined with other nutrients, such as zinc, iron, or manganese, which may enhance its absorption and effectiveness. You can choose the form and dose of copper that suits your needs and preferences, but remember not to exceed the maximum limit of 10 mg daily.
Enteral: Enteral supplements are those you take through a tube that goes into your stomach or intestines, such as a nasogastric tube, a gastrostomy tube, or a jejunostomy tube. Enteral supplements are usually used when you cannot swallow or digest oral supplements or need more nutrients than oral supplements can provide. However, enteral supplements may cause side effects, such as nausea, vomiting, diarrhea, or bloating, and they may require special equipment and care. Enteral supplements may also interact with other medications or foods that you take, so you should check with your healthcare provider before taking them. Some examples of enteral supplements are:
Vitamin C: You can find vitamin C supplements in liquid or powder form that can be mixed with water or juice and given through a tube. You can also find vitamin C in some enteral formulas, complete or partial nutrition products containing other nutrients, such as protein, carbohydrates, fats, vitamins, and minerals. You can choose the form and dose of vitamin C that suits your needs and preferences, but remember not to exceed the maximum limit of 2000 mg daily.
Vitamin E: You can find vitamin E supplements in liquid or powder form that can be mixed with water or juice and given through a tube. You can also find vitamin E in some enteral formulas, complete or partial nutrition products containing other nutrients, such as protein, carbohydrates, fats, vitamins, and minerals. You can choose the form and dose of vitamin E that suits your needs and preferences, but remember not to exceed the maximum limit of 1000 mg (or 1500 IU) per day.
Zinc: You can find zinc supplements in liquid or powder form that can be mixed with water or juice and given through a tube. You can also find zinc in some enteral formulas and complete or partial nutrition products containing other nutrients, such as protein, carbohydrates, fats, vitamins, and minerals. You can choose the form and dose of zinc that suits your needs and preferences, but remember not to exceed the maximum limit of 40 mg per day.
Copper: You can find copper supplements in liquid or powder form that can be mixed with water or juice and given through a tube. You can also find copper in some enteral formulas and complete or partial nutrition products containing other nutrients, such as protein, carbohydrates, fats, vitamins, and minerals. You can choose the form and dose of copper that suits your needs and preferences, but remember not to exceed the maximum limit of 10 mg daily.
Parenteral: Parenteral supplements are those you take through a vein, such as an intravenous (IV) line or a central venous catheter (CVC). Parenteral supplements are usually used when you cannot take oral or enteral supplements or when you need more nutrients than oral or enteral supplements can provide. However, parenteral supplements may cause side effects, such as infection, inflammation, or clotting, and they may require special equipment and care. Parenteral supplements may also interact with other medications or fluids that you take, so you should check with your healthcare provider before taking them. Some examples of parenteral supplements are:
Vitamin C: You can find vitamin C supplements in liquid form that can be given through a vein. You can also find vitamin C in some parenteral formulas, complete or partial nutrition products containing other nutrients, such as amino acids, glucose, lipids, electrolytes, and trace elements. You can choose the form and dose of vitamin C that suits your needs and preferences, but remember not to exceed the maximum limit of 2000 mg daily.
Vitamin E: You can find vitamin E supplements in liquid form that can be given through a vein. You can also find vitamin E in some parenteral formulas, complete or partial nutrition products containing other nutrients, such as amino acids, glucose, lipids, electrolytes, and trace elements. You can choose the form and dose of vitamin E that suits your needs and preferences, but remember not to exceed the maximum limit of 1000 mg (or 1500 IU) daily.
Zinc: You can find zinc supplements in liquid form that can be given through a vein. In some parenteral formulas, you can also find zinc, complete or partial nutrition products containing other nutrients, such as amino acids, glucose, lipids, electrolytes, and trace elements. You can choose the form and dose of zinc that suits your needs and preferences, but remember not to exceed the maximum limit of 40 mg per day.
Copper: You can find copper supplements in liquid form that can be given through a vein. In some parenteral formulas, you can also find copper, complete or partial nutrition products containing other nutrients, such as amino acids, glucose, lipids, electrolytes, and trace elements. You can choose the form and dose of copper that suits your needs and preferences, but remember not to exceed the maximum limit of 10 mg daily.
Advice for Consulting with Health Care Providers before Starting or Changing any Vitamin or Mineral Supplements
Vitamin and mineral supplements can be helpful for pressure injury prevention and healing, but they can also be harmful if they are not used properly or appropriately. Therefore, you should always consult with your healthcare providers before starting or changing any vitamin or mineral supplements, as they may interact with other medications or conditions that you have. Here are some tips for consulting with your healthcare providers:
Tell them about your current medications, supplements, and medical conditions. Ask them for any potential interactions or contraindications with the vitamin or mineral supplements you want to take.
Ask them about the benefits, risks, and alternatives of the vitamin or mineral supplements you want to take and how they fit with your goals, preferences, and values.
Follow their instructions and recommendations for the type, dose, duration, and frequency of your vitamin or mineral supplements, and report any side effects or problems you experience.
Review your vitamin or mineral supplements with them regularly and update them on any changes in your condition or care plan.
How to Manage Pressure Injuries in Terminally Ill Patients?
Even with the best prevention efforts, pressure injuries may still develop or worsen in terminally ill patients. Therefore, it is important to manage pressure injuries as soon as possible to reduce their impact on the patient’s health and well-being. In this section, we will explain the goals and principles of pressure injury management, provide specific recommendations for different stages and types of pressure injuries, discuss the role of pain management, infection control, and palliative care in pressure injury management, and mention the sources of evidence and best practices for pressure injury management.
Goals and Principles of Pressure Injury Management
The goals of pressure injury management are to:
Promote wound healing: This means helping the wound close and heal by removing dead or damaged tissue, stimulating new tissue growth, and restoring the skin’s function and appearance.
Prevent wound deterioration: This means preventing the wound from worsening by controlling infection, inflammation, and bleeding and preventing further tissue damage or loss.
Relieve wound symptoms: This means relieving wound-related symptoms, such as pain, odor, drainage, and itching, and improving the patient’s comfort and quality of life.
Respect wound preferences: This means respecting the patient’s wishes, choices, and values regarding wound care and comfort and involving them in decision-making.
The principles of pressure injury management are to:
Assess the wound: This means to examine the wound and its surrounding skin and measure its size, depth, color, and condition. This also means identifying the stage and type of the wound and determining its cause and risk factors. This also means evaluating the patient’s general health and nutritional status and considering their goals, preferences, and values. The wound assessment should be done on admission, at regular intervals, and whenever there is a change in the wound or the patient’s condition or care plan.
Clean the wound: This means removing dirt, debris, or dead tissue from the wound and reducing the number of bacteria and other germs that can cause infection or inflammation. This can be done using water, saline, or antiseptic solutions and gentle irrigation, washing, or debridement techniques. The wound cleaning should be done before applying any dressing or bandage and whenever the wound is contaminated or infected.
Dress the wound: This means covering the wound with an appropriate dressing or bandage, which can protect the wound from further damage or infection and create a warm environment that promotes wound healing. Depending on the wound’s characteristics, needs, and goals, various dressings or bandages, such as gauze, foam, hydrogel, hydrocolloid, alginate, or silver, can be used. The wound dressing should be changed regularly whenever wet, soiled, or loose.
Manage the wound site: This means managing the factors that can affect wound healing or deterioration, such as pressure, shear, friction, moisture, and malnutrition. This can be done using various strategies, such as repositioning the patient, providing appropriate support surfaces, keeping the skin clean and dry, and optimizing the nutritional status. The wound site management should be done continuously, and whenever there is a change in the wound or the patient’s condition or care plan.
Specific Recommendations for Different Stages and Types of Pressure Injuries
Pressure injuries can be classified into different stages and types based on their appearance and severity. The stage and type of the pressure injury can affect the choice and outcome of the wound management interventions. The following are some specific recommendations for different stages and types of pressure injuries, based on the International Guideline and the AAFP guideline:
Stage 1: Stage 1 pressure injuries are those that have intact skin but show signs of redness, warmth, or hardness, which do not fade when pressed. Stage 1 pressure injuries are usually caused by mild or short-term pressure and can be reversed if the pressure is relieved. To manage stage 1 pressure injuries, the following interventions are suggested:
Relieve the pressure from the affected area by repositioning the patient, using pillows, wedges, or foam devices, and providing appropriate support surfaces.
Monitor the skin for any changes or signs of deterioration, such as blistering, cracking, or infection, and report them to the health care provider.
To prevent dryness or irritation, keep the skin clean and dry and apply moisturizers, barrier creams, or films.
Do not use massage, heat, or cold therapy, as they can worsen skin damage or mask the signs of deterioration.
Stage 2: Stage 2 pressure injuries have broken skin but show signs of shallow or partial-thickness tissue loss, such as blisters, abrasions, or shallow ulcers. Stage 2 pressure injuries are usually caused by moderate or long-term pressure and can be healed if the pressure is relieved and the wound is treated. To manage stage 2 pressure injuries, the following interventions are suggested:
Relieve the pressure from the affected area by repositioning the patient, using pillows, wedges, or foam devices, and providing appropriate support surfaces.
Clean the wound with water, saline, or antiseptic solutions and gently remove dirt, debris, or dead tissue using irrigation, washing, or debridement techniques.
Dress the wound with an appropriate dressing or bandage, which can protect the wound from further damage or infection and create a moist and warm environment that can promote wound healing. Examples of suitable dressings or bandages are gauze, foam, hydrogel, or hydrocolloid.
Change the dressing or bandage regularly when wet, soiled, or loose. Monitor the wound for any changes or signs of healing or deterioration, such as granulation, epithelialization, or infection, and report them to the health care provider.
Optimize the nutritional status by providing adequate calories, protein, fluids, and micronutrients, such as vitamins C and E, zinc, and copper, essential for wound healing. Consult a dietitian for individualized recommendations and monitoring.
Stage 3: Stage 3 pressure injuries are those that have broken skin and show signs of deep or full-thickness tissue loss, such as deep ulcers, tunnels, or undermining. Stage 3 pressure injuries are usually caused by severe or prolonged pressure and can be difficult to heal, especially if the patient has other medical problems or poor nutritional status. To manage stage 3 pressure injuries, the following interventions are suggested:
Relieve the pressure from the affected area by repositioning the patient, using pillows, wedges, or foam devices, and providing appropriate support surfaces.
Clean the wound with water, saline, or antiseptic solutions, and gently remove any dirt, debris, or dead tissue using irrigation, washing, or debridement techniques. Debridement is especially important for stage 3 pressure injuries, as it can remove necrotic or sloughy tissue that can impair wound healing or cause infection. Debridement can be done using various methods, such as surgical, mechanical, enzymatic, or biological, depending on the wound’s characteristics, needs, and goals. Consult a wound care specialist for individualized recommendations and monitoring.
Dress the wound with an appropriate dressing or bandage. This can protect the wound from further damage or infection and create a moist and warm environment that can promote wound healing. Examples of suitable dressings or bandages are foam, hydrogel, hydrocolloid, alginate, or silver. Alginate and silver dressings are especially useful for stage 3 pressure injuries, as they can absorb excess drainage and prevent or treat infection. Consult a wound care specialist for individualized recommendations and monitoring.
Change the dressing or bandage regularly when wet, soiled, or loose. Monitor the wound for any changes or signs of healing or deterioration, such as granulation, epithelialization, or infection, and report them to the health care provider.
Optimize the nutritional status by providing adequate calories, protein, fluids, and micronutrients, such as vitamins C and E, zinc, and copper, essential for wound healing. Consult a dietitian for individualized recommendations and monitoring.
Stage 4: Stage 4 pressure injuries have broken skin and show signs of extensive or full-thickness tissue loss, such as deep ulcers, tunnels, undermining, or exposed bone, muscle, or tendon. Stage 4 pressure injuries are usually caused by severe or prolonged pressure and can be exceedingly difficult to heal, especially if the patient has other medical problems or poor nutritional status. To manage stage 4 pressure injuries, the following interventions are suggested:
Relieve the pressure from the affected area by repositioning the patient, using pillows, wedges, or foam devices, and providing appropriate support surfaces.
Clean the wound with water, saline, or antiseptic solutions, and gently remove any dirt, debris, or dead tissue using irrigation, washing, or debridement techniques. Debridement is especially important for stage 4 pressure injuries, as it can remove necrotic or sloughy tissue that can impair wound healing or cause infection. Debridement can be done using various methods, such as surgical, mechanical, enzymatic, or biological, depending on the wound’s characteristics, needs, and goals. Consult a wound care specialist for individualized recommendations and monitoring.
Dress the wound with an appropriate dressing or bandage. This can protect the wound from further damage or infection and create a moist and warm environment that can promote wound healing. Examples of suitable dressings or bandages are foam, hydrogel, hydrocolloid, alginate, or silver. Alginate and silver dressings are especially useful for stage 4 pressure injuries, as they can absorb excess drainage and prevent or treat infection. Consult a wound care specialist for individualized recommendations and monitoring.
Change the dressing or bandage regularly when wet, soiled, or loose. Monitor the wound for any changes or signs of healing or deterioration, such as granulation, epithelialization, or infection, and report them to the health care provider.
Optimize the nutritional status by providing adequate calories, protein, fluids, and micronutrients, such as vitamins C and E, zinc, and copper, essential for wound healing. Consult a dietitian for individualized recommendations and monitoring.
Consider surgical intervention if the wound is too large, deep, or complex to heal by conservative methods or if the patient has other medical problems or poor nutritional status that impair wound healing. Surgical intervention can involve various procedures, such as skin grafts, flaps, or artificial skin, which can cover the wound and restore the skin’s function and appearance. Consult a surgeon for individualized recommendations and monitoring.
Unstageable: Unstageable pressure injuries are those that have broken skin and show signs of full-thickness tissue loss, but the wound bed is covered by a thick layer of necrotic or sloughy tissue, which makes it impossible to determine the depth or extent of the wound. Unstageable pressure injuries are usually caused by severe or prolonged pressure and can be exceedingly difficult to heal, especially if the patient has other medical problems or poor nutritional status. To manage unstageable pressure injuries, the following interventions are suggested:
Relieve the pressure from the affected area by repositioning the patient, using pillows, wedges, or foam devices, and providing appropriate support surfaces.
Clean the wound with water, saline, or antiseptic solutions, and gently remove any dirt, debris, or dead tissue using irrigation, washing, or debridement techniques. Debridement is especially important for unstageable pressure injuries, as it can remove necrotic or sloughy tissue that can impair wound healing or cause infection. Debridement can be done using various methods, such as surgical, mechanical, enzymatic, or biological, depending on the wound’s characteristics, needs, and goals. Consult a wound care specialist for individualized recommendations and monitoring.
Dress the wound with an appropriate dressing or bandage, which can protect the wound from further damage or infection and create a moist and warm environment that can promote wound healing. Examples of suitable dressings or bandages are foam, hydrogel, hydrocolloid, alginate, or silver. Alginate and silver dressings are especially useful for unstageable pressure injuries, as they can absorb excess drainage and prevent or treat infection. Consult a wound care specialist for individualized recommendations and monitoring.
Change the dressing or bandage regularly when wet, soiled, or loose. Monitor the wound for any changes or signs of healing or deterioration, such as granulation, epithelialization, or infection, and report them to the health care provider.
Optimize the nutritional status by providing adequate calories, protein, fluids, and micronutrients, such as vitamins C and E, zinc, and copper, essential for wound healing. Consult a dietitian for individualized recommendations and monitoring.
Consider surgical intervention if the wound is too large, deep, or complex to heal by conservative methods or if the patient has other medical problems or poor nutritional status that impair wound healing. Surgical intervention can involve various procedures, such as skin grafts, flaps, or artificial skin, which can cover the wound and restore the skin’s function and appearance. Consult a surgeon for individualized recommendations and monitoring.
Infected: Infected pressure injuries have signs of infection, such as increased pain, redness, swelling, heat, odor, drainage, or fever. Infection can occur in any stage or type of pressure injury, can delay or prevent wound healing, and increases the risk of complications, such as sepsis, osteomyelitis, or amputation. To manage infected pressure injuries, the following interventions are suggested:
Relieve the pressure from the affected area by repositioning the patient, using pillows, wedges, or foam devices, and providing appropriate support surfaces.
Clean the wound with water, saline, or antiseptic solutions, and gently remove any dirt, debris, or dead tissue using irrigation, washing, or debridement techniques. Debridement is especially important for infected pressure injuries, as it can remove the necrotic or sloughy tissue that can harbor bacteria and cause infection. Debridement can be done using various methods, such as surgical, mechanical, enzymatic, or biological, depending on the wound’s characteristics, needs, and goals. Consult a wound care specialist for individualized recommendations and monitoring.
Dress the wound with an appropriate dressing or bandage, which can protect the wound from further damage or infection and create a moist and warm environment that can promote wound healing. Examples of suitable dressings or bandages are foam, hydrogel, hydrocolloid, alginate, or silver. Silver dressings are especially useful for infected pressure injuries, as they have antibacterial and anti-inflammatory properties, which can prevent or treat infection. Consult a wound care specialist for individualized recommendations and monitoring.
Change the dressing or bandage regularly when wet, soiled, or loose. Monitor the wound for any changes or signs of healing or deterioration, such as granulation, epithelialization, or infection, and report them to the health care provider.
Optimize the nutritional status by providing adequate calories, protein, fluids, and micronutrients, such as vitamins C and E, zinc, and copper, essential for wound healing. Consult a dietitian for individualized recommendations and monitoring.
Administer antibiotics if the wound is clinically or microbiologically infected or if the patient has signs of systemic infection, such as fever, chills, or malaise. Depending on the infection’s type, severity, and location, antibiotics can be given orally, topically, or intravenously. Consult a physician for individualized recommendations and monitoring.
Role of Pain Management, Infection Control, and Palliative Care in Pressure Injury Management
Pain management, infection control, and palliative care are important aspects of pressure injury management, as they can affect the patient’s health and well-being, as well as their wound healing and recovery. The following are some of the roles and functions of pain management, infection control, and palliative care in pressure injury management:
Pain management: Pain management is assessing, treating, and preventing pain, an unpleasant physical or emotional sensation that can interfere with the patient’s function and quality of life. Pain can be caused by various factors, such as pressure, infection, inflammation, or nerve damage, and can vary in intensity, frequency, and duration. Pain can also affect the wound-healing process by impairing blood flow, oxygen delivery, and immune function and by increasing stress, anxiety, and depression. To manage pain, the following interventions are suggested:
Assess the pain using valid and reliable tools and methods, such as numerical scales, verbal descriptors, or facial expressions. Consider the patient’s medical history, diagnosis, prognosis, symptoms, medications, and treatments, as well as their personal, cultural, and spiritual factors, such as preferences, values, beliefs, and practices. Review and update the pain assessment regularly and whenever there is a change in the pain or the patient’s condition or care plan.
Treat the pain using appropriate, safe techniques and medications and follow professional standards and guidelines. Use the WHO analgesic ladder, which is a stepwise approach to pain management that involves using non-opioid, opioid, and adjuvant analgesics, depending on the pain’s severity, type, and cause. Use the multimodal approach, a combination of pharmacological and non-pharmacological methods, such as relaxation, distraction, or massage, to enhance pain relief and reduce side effects. Use the patient-centered approach based on the patient’s goals, preferences, and values and involve them in decision-making. Consult a pain specialist for individualized recommendations and monitoring.
Prevent the pain by identifying and avoiding or reducing the factors that can cause or worsen the pain, such as pressure, infection, inflammation, or nerve damage. Use various strategies, such as repositioning the patient, providing appropriate support surfaces, cleaning and dressing the wound, and optimizing the nutritional status. Educate and support the patient and the family or caregivers on the causes, prevention, and treatment of pain, and provide them with clear, accurate, and relevant information and resources, such as brochures, websites, or videos.
Infection control: Infection control prevents, detects, and treats infection, as well as the invasion and multiplication of bacteria or other germs that can cause disease or inflammation. Infection can occur in any stage or type of pressure injury, can delay or prevent wound healing, and increases the risk of complications, such as sepsis, osteomyelitis, or amputation. To control infection, the following interventions are suggested:
Prevent infection using aseptic techniques and precautions, such as washing hands, wearing gloves, and sterilizing equipment when handling the wound or the dressing. Use appropriate dressings or bandages to protect the wound from further contamination or infection, and change them regularly whenever they are wet, soiled, or loose. Educate and support the patient and the family or caregivers on the signs, prevention, and treatment of infection, and provide them with clear, accurate, and relevant information and resources, such as brochures, websites, or videos.
Detect infection by monitoring the wound and the patient for signs or symptoms, such as increased pain, redness, swelling, heat, odor, drainage, or fever. Use valid and reliable tools and methods, such as wound swabs, cultures, or biopsies, to identify the type and number of bacteria or other germs in the wound. Review and update the infection assessment regularly and whenever there is a change in the wound, the patient’s condition, or the care plan.
Treat infection using appropriate and safe techniques and medications and follow professional standards and guidelines. Use topical or systemic antibiotics, depending on the infection’s type, severity, and location. Use wound irrigation, debridement, or dressing changes to remove the infected or necrotic tissue and reduce the bacterial load. To prevent or treat infection, use wound dressings or bandages with antibacterial or anti-inflammatory properties, such as silver, iodine, or honey. Consult a physician or a wound care specialist for individualized recommendations and monitoring.
Palliative care: Palliative care provides physical, emotional, and spiritual care and support for patients with life-limiting illnesses and their families or caregivers. Palliative care aims to improve the patient’s quality of life, comfort, and dignity and to respect their wishes and values regarding their care and comfort. Palliative care can be provided in any setting, such as home, hospice, or hospital, and by any health care provider, such as a nurse, a physician, a social worker, or a chaplain. Palliative care can be integrated with pressure injury management by using the following interventions:
Communicate with the patient and the family or caregivers, using clear, honest, and empathic language and avoiding medical jargon or technical terms. Listen to their concerns, questions, or doubts, and address them respectfully and compassionately. Involve them in the decision-making process and honor their choices and rights regarding their care and comfort. Please provide them with clear, accurate, relevant information and resources, such as brochures, websites, or videos.
Coordinate with the health care team, using a multidisciplinary and collaborative approach, which involves the patient, the family, the caregivers, and other health professionals, such as a nurse, a physician, a dietitian, a wound care specialist, a pain specialist, a counselor, a social worker, or a chaplain. Communicate and document the patient’s condition, goals, preferences, and values, and follow the professional standards and guidelines. Review and revise the care plan regularly and whenever there is a change in the patient’s condition or care plan.
Use appropriate and safe techniques and medications to manage the symptoms and follow professional standards and guidelines. Use pharmacological and non-pharmacological methods, such as analgesics, anti-inflammatories, antiseptics, or relaxation, to relieve the wound-related symptoms, such as pain, odor, drainage, or itching. Use pharmacological and non-pharmacological methods, such as sedatives, antidepressants, antianxiety, or counseling, to relieve the non-wound-related symptoms, such as fatigue, anxiety, or depression. Use pharmacological and non-pharmacological methods, such as opioids, morphine, or comfort measures, to relieve end-of-life symptoms, such as dyspnea, agitation, or delirium. Consult a palliative care specialist for individualized recommendations and monitoring.
Provide emotional and spiritual support, using appropriate and respectful techniques and methods and following the personal, cultural, and spiritual factors of the patient and the family or caregivers. Use various strategies, such as listening, validating, empathizing, or encouraging, to enhance the coping and resilience of the patient and the family or caregivers. Use various strategies, such as prayer, meditation, music, or art, to enhance the meaning and purpose of the patient and the family or caregivers. Use various strategies, such as bereavement, grief, or memorial, to enhance the closure and acceptance of the patient and the family or caregivers. Refer them to other professionals or services, such as a counselor, a social worker, or a support group, if needed.
Sources of Evidence and Best Practices for Pressure Injury Management
The sources of evidence and best practices for pressure injury management are based on the latest scientific research and clinical experience. Some of the most authoritative and comprehensive sources are:
The International Guideline: This global guideline recommends preventing and treating pressure injuries in all types of patients, settings, and conditions. It was developed by a panel of experts from various disciplines and countries and updated every four years. The latest version was published in 2019.
The AAFP guideline: This local guideline provides recommendations for managing chronic wounds, including pressure injuries, in primary care settings in the United States. It was developed by the American Academy of Family Physicians (AAFP), a national medical organization that represents family physicians and their patients. The latest version was published in 2018.
We encourage you to consult these sources for more detailed, specific information and guidance on pressure injury management. You can also ask your healthcare providers for their advice and expertise.
Conclusion
This article discussed pressure injury prevention and management for terminally ill patients. We have explained what pressure injuries are, how they develop, and how they affect the patient’s health and well-being. We have also provided practical and evidence-based tips and strategies for preventing and managing pressure injuries, such as repositioning, nutrition, exercise, vitamins, minerals, bandages, pain management, infection control, and palliative care. We hope this article has given you useful information and guidance on this important and challenging issue.
Pressure injury prevention and management benefit the patient, family, and caregivers. By preventing and managing pressure injuries, you can improve the patient’s quality of life, comfort, and dignity and reduce the risk of complications, such as infection, sepsis, or amputation. You can also reduce the burden and stress of caring for the patient and enhance your coping and resilience. You can also respect patients’ wishes and values regarding their care and comfort and honor their choices and rights.
If you want to learn more about pressure injury prevention and management, or if you need any help or support, here are some reliable and relevant resources that you can access:
The International Guideline: This global guideline provides recommendations for preventing and treating pressure injuries for all types of patients, settings, and conditions.
The AAFP guideline: This local guideline provides recommendations for managing chronic wounds, including pressure injuries, in primary care settings in the United States.
The Wound Care Society: This non-profit organization aims to improve the care and outcomes of patients with wounds, such as pressure injuries.
The American Hospice Foundation: This non-profit organization supports programs that serve the needs of terminally ill and grieving individuals of all ages.
You can also contact your local health professionals, support groups, or helplines, which can offer you advice and assistance. Here are some examples of contact details that you can use:
Your primary care provider: This person knows you and your medical history best and can coordinate your care and refer you to other specialists or services. You can call or visit your primary care provider with questions or concerns about pressure injury prevention, management, or other health issues.
Your wound care specialist: This person has specialized training and experience in treating wounds, such as pressure injuries. You can consult your wound care specialist with any questions or concerns about pressure injury prevention, management, or other wound issues.
Your palliative care specialist: This person has specialized training and experience in providing physical, emotional, and spiritual care and support for patients with life-limiting illnesses and their families or caregivers. You can consult your palliative care specialist for any questions or concerns about pressure injury prevention, management, or other end-of-life issues.
Your local support group: This is a group of people who share similar experiences and challenges, such as caring for a terminally ill patient with pressure injuries. You can join your local support group with questions or concerns about pressure injury prevention, management, or other caregiving issues. You can also find emotional and psychological support, coping and resilience strategies, and social and peer connections from your local support group.
Your local helpline: This is a phone number that you can call for any questions or concerns about pressure injury prevention and management or any other health or caregiving issues. You can also find emotional and psychological support, crisis intervention, and referral services from your local helpline.
We encourage you to seek help and support when you need it and to communicate with the patient and the healthcare team. You are not alone in this journey, and you have many resources and allies who can assist you. Remember that you are doing a wonderful job and that you are making a difference in the patient’s life. We thank you for your attention and interest in this article. We hope you have found it helpful and informative.
