10.1 Skin and Mucous Membrane Symptoms
Key Takeaways
- A Kennedy terminal ulcer is sudden terminal ulceration (often pear- or butterfly-shaped over the sacrum) and is not automatically a quality failure when prevention was appropriate.
- NPIAP staging names depth; never reverse-stage a healing full-thickness wound, and do not call moisture-associated damage a stage 2 pressure injury by default.
- Malignant fungating wounds are usually managed to contain odor, exudate, bleeding, and appearance; topical metronidazole and charcoal dressings are first-line odor tools.
- Xerostomia needs alcohol-free mouth care; candidiasis is treated with nystatin for limited oral disease and fluconazole when disease is extensive or esophageal; pruritus is treated by mechanism, not with antihistamines alone.
Why this cluster scores on CHPN
Certified Hospice and Palliative Nurse (CHPN) Domain 3 — Patient Care: Symptom Management — includes skin, mucous membrane, nutritional, hematologic, and psychospiritual symptoms alongside the better-known dyspnea and nausea items. HPCC scores the exam on a 200 to 800 scale with 500 as the passing scaled score; this chapter will not make that cut by itself, but these stems are easy points if you practice goal selection. The exam is less interested in whether you can recite a poster of stages and more interested in whether you will chase closure of a dying wound, treat thrush, or wrongly treat a terminal ulcer as a survey failure.
Families often hear skin breakdown as neglect. The correct CHPN move is to distinguish preventable pressure injury from terminal skin failure, and healable tissue from containment of odor, exudate, pain, and bleeding.
Pressure injury: stage what you see
Use National Pressure Injury Advisory Panel (NPIAP) language.
- Stage 1: Intact skin with non-blanchable erythema. On darker skin, look for color change, warmth, firmness, or pain rather than redness alone.
- Stage 2: Partial-thickness loss with viable pink or red dermis, or a serum-filled blister. No slough, no granulation, no adipose. Moisture-associated skin damage, medical adhesive injury, and skin tears are not automatically stage 2.
- Stage 3: Full-thickness loss with visible adipose; slough or eschar may be present; fascia, muscle, and bone are not exposed.
- Stage 4: Full-thickness loss with exposed fascia, muscle, tendon, ligament, cartilage, or bone.
- Unstageable: The base is hidden by slough or eschar; do not guess a number. Stable, dry heel eschar may be left as a biologic cover when that matches goals.
- Deep tissue pressure injury: Persistent non-blanchable deep red, maroon, or purple discoloration; it may evolve quickly.
Do not reverse-stage. A healing full-thickness wound remains a healing stage 3 or 4. Prevention still belongs in hospice when it matches comfort: a support surface, heel offloading, moisture control, and turning the patient will tolerate. Cachexia and hypoperfusion mean extra calories on a tray will not heal every wound. Document what you offered and what the patient declined.
SCALE changes and the Kennedy terminal ulcer
The Skin Changes At Life's End (SCALE) consensus describes hypoperfusion of the skin as other organs fail. Some injuries are unavoidable even when turning, surfaces, and moisture care were appropriate. That is not a license to stop all prevention. It is a license to stop treating every sacral color change as proof of poor nursing.
The Kennedy terminal ulcer is sudden terminal ulceration, often pear-shaped, butterfly-shaped, or horseshoe-shaped over the sacrum, appearing red, yellow, or black days to weeks before death. Describe it carefully as terminal ulceration, a marker of dying physiology. It is not automatically a quality failure. Continue gentle, goal-concordant positioning. Document onset, shape, color, and the prevention already in place. Do not reflexively escalate to a hospital wound vacuum, surgical debridement, or a neglect narrative when the clinical picture is terminal skin failure and the family needed explanation, not blame.
Malignant fungating wounds
A growing tumor will not granulate closed. Agree the goal with the patient and family: odor, exudate, bleeding, pain, and being presentable for visitors — not complete healing. Anaerobic odor responds to topical metronidazole (gel, or crushed tablets in a carrier) and charcoal dressings. Change dressings before they saturate. Use nonadherent layers on friable tumor. For bleeding, use local pressure, alginate, topical hemostatics, and sometimes palliative radiation. Do not wet-to-dry a bleeding tumor to chase a clean bed. Silver dressings and honey products appear in some protocols; they are adjuncts, not a reason to ignore metronidazole when odor is the complaint.
Mouth, mucosa, and itch
Xerostomia follows opioids, anticholinergics, oxygen, radiation, and mouth breathing. Alcohol rinses worsen it. Use saliva substitutes, frequent sips, ice chips if the swallow is safe, sugar-free gum or pilocarpine when glands can still work, a humidifier, and a medication review.
Candidiasis produces plaques that scrape, unlike leukoplakia. Angular cheilitis and an erythematous tongue still count. Nystatin suspension is reasonable for limited oral disease. Fluconazole is the better pick when disease is extensive, esophageal (odynophagia, retrosternal pain), or nystatin has failed.
Mucositis needs bland saline or bicarbonate rinses, a soft brush, infection treatment, topical anesthetic before meals, and no alcohol rinses. Neutropenic mucositis in hospice is a comfort and bleeding problem, not an automatic hospital transfer.
Pruritus is mechanism-based. Antihistamines disappoint when the pathway is not histamine. Uremic itch: emollients plus gabapentin or pregabalin; dialysis only if goals include it. Cholestatic itch: emollients, sertraline, rifampin, or naltrexone in selected patients; bile-acid binders help only if bile reaches the intestine. Opioid itch: rotate the opioid; antihistamines may sedate without relieving neuraxial-type itch.
Wound-goal table: heal versus contain odor and exudate
| Situation | Primary goal | Typical CHPN actions | What not to do |
|---|---|---|---|
| Pressure injury in a patient who still turns, eats, and has weeks to months | Heal if perfusion and goals allow | Offload, moisture balance, treat infection, support surfaces | Reverse-stage; ignore offloading |
| Kennedy / SCALE terminal ulcer in active dying | Comfort and honest documentation, not closure | Gentle positioning the patient tolerates; protect from shear; explain to family | Treat as automatic neglect or force aggressive debridement |
| Fungating malignant wound | Contain odor, exudate, bleeding, appearance | Topical metronidazole, charcoal dressings, nonadherent layers, hemostasis, palliative radiation if bleeding | Wet-to-dry debridement for healing |
| Xerostomia, mucositis, or thrush | Comfort, swallow, speech | Alcohol-free substitutes and rinses; nystatin or fluconazole | Alcohol mouthwash to clean the mouth |
| Pruritus from uremia, cholestasis, or opioids | Mechanism-based relief | Emollients; gabapentin; opioid rotation; selected cholestasis drugs | Diphenhydramine as the only plan |
Exam stems often pair a family accusation of poor turning with a pear-shaped sacral wound that appeared over a day or two. Name SCALE or a Kennedy terminal ulcer, continue gentle prevention, and do not convert the case into a quality-failure story. Other stems offer a malodorous chest-wall wound; topical metronidazole plus odor-adsorbing dressings beats systemic vancomycin or scheduled wet-to-dry packing.
A hospice patient develops a sudden pear-shaped sacral wound over 48 hours. The family says the staff must have failed to turn the patient. Prevention documentation is complete. What is the best CHPN interpretation?
A patient with a fungating chest-wall tumor reports a foul odor that keeps visitors away. Which local plan best matches a containment goal?
Which statement about mucous-membrane and itch management is most accurate for CHPN decision-making?