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    Back to Module 10: Common Physical Symptoms
    Specific Symptoms

     
    Breathlessness (Dyspnea)
    Nausea and Vomiting
    Constipation
    Diarrhea
    Anorexia/Cachexia
    Fatigue/Weakness
    Fluid Balance/Edema
    Skin Odors
    Insomnia

    Skin

    Case Example

    EK is a 103-year-old housewife with advanced dementia. She has been a resident of a nursing home for the past 7 years. She has become progressively bedbound. Several bedsores over bony prominences have appeared.

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    Definition/Description

    • Skin care is often overlooked in physician education
      • Yet, skin breakdown and ulceration can be a source of significant morbidity for both the patient and family

      • The associated pain can be significant

      • Exudates, particularly purulent ones, can be soiling and malodorous

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    Management

    • Good care requires
      • Close collaboration with nurses and other caregivers, as most cases of skin breakdown are preventable

      • Prevention is much easier than treatment once skin breakdown occurs
    • Hygiene
      • Encourage family and caregivers to keep skin clean and dry

      • A variety of nursing techniques are appropriate

      • Absorbent surfaces, urinary catheters and rectal tubes may be of assistance if soiling is constant and/or the patient is highly debilitated
    • Protection
      • Cover areas with appropriate dressings where prolonged urine or stool contact may occur

      • Cover fragile skin that is at risk for breakdown with clear, occlusive dressings

      • Cover pressure points with thin, hydrocolloid dressings
    • Supports
      • Appropriate bed coverings will optimize weight distribution, reduce the risk of decubitus ulcer development, and minimize contact pain

      • Use draw sheets to move/turn cachectic patients

      • Egg crate foam pads, or other support mattresses, should be thick enough to lift the patient from the bed

      • One rule-of-thumb is to ensure that there is at least 1 inch of foam between the patient’s lowest point and the surface of the bed

      • If foam isn’t enough, air mattresses or other special air-flotation beds may be required to fully support the patient
    • Pressure ulcers
      • If overall maintenance or improvement of function is the goal, and prognosis is expected to be weeks to months

        • Then stage and treat the ulcer with accepted management guidelines (see the AHCPR management guidelines for pressure ulcers)

        • Avoid all iodine-containing products as they will inhibit reepithelialization

      • If prognosis is limited (days to weeks) and intent is to optimize quality of life

        • Conservative management strategy to minimize morbidity is appropriate

        • Regular cleaning with saline or Betadine is helpful

        • Cover ulcers with appropriate protective dressings that absorb exudates

      • Prolonged pressure

      • Inactivity

      • Closely associated with mortality

      • Easier to prevent than treat
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