Published on January 5, 2008
MALIGNANT WOUNDS: MALIGNANT WOUNDS Connie Sarvis RN, BN, MN, CON(C), IIWCC, CWS Skin and Wound Consultant Seven Oaks General Hospital Malignant Wound?Fungating Wound?Cutaneous Malignancy?Malignant Cutaneous Ulcer?Tumor Necrosis?: Malignant Wound? Fungating Wound? Cutaneous Malignancy? Malignant Cutaneous Ulcer? Tumor Necrosis? How Common Are They?: How Common Are They? 5-10% of patients with metastatic cancer will develop a malignant wound! Wound Care Designed to afford Relief without Cure Slide4: Most Common Sites Breast Head/Neck Back/Trunk/Abdomen Groin/Axilla Genital Slide5: How do they develop? Slide6: From a Primary Skin cancer left untreated. Ie. Basal cell ca Squamous cell ca Slide9: A Primary Tumor invading up into and through the skin. Ie. Breast tumor Slide11: Tumor has invaded blood or lymph vessels – small skin capillaries trap malignant cells Slide14: During Surgery – seeding of malignant cells in the dermis occurs Slide18: Conversion: Malignant wound develops in another chronic ulcer/scar tissue Slide20: PATHOPHYSIOLOGY! Starts as discrete, non tender nodules Can be skin tone, pink, red, violet, blue, black or brown! As malignant cells grow and divide, the nodules enlarge – interfere with skin capillaries and lymph vessels Slide21: Tumor very disorganized! – poor skin perfusion, edema and necrosis occurs Tumors often extend into deeper structures – sinus and fistula formation Slide22: TREATMENT Slide23: SURGERY Used occasionally to reduce tumor mass but may not always be possible due to bleeding, infection, etc. Slide24: Chemotherapy Can decrease tumor mass Depends on tumor response Slide25: RADIOTHERAPY Can reduce the size of mass – controlling exudate, bleeding and pain Adding radiotherapy reactions to wound Slide29: ASSESSMENT Location of Wound Size, Depth and Shape Amount and Nature of Exudate Presence and Level of Malodor Type of Tissue Present Signs and Symptoms of Infection Nature and Type of Pain Condition of Peri-wound Bleeding Slide30: ASSOCIATED PROBLEMS WHAT DOES THE PATIENT THINK IS THE MOST IMPORTANT? Slide31: ODOR!! Anaerobic Bacteria infecting or colonizing necrotic tissue-Putrescine, Cadaverine Klebsiella, Pseudomonas & Proteus Necrotic Tissue Odor Stale Exudate Slide32: Presence of Infection Tissue Degradation Anaerobic Bacterial Colonization Tissue Necrosis Malodor Slide33: Debridement Remove necrotic tissue where bacteria are Sharp? Mechanical? Autolytic? Slide35: SYSTEMIC ANTIBIOTICS Control Odor from Bacteria’s Metabolic End Products Bacterial Resistance Adverse Effects Slide36: FLAGYL (Metronidazole) gel - .75% -displacement tablets crushed in gel oral tablets (200-500 mg. TID) IV/irrigation Anaerobes only – Binds their DNA Slide37: SILVER/IODOSORB Reaches the Gram positive cocci and gram negative rods – Pseudomonas No bacterial resistance Longer to control odor Slide39: CHARCOAL DRESSINGS Absorbs volatile malodorous chemicals from wound before they pass into air Needs to be an airtight seal Slide40: Pouching? Increase Frequency of Drsg. Changes Room Sprays – Nausea!! Mentholatum applied to Nostrils Kitty Litter, Charcoal, Baking Soda, Vinegar Distraction Techniques Slide42: Tumor Cells can secrete Vascular Permeability Factor – vessels become more permeable to plasma colloids and fibrinogen Inflammatory reaction - Histamines Slide43: Amber Exudate Cloudy Purulent Sanguinous Hemo-purulent Serous Slide44: THE 5 C’S OF EXUDATE MANAGEMENT CAUSE CONTROL COMPONENTS CONTAINMENT COMPLICATIONS Slide45: CAUSE Lymphedema Infection Drug-related Decreased se albumin Heart Failure Slide46: CONTROL Is systemic and or local control possible? Slide47: COMPONENTS VISCOSITY? BACTERIA? NECROTIC MATERIAL? Slide48: CONTAINMENT Collection Devices Capillary Action Dressings VAC Absorptive Dressings Bacterial Control Dressings Slide49: COMPLICATIONS Slide51: Very fragile, friable tissue!!! Spontaneous bleeding if tumor erodes into a blood vessel – profuse Bleeding can be compounded by decreased platelet function Infection? Slide53: PREVENT TRAUMA!! Paraffin/tulle? Gauze? Telfa? Silicone? Slide54: Control Bleeding Alginates Silver Nitrate Gel Foams Fibrinolytic Inhibitors Topical Adrenaline Sucralfate Slide55: PRESSURE? OR ICE? Slide56: Tumor pressing on nerve endings During dressing changes Exposure of Dermis to air Slide57: PAIN Avoid Trauma Gentle Cleansing- without gauze No cold irrigations No H2O2, Iodine, Chlorhexidine, Eusol!! Morphine gel (1 mg./1 ml hydrogel or metronidazole gel) Slide58: Excoriation Pruritis Slide59: EXCORIATION Barriers – No Sting Hydrocolloid Frames Zinc Oxide Avoid Tape – Netting/garments Pouching Diaper Technology Slide61: PRURITIS Antihistamines? Cool Hydrogel Sheets Menthol Cream TENS? Avoid vasodilation!! Moisturizers (Avoid Lanolin) Slide66: QUESTIONS?