Maintenance of skin integrity is a quality indicator of care worldwide. The ageing process can render skin fragile increasing the elderly persons susceptibility to skin damage from trauma, unintentional or intentional.

 

There are many challenges to complex wound management in the elderly. Multiple comorbidities, poly pharmacy, the presence of dementia and in some instances related Behavioural Psychological Symptoms of Dementia (BPSD) are factors that can adversely impact applied wound management strategies and wound healing. Morbid obesity in conjunction with reduced mobility engendering associated skin changes from pressure, intertrigo, cellulitis and lymphoedema can increase complexity.

 

Modern therapies facilitating longevity coupled with advanced surgical techniques allows for more complicated surgical procedures being performed in the aged population. This, along with shorter lengths of stay within acute hospitals means the elderly are discharged to aged care settings with major, complex acute wounds such as surgical reconstruction and use of advanced tissue replacement therapies such as Biodegradable temporising matrix (BTM). Management of these wounds can be beyond the scope and expertise of nursing staff.

 

While the role and benefits of wound specialists in the acute and community sectors is well recognised internationally integration of the role into the aged care sector is less well established. In Australia, few aged care providers employ Nurse Practitioners or specialists in wound management to support clinical staff to implement best practice in wound, ostomy and skin care. This is particularly important given the complexity and chronicity of some wounds that require urgent escalation for specialist review. A further consideration is skin care at life’s end, the management of the non-healable wounds where the objectives of wound management are directed at symptom control, comfort being the primary concern.

 

This presentation will outline the management of three case studies where wound specialists played a key role in supporting clinical staff to manage these individuals and their complex wounds.

 

Case A will demonstrate the challenges of managing an elderly woman with a Cluster B type personality who had multiple wounds arising from morbid obesity, bilateral venous leg ulceration with concomitant lower leg oedema, sacral pressure injury from declining mobility and venous congestion, and multiple wound infections.

 

Case B will illustrate the management of a large concave wound on the scalp of a 75-year-old man following multiple surgical procedures post removal of a Squamous Cell Carcinoma (SCC) involving bone requiring bone burring and Biodegradable Temporising Matrix; craniectomy and titanium mesh cranioplasty with a free latissimus dorsi flap; removal of mesh cranioplasty and free Anterolateral thigh (ALT) flap reconstruction with BTM to the donor site.

 

Case C will discuss the management of a 75-year-old socially isolated frail malnourished man with a large fungating ulcerative SCC of his neck beneath the Left mandible. Radiotherapy was ceased at his request. Wound management goals centred on symptom control, devising a wound management strategy that was acceptable to him and manageable by staff and liaison with palliative care services. Secondary to this was the management of an end colostomy for segmental volvulus.

Dr Jenny Prentice PhD BN RN Stomal Therapy Nurse, Cert., Palliative Care, Dip Project Management.

 

Jenny has 48 years’ experience in clinical nursing, stomal therapy, wound management, education, research and administrative roles in acute public and private hospitals, community and aged care sectors and academia in Australasia.

 

In 1993, Jenny was instrumental in establishing Wounds Australia and is an inaugural Fellow and past President of Wounds Australia. She was Founding Editor of Wound Practice & Research Journal of Wounds Australia remaining sole or co-Editor for 15 years.

 

Jenny is Editor of the World Council of Enterostomal Therapists (WCET®) Journal and is an Editorial Board Member for Advances in Skin & Wound Care, the International Wound Journal, Wound Practice & Research and is the Australia/New Zealand Director, International Skin Tear Advisory Panel. She is also a member of the WCET® International Ostomy Guideline Development Group.

Currently, Jenny is a nurse consultant in wound skin and ostomy care for Hall & Prior, a large, aged care provider in Perth Western Australia and New South Wales, Australia. She consults independently nationally and internationally.