MALIGNANT WOUNDS

Connie Sarvis RN, BN, MN, CON(C), IIWCC, CWS

Skin and Wound ConsultantSeven Oaks General Hospital

Malignant Wound?Fungating Wound?

Cutaneous Malignancy?Malignant Cutaneous

Ulcer?Tumor Necrosis?

How Common Are They?

5-10% of patients with metastatic cancer will

develop a malignant wound!

Wound Care Designed to afford Relief without Cure

Most Common Sites

Breast

Head/Neck

Back/Trunk/Abdomen

Groin/Axilla

Genital

How do they develop?

From a Primary Skin cancer left

untreated.

Ie. Basal cell ca

Squamous cell ca

A Primary Tumor invading up into and through the

skin.

Ie. Breast tumor

Tumor has invaded blood or lymph

vessels

– small skin capillaries trap malignant cells

During Surgery – seeding of

malignant cells in the dermis occurs

Conversion:

Malignant wound develops in

another chronic ulcer/scar tissue

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

Tumor very disorganized! – poor skin perfusion, edema and necrosis occurs

Tumors often extend into deeper structures – sinus and fistula formation

TREATMENT

SURGERY

Used occasionally to reduce tumor mass but may not always be possible due to bleeding, infection, etc.

Chemotherapy

Can decrease tumor mass

Depends on tumor response

RADIOTHERAPY

Can reduce the size of mass – controlling exudate, bleeding and pain

Adding radiotherapy reactions to wound

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

ASSOCIATED PROBLEMS

WHAT DOES THE PATIENT

THINK IS THE MOST

IMPORTANT?

ODOR!! Anaerobic Bacteria infecting

or colonizing necrotic tissue-Putrescine, Cadaverine

Klebsiella, Pseudomonas & Proteus

Necrotic Tissue Odor

Stale Exudate

Presence of Infection

Tissue Degradation

Anaerobic Bacterial Colonization

Tissue Necrosis

Malodor

Debridement

Remove necrotic tissue where bacteria are

Sharp?

Mechanical?

Autolytic?

SYSTEMIC ANTIBIOTICS

Control Odor from Bacteria’s Metabolic End Products

Bacterial Resistance

Adverse Effects

FLAGYL (Metronidazole)

gel - .75% -displacement

tablets crushed in gel

oral tablets (200-500 mg. TID)

IV/irrigation

Anaerobes only – Binds their DNA

SILVER/IODOSORB

Reaches the Gram positive cocci and gram negative rods – Pseudomonas

No bacterial resistance

Longer to control odor

CHARCOAL DRESSINGS

Absorbs volatile malodorous chemicals from wound before they pass into air

Needs to be an airtight seal

Pouching?

Increase Frequency of Drsg. Changes

Room Sprays – Nausea!!

Mentholatum applied to Nostrils

Kitty Litter, Charcoal, Baking Soda, Vinegar

Distraction Techniques

Tumor Cells can secrete Vascular Permeability Factor – vessels become more permeable to plasma colloids and fibrinogen

Inflammatory reaction - Histamines

Amber Exudate

Cloudy

Purulent

Sanguinous

Hemo-purulent

Serous

THE 5 C’S OF EXUDATE MANAGEMENT

CAUSE

CONTROL

COMPONENTS

CONTAINMENT

COMPLICATIONS

CAUSELymphedem

a

Infection

Drug-related

Decreased se albumin

Heart Failure

CONTROL

Is systemic and or local control possible?

COMPONENTS

VISCOSITY?

BACTERIA?

NECROTIC MATERIAL?

CONTAINMENT

Collection Devices

Capillary Action

Dressings

VAC

Absorptive Dressings

Bacterial Control

Dressings

COMPLICATIONS

Very fragile, friable tissue!!!

Spontaneous bleeding if tumor erodes into a blood vessel – profuse

Bleeding can be compounded by decreased platelet function

Infection?

PREVENT TRAUMA!!

Paraffin/tulle?

Gauze?

Telfa?

Silicone?

Control Bleeding

Alginates

Silver Nitrate

Gel Foams

Fibrinolytic Inhibitors

Topical Adrenaline

Sucralfate

PRESSURE?

OR

ICE?

Tumor pressing on nerve endings

During dressing changes

Exposure of Dermis to air

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)

Excoriation

Pruritis

EXCORIATION Barriers – No Sting

Hydrocolloid Frames

Zinc Oxide

Avoid Tape – Netting/garments

Pouching

Diaper Technology

PRURITIS Antihistamines?

Cool Hydrogel Sheets

Menthol Cream

TENS?

Avoid vasodilation!!

Moisturizers (Avoid Lanolin)

QUESTIONS?