Page 10 - Wound Care at End of Life Content: A Guide for Hospice Professionals - DEMO

Environmental Factors

ENVIRONMENTAL FACTORS:
Successful treatment of a wound requires a holistic approach incorporating assessment of the
entire patient and co‐existing environmental factors, not just the wound. This comprehensive
approach identifies and then controls or eliminates factors that impact wound healing.
Environmental factors include offloading pressure, providing the appropriate support surface,
protecting the skin from moisture, and reducing shear and friction. Develop wound care plans
in conjunction with the patient and caregiver, determining what causes them the most concern,
seeking their input in developing a plan of care.

Minimize Pressure:
1
Patient immobility is the most significant risk factor in pressure ulcer development. Offloading
pressure creates an environment that enhances soft tissue viability and promotes healing of
pressure ulcers. Support surfaces alone neither prevent nor heal ulcers. They are part of the
2
total program of prevention and treatment. Other interventions to offload pressure include:
 Repositioning: Shift and adjust patient position at least every 2 hours if at risk for skin
breakdown or if skin breakdown is already present. Pillows or foam wedges keep bony
prominences from direct contact with one another. Always assess and treat for pain if
repositioning causes discomfort to the patient.
 Pressure relief for heels: “Floating the heels” is achieved by placing a pillow longitudinally under
the calves of the bedbound patient keeping the heels suspended in air. Heel protection devices
that completely float the heel are also effective. While no one product has been found to be
superior to another, “moon boots” (heel pillows) are not recommended.
 Side‐lying position: When the patient is positioned on his side, avoid positioning directly on the
trochanter.
 Position of head of bed: Maintain head of the bed at the lowest degree of elevation medically
necessary in order to minimize shear and friction.
 Lifting devices: Use of lift sheets will minimize sheer and friction when repositioning the patient.
 Pressure from sitting: At risk patients should move at least every hour. If possible, the patient
should be taught to shift weight every 15 minutes.
 Pressure‐reducing devices for chairs: Chair cushions will redistribute pressure. Do NOT use
donut‐type devices; these tend to cause damage rather than good pressure reduction.

Manage Moisture:
Skin may be exposed to a variety of substances that are detrimental to healing or increase the
risk of breakdown due to moisture (e.g., urine, stool, perspiration, wound exudate). The
prolonged presence of moisture on the skin places the skin at risk of maceration. Maceration
weakens collagen fibers and skin resilience, especially in the presence of mechanical (e.g.,
friction, tape removal, pressure) or chemical exposure (e.g., harsh skin cleansers, GI secretions,
3
stool). Wet or moist skin has increased fragility, decreased ability to withstand friction and
shear, and a tendency to adhere to bed linens. Susceptibility to irritation, rashes, and infection
is also increased. 4

While moisture itself (urine, perspiration, wound exudate) is not caustic to the skin, chemical
3
moisture is caustic due to acidic pH or presence of enzymes. Patients with fecal incontinence
6