肯尼迪末期潰瘍處置－挑戰與照護

Management of Patients With Kennedy Terminal Ulcer: Challenges and Best Practices

10.6224/JN.202304_70(2).12

羅淑芬(Shu-Fen LO)；吳麗月(Li-Yueh WU)；羅元均(Yuan-Chun LO)

肯尼迪末期潰瘍 ； 生命末期皮膚衰竭 ； 護理 ； 安寧緩和照護 ； Kennedy terminal ulcer ； end of life skin failure ； nursing ； palliative care

護理雜誌

70卷2期（2023 / 04 / 01）

95 - 101

繁體中文;英文

不論是在急性醫院、長照機構或是居家，生命末期病人因血液動力學改變、皮膚組織灌流不足，使得皮膚在極短時間從表淺潰瘍發展到全皮層損傷，稱之為肯尼迪末期潰瘍（Kennedy terminal ulcer），也是難避免的皮膚損傷，更常好發於生命末期前1天到前6週，屬死亡過程的一部分，即使醫護人員已提供病人完善照護處置，此潰瘍仍可能發生。家屬及護理人員常因對肯尼迪末期潰瘍致病機轉不了解，混淆認為是壓力性損傷，進而採用積極照護為目標與處置，但照護成效不佳，反而引發心理壓力與誤解。此時，病人的照護目標應重於促進生命末期之舒適護理而非傷口癒合，依循全人、全家、全隊、全程照顧原則，輔以病人評估（patient center holistic assessment）、病人與家屬的期望（preference of patient and family）、皮膚保護（protection of skin）、傷口處置（prescription of wound）、維持高品質照護（preservation quality of care）之照護策略協助病人及其家屬獲得最佳的生活品質。本文針對肯尼迪末期潰瘍定義、病理生理變化、臨床表徵、照護處置進行文獻彙整，作為護理照護處置依據，並提供相關照護品質指標監測之政策參考。

Whether receiving acute, long-term, or home care, patients at the end of life may experience skin failure due to hemodynamic changes and insufficient perfusion of skin tissue. Skin failure begins as superficial ulcers that can quickly become full-thickness lesions, which are referred to as Kennedy terminal ulcers. Skin lesions commonly occur in the final 6 weeks of life and can occur even in the presence of a comprehensive care plan. The pathogenesis of Kennedy terminal ulcers is often misunderstood and these ulcers are commonly misdiagnosed as pressure injuries. This confusion may lead to aggressive care with subpar clinical outcomes that cause further psychological and emotional distress to patients and family members. Patients at the end of life must be provided care focused on their comfort rather than wound healing. To provide the highest quality of care to patients, four end-of-life strategies should be used, including: taking account of the preferences of patients and families, protecting the skin, describing the wound, and preserving a high quality of care. The terms, pathophysiological and clinical manifestations, and nursing treatments related to skin failure at the end of life described in the literature are introduced in this paper. Furthermore, monitoring indicators of nursing quality are provided.

1. Artico, M.,Dante, A.,D’Angelo, D.,Lamarca, L.,Mastroianni, C.,Petitti, T.,Piredda, M.,De Marinis, M. G.(2018).Prevalence, incidence and associated factors of pressure ulcers in home palliative care patients: A retrospective chart review.Palliative Medicine,32(1),299-307.
2. Ayello, E. A.,Levine, J. M.,Langemo, D.,Kennedy-Evans, K. L.,Brennan, M. R.,Gary Sibbald, R.(2019).Reexamining the literature on terminal ulcers, SCALE, skin failure, and unavoidable pressure injuries.Advances in Skin & Wound Care,32(3),109-121.
3. Bain, M.,Hara, J.,Carter, M. J.(2020).The pathophysiology of skin failure vs. pressure injury: Conditions that cause integument destruction and their associated implications.Wounds,32(11),319-327.
4. Bateman, J.(2019).Kennedy terminal ulcer #383.Journal of Palliative Medicine,22(12),1612-1613.
5. Beele, H.,Smet, S.,Van Damme, N.,Beeckman, D.(2018).Incontinence-associated dermatitis: Pathogenesis, contributing factors, prevention and management options.Drugs & Aging,35(1),1-10.
6. Beldon, P.(2011).Skin changes at life’s end: SCALE ulcer or pressure ulcer?.British Journal of Community Nursing,16(10),491-494.
7. Brennan, M. R.,Thomas, L.,Kline, M.(2019).Prelude to death or practice failure? Trombley-Brennan terminal tissue injury update.American Journal of Hospice & Palliative Medicine,36(11),1016-1019.
8. Delmore, B.,Cox, J.,Rolnitzky, L.,Chu, A.,Stolfi, A.(2015).Differentiating a pressure ulcer from acute skin failure in the adult critical care patient.Advances in Skin & Wound Care,28(11),514-524.
9. Edsberg, L. E.,Black, J. M.,Goldberg, M.,McNichol, L.,Moore, L.,Sieggreen, M.(2016).Revised national pressure ulcer advisory panel pressure injury staging system: Revised pressure injury staging system.Journal of Wound, Ostomy, and Continence Nursing,43(6),585-597.
10. Hill, R.,Petersen, A.(2020).Skin failure clinical indicator scale: Proposal of a tool for distinguishing skin failure from a pressure injury.Wounds,32(10),272-278.
11. Jakobsen, T. B. T.,Pittureri, C.,Seganti, P.,Borissova, E.,Balzani, I.,Fabbri, S.,Amati, P.,Donigaglia, S.,Gallina, S.,Fabbri, E.(2020).Incidence and prevalence of pressure ulcers in cancer patients admitted to hospice: A multicentre prospective cohort study.International Wound Journal,17(3),641-649.
12. Kennedy, K. L.(1989).The prevalence of pressure ulcers in an intermediate care facility.Decubitus,2(2),44-45.
13. Langemo, D. K.,Brown, G.(2006).Skin fails too: Acute, chronic, and end-stage skin failure.Advances in Skin & Wound Care,19(4),206-211.
14. Latimer, S.,Shaw, J.,Hunt, T.,Mackrell, K.,Gillespie, B. M.(2019).Kennedy terminal ulcers: A scoping review.Journal of Hospice and Palliative Nursing,21(4),257-263.
15. Levine, J. M.(2017).Unavoidable pressure injuries, terminal ulceration, and skin failure: In search of a unifying classification system.Advances in Skin & Wound Care,30(5),200-202.
16. Miller, M. S.(2017).The death of the Kennedy terminal ulcer.Journal of the American College of Clinical Wound Specialists,8(1-3),44-46.
17. Roca-Biosca, A.,Rubio-Rico, L.,De Molina-Fernández, M. I.,Martinez-Castillo, J. F.,Pancorbo-Hidalgo, P. L.,García-Fernández, F. P.(2021).Kennedy terminal ulcer and other skin wounds at the end of life: An integrative review.Journal of Tissue Viability,30(2),178-182.
18. Schank, J. E.(2015).The NPUAP meeting - This was no consensus conference.The Journal of the American College of Clinical Wound Specialists,7(1-3),19-24.
19. Sibbald, R. G.,Ayello, E. A.(2020).Terminal ulcers, SCALE, skin failure, and unavoidable pressure injuries: Results of the 2019 terminology survey.Advances in Skin & Wound Care,33(3),137-145.
20. Sibbald, R. G.,Elliott, J. A.,Persaud-Jaimangal, R.,Goodman, L.,Armstrong, D. G.,Harley, C.,Coelho, S.,Xi, N.,Evans, R.,Mayer, D. O.,Zhao, X.,Heil, J.,Kotru, B.,Delmore, B.,LeBlanc, K.,Ayello, E. A.,Smart, H.,Tariq, G.,Alavi, A.,Somayaji, R.(2021).Wound bed preparation 2021.Advances in Skin & Wound Care,34(4),183-195.
21. Song, E. H., & Costa, I. (2021). Skin failure - Introduction and assessment. WoundReference. Retrieved August 4, 2022, from https://woundreference.com/app/topic?id=is-it-really-skin-failure
22. Yastrub, D. J.(2010).Pressure or pathology: Distinguishing pressure ulcers from the Kennedy terminal ulcer.Journal of Wound, Ostomy, and Continence Nursing,37(3),249-250.