Malignant / Fungating Wounds - Wound Care Nursing

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Malignant / FungatingWoundsA Clinical PerspectiveF. Alex Khan, APRN ACNS-BC MSNEmail: 18

Malignant WoundsMALIGNANT / FUNGATINGWOUNDSMalignant WoundsMalignant wounds are caused by the metastaticspread from a malignant tumor. Cancerous cellscause massive damage to the localized tissue,through a combination of proliferative growth,ischemia and ulceration. These Wounds are nonhealable due to co-existing untreatable medical lifelimiting conditions.2018

Malignant WoundsMALIGNANT / FUNGATINGWOUNDSMalignant Wounds2018

Malignant WoundsMALIGNANT / FUNGATINGWOUNDSStatisticsPrimary skin cancer such as a squamous or basal cellcarcinoma and malignant melanoma can develop intoa malignant fungating wound if left untreated. Themost common malignant / fungating wound sitesinclude breast 62%, head and face 24% and groin andgenitals 3%.2018

Malignant WoundsCharacteristicsMALIGNANT / FUNGATINGWOUNDSMalignant wounds are usually polymicrobic, containingboth aerobic and anaerobic bacteria causing foul odorand purulent drainage from the tissue necrosis.Anaerobic bacteria emit putrescine and cadaverine,which results in foul odors and some aerobic bacteriasuch as Proteus and Klebsiella can also produce foulodors. Each wound is unique but pain, foul odor, bleeding,and tissue necrosis is common in malignant wounds .2018

Malignant WoundsRadiation TherapyMALIGNANT / FUNGATINGWOUNDS As a result of radiation therapy (3) three types of skinproblems are commonly seen: Erythema (Redness) Dry Desquamation Moist Desquamation Skin Ulcers2018

Malignant WoundsMALIGNANT / FUNGATINGWOUNDSRadiation Therapy2018

Malignant WoundsMALIGNANT / FUNGATINGWOUNDSRadiation TherapyPrimary SiteMetastatic Cutaneous SitesLung and BreastHead, neck, anterior chestGastrointestinalUpper abdominal wall, suture linesGenitourinaryLower abdominal wall and external genitalsStomachUmbilicus, suture linesMelanomaExtremitiesOral CavityFace2018

Malignant WoundsMalignant DegenerationMALIGNANT / FUNGATINGWOUNDSChronic wounds may exhibitchronic inflammation thatcan undergomalignant transformation.A Marjolin ulcermay develop in an areaof chronic inflammation.2018

Malignant WoundsMALIGNANT / FUNGATINGWOUNDSMarjolin Ulcer2018

Malignant WoundsMALIGNANT / FUNGATINGWOUNDSKennedy Terminal Ulcer A pressure ulcer some people develop atend of life .Sudden onset Associated with imminent death Pear, butterfly, or horseshoe shaped Often on coccyx or sacrum Skin Failure: Occurs when skin andunderlying tissue develops necrosis due tolack of tissue perfusion associated withsevere dysfunction or failure of other organsystems.2018

Malignant WoundsManagement StrategiesMALIGNANT / FUNGATINGWOUNDSIn some malignant/fungating wounds; treating oncologist canperform palliative radiotherapy, which can reduce drainageand bleeding. Further, Chemotherapy can be used to reducethe size of the tumor, reduce pain, and bleeding. Hormonetherapy can be used to reduce the symptoms associated withhormone responsive tumors such as breast cancers.Surgical excision of the malignant tissue is also useful inreducing the size of the wound and allows better woundmanagement options.2018

Malignant WoundsManagement StrategiesMALIGNANT / FUNGATINGWOUNDS Managing malignant wounds is frequently based onexpert opinion and the experiences of the clinicians. The assessment of a malignant wound requires clinicianto gain insight into the patient’s perception of the woundand its consequent impact on his/her life. Nursing care requires counseling skills and knowing howto provide care that is based on an awareness of andinsight into the patients’ experience2018

Malignant WoundsManagement StrategiesMALIGNANT / FUNGATINGWOUNDS Treatment selections should include those that provideminimum side effects and maximum benefit to the client. Establish goal of care Healing vs Palliation Wound bed preparation will vary based on the goal. Ifpalliation is the goal, tissue debridement andmanagement of bacterial overload is required to minimizeodor and decrease risk of infection.2018

Malignant WoundsManagement StrategiesMALIGNANT / FUNGATINGWOUNDS The impact of a malignant/ fungating wound on a patient’slife cannot be underestimated. It can have a devastatingeffect on physical, psychological and social wellbeing aswell as on the family and friends. Treatment plan shall include the management of; Pain,Comfort, Psychological factors, Aesthetics, odor,drainage, and quality of life.2018

Malignant WoundsManagement StrategiesMALIGNANT / FUNGATINGWOUNDSPain ManagementAlthough many patients experience debilitating pain at theend of life, there are many options to improve analgesia andquality of life. Appropriate pain assessment with attention topatient needs and specific goals, helps tailor individualtreatment plans.Medications: Morphine, Hydromorphone, Oxycodone,Methadone, Fentanyl2018

Malignant WoundsManagement StrategiesMALIGNANT / FUNGATINGWOUNDSExudate / Drainage ManagementFor wounds with mild to moderate drainage; use of superabsorbent pads is recommended. For copious drainage,Negative Pressure Wound Therapy is ideal; only if patient isable to tolerate it.2018

Malignant WoundsManagement StrategiesMALIGNANT / FUNGATINGWOUNDSExudate / Drainage ManagementFor wounds with frequent bleeding issues can be managedwith:- Hemostatic dressings- Surgifoam/Gelfoam to fill the cavity- Silver Nitrate sticks- Topical Tranexamic acid (TXA)2018

Malignant WoundsManagement StrategiesOdor ManagementMALIGNANT / FUNGATINGWOUNDSWound malodor causes serious physical and psychological effectson the client. Management may include:- Removal of necrotic tissue- Sharp Wound Debridement- Wound Culture – Antibiotics & Antifungals- Topical Antimicrobials / Antifungals: Dakin’s Solution, Gentianviolet, Methylene Blue, Polyhexanide solution, Cider, Baxedin.Vinegar,Metronidazole Powder, Nystatin Powder, Charcoal dsg.- Malodor Concealers – Lavender Oil, Chamomile Oil2018

References Bergstrom, K. Assessment and Management of Fungating Wounds. Source: Journal of Wound, Ostomy and ContinenceNursing. 38 (1): 31-37, 2011 Jan/Feb Bryant, R. (2000). Acute and Chronic Wounds: Nursing Management,Second Edition (pp. 374-379). Mosby Inc. Barton, P., & Parslow, N, (1998) Caring for Oncology Wounds.Management Guidelines Krasner, D, Rodeheaver G, Sibbald G. (2001) Chronic Wound Care Third Edition Chapter 10 (pp. 79-90) Kohr, Rosemary. Sawhney, Mona. Advanced practice nurses' role in the treatment of pain. [Review] [23 refs] Source: CanadianNurse. 101(3): 30-4, 2005. March Reddy, M., Kohr, R., Queen, D., Sibbald, R Gary. Practical treatment of wound pain and trauma: a patient-centered approach.An overview. Ostomy Wound Management. 49(4 Suppl):2-15, 2003 Apr Sibblad, G., Woo, K. & Goodman, L. Update on Wound Bed Preparation 2011: A review of the principles of treating theroot cause of wounds, pain and wound healing, and local wound care. Wound Care Canada, vol. 10, number 10, pp18-22 Woo, K. & Sibbald, G. (2010). Local Wound Care for Malignant and Palliative Wounds. ADV SKIN WOUND CARE 2010;23:41728; quiz 429-30 www.woundcarenurses.org2018

Practical treatment of wound pain and trauma: a patient-centered approach. An overview. Ostomy Wound Management. 49(4 Suppl):2-15, 2003 Apr . K. & Goodman, L. Update on Wound Bed Preparation 2011: A review of the principles of treating the root cause of wounds, pain and wound healing, and

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