Guidelines for a Palliative Approach in Residential Aged Care

6.10 SKIN INTEGRITY
The major skin problems associated with ageing include oedema of limbs, wounds and ulcers.
Normally the goal of wound management is to promote healing; however, in a palliative
approach this may not be possible, particularly in terminal care (See Chapter 14, ‘End-of-life
(terminal) care’).
It is anticipated that most care assistants and nurses in RACFs will have considerable experience
in providing adequate skin care, so these procedures will not be repeated here. Suffice to say
that skin integrity is important for residents receiving a palliative approach. The complexity
of maintaining skin integrity with a palliative approach requires a multidisciplinary team
intervention that involves family members and carers. Any provision of information for the
family and carers must be approached in a sensitive and realistic manner. With this in mind, the
treatment for skin integrity should be realistic and agreed to by all concerned.
A recent systematic review of support surfaces for pressure ulcer prevention concluded that
higher specification foam mattresses rather than standard foam mattresses could reduce the
occurrence of pressure ulcers in people at risk [226] (Level I). The Reviewers’ considered that the
benefits of using alternating and constant low pressure devices and different alternating pressure
devices (both static and dynamic, i.e., alternating pressure supports, low air-loss mattresses or
beds) were unclear due to reviewers’ concerns regarding the methodologies used in RCTs. The
Reviewers also concluded that there was insufficient evidence to support the merits of overlays
(with the exception of Australian medical sheepskins), seat cushions, limb protectors, turning
tables, and electrical stimulation (with or without gels) to decrease the incidence of pressure
ulcers [226] (Level I).
Some benefit was found for the use of Australian Medical Sheepskins (natural not synthetic
fibre), which are manufactured to conform to Australian standards, for reducing pressure ulcers,
particularly for people who were at low to moderate risk [226] (Level I). Further studies have
been conducted and the results appear promising. [227–229] For example, a recent RCT involving
441 people with an average age of 63 years was conducted to determine the effectiveness of
the Australian medical sheepskin in preventing pressure ulcers in a hospital population at low
to moderate risk [227] (Level II). After being formally assessed for the risk of developing ulcers
the participants were randomly allocated to the sheepskin group (n = 218) or the referent
group (n = 223) to receive usual treatment as determined by the ward staff. Participants in the
sheepskin group were found to have developed new pressure ulcers at less than half the rate
of those in the usual treatment group. Although the setting for this study was acute care, the
average age of the participants (M = 62.1 years) suggests that this approach may be appropriate
for residents in aged care settings; however, further research in aged care is required.
Although it has been common practice to turn the resident every two hours to prevent ulcers,
a more suitable approach is based on the individual resident’s assessed need. To determine the
appropriateness of such practices the following questions have been proposed [230] (Level EO):
• Is it essential to alter the position of the resident?
• Will the intervention cause more discomfort than is necessary?
• Can we use other alternatives such as Australian Medical Sheepskins? (See also Chapter 14,
End-of-life Care for further discussion of comfort associated with frequent position changes).
104 Guidelines for a Palliative Approach in Residential Aged Care