Chapter 25: Wound management
Skip chapter table of contents and go to main content
Source: World Union of Wound Healing Societies (WUWHS [150]). Reproduced with permission of WUWHS.
Source: World Union of Wound Healing Societies (WUWHS [150]). Reproduced with permission of WUWHS.
Local wound management
Symptom management and local wound management are the foci of care for a patient with a malignant fungating wound. TIME wound bed preparation (TIME/WBP) principles comprise four components underpinning the wound bed preparation (European Wound Management Association [39]).
- Tissue management.
- Inflammation/infection control.
- Moisture balance.
- Epithelial advancement.
These principles can be applied in palliative wound care (Grocott [54]) as autolytic debridement and moisture management can enhance quality of life. Effectively controlling symptoms can increase independence and help patients regain a measure of control over their lives (Grocott [54]).
Each patient responds individually to having such a wound, the consequences of which impinge on physical, psychological, social, sexual as well as spiritual well‐being. The highest level of nursing expertise is required. Informing patients can lead them to understand their signs and symptoms and enable them to report accurately and live more positively with their wound (Lo et al. [82]).
Whilst the appearance and presenting symptoms of malignant fungating wounds are unique, the most common symptoms associated with fungating wounds are heavy exudates, malodour, bleeding, pain and pruritus (Grocott [54], Hampton [62], Lund‐Neilson et al. [85]).
Exudate
When skin integrity is broken through the development of a wound, the body initiates an inflammatory response where mediators such as histamines make capillaries more permeable and facilitate the movement of electrolytes, nutrients and proteins, growth factors, matrix metalloproteinases, platelets and micro‐organisms, producing additional fluid in the wound and forming the basis of an exudate (Barrett et al. [13]). Exudate is required in wound healing to provide nutrients to the wound bed, aid autolytic debridement and facilitate the process of epithelialization to allow the cells to move across the wound bed.
Malignant fungating wounds have the propensity to produce high amounts of exudate, which can be as much as one litre per day (EONS [38]). The high level of exudate is the result of abnormal capillary permeability within the wound which can be caused by disordered blood vessels within the tumour (Naylor [101]), autolysis of necrotic tissue by bacterial proteases and the inflammatory process associated with infections (EONS [38]).
Effective clinical management of highly exuding wounds is essential for patients to reduce malodour, reduce the risk of leakage onto clothing and bedding, as well as increase their comfort and confidence (Grocott [54]). If patients experience leakage through their dressings it can lead to embarrassment, anxiety and feelings of being unclean which have the potential to lead to depression and social isolation with an overall negative impact on their quality of life. Failure to control wound exudate also results in an increased frequency of nursing interventions and an overall increase in the expenditure on wound management products and resources (Dowsett [35]).
Assessment of exudate
A description of exudate, including the appearance and amount, should be recorded at each dressing change. Healthcare professionals should understand the implications for the presence and appearance of exudate. A change in exudate should initiate a change in the wound management plan for the patient. Assessment of the level of the exudate has traditionally been in terms of ‘low’, ‘moderate’ and ‘high’ or + , + + , + + + , which can be very subjective (Tickle [134]).
Table 25.2 indicates the significance of the colour and Table 25.3 the significance of the consistency of wound exudate and what the nurse should take into consideration when assessing the patient.
Table 25.2 Significance of the colour of exudate
| Characteristic | Possible cause |
|---|---|
| Clear, amber | Serous exudate, often considered ‘normal’, but may be associated with infection by fibrinolysin‐producing bacteria such as Staphylococcus aureus; may also be due to fluid from a urinary or lymphatic fistula |
| Cloudy, milky or creamy | May indicate the presence of fibrin strands (fibrinous exudate – a response to inflammation) or infection (purulent exudate containing white blood cells and bacteria) |
| Pink or red | Due to the presence of red blood cells and indicating capillary damage (sanguineous or haemorrhagic exudate) |
| Green | May be indicative of bacterial infection, e.g. Pseudomonas aeruginosa |
| Yellow or brown | May be due to the presence of wound slough or material from an enteric or urinary fistula |
| Grey or blue | May be related to the use of silver‐containing dressings |
Table 25.3 Significance of exudate consistency
| Characteristic | Possible cause |
|---|---|
| High viscosity (thick, sometimes sticky) | High protein content due to:
Necrotic material
Enteric fistula
Residue from some types of dressings or topical preparations |
| Low viscosity (thin, ‘runny’) | Low protein content due to:
Urinary, lymphatic or joint space fistula
Bacterial growth or infection
Necrotic tissue Sinus/enteric or urinary fistula |
Management of exudate
Table 25.4 sets out appropriate ways to manage exuding malignant fungating wounds.
Table 25.4 Dressings and equipment for the management of wound exudate
| Amount | Dressings | |
|---|---|---|
| Lightly exuding wounds | Hydrogels/hydrocolloids/absorbent vapour‐permeable adhesive dressings | Contain exudate and maintain moist environment – minimize risk of pain/trauma/bleeding at dressing change (Naylor [101]) |
| Moderate– heavy exudate | Alginates/alginate plus (e.g. Sorbsan/Kaltostat) | When in contact with exudate forms a gel, which maintains a high humidity in the wound, they reduce the occurrence of exudate macerating surrounding skin |
| Hydrofibre (e.g. Aquacel) | Hydrofibres have a different method of action to an alginate in that they absorb and retain fluid in the dressing | |
| Foam dressings (e.g. Allevyn/Mepilex) | Absorb exudate into the matrix of the dressing. Some can transmit the water vapour through the surface of the dressing so that it can evaporate into the air (Adderley [2]). Foams should not be covered with occlusive film or similar as their function will be affected | |
| High‐absorbency dressings (e.g. Eclypse) | Some incorporate a gelling technology within the dressing similar to that used in disposable nappies. They are able to retain much higher levels of exudate within the dressing. They can reduce the number of dressing changes required. However, they can become heavy when saturated and cause the dressing to sag | |
| Wounds with sinus/fistula | Wound manager bag systems | Can be beneficial in containing odour and keeping the exudate away from the surrounding skin. Particularly beneficial if there is a fistula or a deep open wound producing copious amounts of exudate (Adderley [2]) |
Topical negative pressure
Topical negative pressure takes the fluid away from the wound by applying negative pressure. The system is not advocated for use in malignant wounds due to the potential for increasing cell activity; however, it may be appropriate to consider using a negative pressure pump as an alternative to conventional dressings in end of life care. Negative pressure may improve a patient's quality of life by managing three of the most challenging symptoms associated with dressing changes, namely exudate, odour and pain (Riot et al. [116]).
Periwound skin
If moisture becomes trapped under a dressing and the skin is in contact with the moisture for an extended time the epidermal cells can become waterlogged and prone to excoriation and stripping of the skin, potentially leading to an increase in the wound size. Exudate in chronic wounds appears to be more corrosive than in acute wounds and can lead to more damage to surrounding skin. It is possible to frame a wound using thin hydrocolloid dressings or semi‐permeable films, which can help to protect the skin and can also be effective in anchoring the secondary dressings in place. A protective, non‐alcohol based skin barrier such as Cavilon can be used prior to dressing application to protect the skin from damage due to excessive exudate (Benbow [17]) and can be beneficial in assisting adhesive dressings to form a good seal. Ideally the protective barrier should be used prior to any skin damage as pain and skin damage can impair the adherence of a dressing. Trauma to the skin can also be reduced by using atraumatic dressings, elastic vests and netting or tubular bandages to hold dressings in place (Draper [36]).
Malodour
The malodour from a malignant wound is often the most distressing symptom for a patient (Benbow [15]) and can have a profound impact on their quality of life. Malodour can cause nausea, vomiting and involuntary gagging (Lund‐Neilson et al. [86]) leading to a reduction in appetite and weight loss, with subsequent poor nutrition at a time when good nutrition is of high importance to their condition. A referral to the dietician service may be of benefit to the patient (Wilson [144]). Malodour can cause feelings of embarrassment and repulsion and lead to social isolation and depression. This is at a time when the support of family and friends is crucial for patients to cope with the physical and psychological impact of their progressive disease.
Malodour can be caused by necrotic and poorly vascularized tissue, the presence of bacteria, high levels of exudate (Gethin [47]) or stagnant exudate in the dressing. The type of tissue present in the wound is often the cause of malodour: devitalized and necrotic tissue can be an ideal environment for anaerobic and aerobic bacteria which can produce volatile agents. Anaerobic bacteria such as Clostridium and aerobic bacteria such as Proteus, Klebsiella and Pseudomonas are the organisms most frequently isolated in malignant wounds (Thomas et al. [133]).
It is difficult to quantify and describe odour because a person's perception is very subjective (Benbow [14]) and this makes assessment of the wound and effectiveness of the dressings difficult. This could contribute to the reason for a lack of empirical research into the management of malodour in wounds and the effectiveness of dressings to control odour (Gethin et al. [49]).
Management of malodour
When changing dressings, ensure that the room is well ventilated and that the dressings are disposed of quickly and appropriately following removal (Wilson [144]). Finding a dressing large enough to contain leakage is often a challenge. The frequency of the dressing changes may need to be increased to reduce the odour. The dressings may quickly become saturated with wound exudate, blood and pieces of necrotic tissue and increase the malodour when left in place (Schiech [124]). Dressings appropriate for the management of malodour in malignant fungating wounds are listed in Table 25.5.
Table 25.5 Dressings and agents for the management of wound malodour
| Dressing/agent | Description | Application | Comments |
|---|---|---|---|
| Charcoal, e.g. Clinisorb/Carboflex/Carbonet | Effective for reducing malodour
Absorbs small molecules and bacterial spores, making it a powerful deodorizer (Williams [143])
Available as either carbon only or incorporated with an additional dressing such as an alginate or an antimicrobial | If used on dry wounds, apply over a non‐adherent dressing
Consult specific manufacturer's guidance | Conflicting studies as to effectiveness of carbon when wet
Studies by Hampton ([60]) and Morris ([98]) showed Clinisorb could be used as a primary dressing without affecting malodour‐controlling properties
Draper ([36]) found carbon dressings most effective when kept dry and applied as a sealed unit, not always possible with fragile skin
Lee et al. ([79]) found that fibres may break away from dressings and they were not effective when wet. Only absorb odour, do not act on source |
| Silver dressings, e.g. Aquacel Ag/Acticoat | Silver is an inert metal which becomes active when it interacts with wound exudate. Ionic silver is released into the wound bed. Silver ions bind to and denature bacterial DNA and RNA, inhibiting replication (Hampton [62]) | Consult specific manufacturer's guidelines
Specific silver dressings such as Acticoat require activation with water prior to application | There is limited research in the use of silver dressings in malignant wounds but observation in clinical practice has shown that they can be effective in odour control (Hampton [62]).
When there is an infection present, the reduction of bacteria should lead to reduction in odour and symptoms of infection
Expensive and should only be used when requirement for antimicrobial dressing is confirmed (Alexander [6]) |
| Manuka honey, e.g. Activon | Manuka honey has levels of hydrogen peroxide which have a destructive effect on bacteria. Bacteria are metabolized by honey's glucose to produce lactic acid instead of the amino acids that produce malodorous ammonia, amines and sulphur compounds (White [141])
Available as an ointment, impregnated gauze or alginate dressing | Medical grade honey should be replaced or refreshed if exudate is very high or it stops being effective
Contraindications:
Patients may experience a ‘stinging/burning’ sensation on initial application – remove dressing if patient not able to tolerate | Can reduce bacterial load, combat odour, assist with debridement and have an anti‐inflammatory action, whilst thought to be harmless to healthy tissue (Booth [22]).
Antimicrobial and debridement actions beneficial in management of malodour as they assist in removing slough and bacteria, often the cause of the odour
Not suitable for highly exuding wounds |
Iodine:
| Cadexomer iodine is an antimicrobial agent that can be used to reduce malodour in malignant wounds (Hampton [62], Seaman [128])
Iodine penetrates micro‐organisms and attacks key protein groups, nucleotides and fatty acids, which kills the bacteria (Angel et al. [8]) | Consult specific manufacturer's guidance for application
Available as impregnated knitted viscose, gel sheets or paste
Contraindications: dry necrotic tissue or patients with known sensitivity. Do not use with children, pregnant or lactating patients/thyroid or renal impairment | Care should be taken when considering use of iodine in friable wounds as it has a tendency to cause wounds to bleed more easily (Hampton [62])
Cadexomer iodine formats are slow release and are activated on exposure to exudate. They are able to absorb high levels of exudate, forming a gel and reducing the wound bioburden |
| Larvae | Larval secretions liquefy necrotic and non‐viable tissue
Proteinaceous material is then ingested by the larvae (BioMonde [19]) | Maggots are sealed in a finely woven polyester net pouch. Check the wound daily and change secondary dressings. Larvae can remain on the wound for 4 days prior to changing (BioMonde [19]) | There is conflicting evidence on the use of larvae therapy in the management of malignant wounds. It is thought by some authors that larvae therapy may increase the incidence of bleeding in friable tissue (Alexander [6]). Jones et al. ([74]) and Sealby ([127]) described the successful use of larvae therapy in the management of malignant wounds |
| Essential oils, aromatherapy candles, room deodorizers or fragrances | Pleasant and familiar smells can increase the production of endorphins, aiding relaxation (James [72]) | Essential oils can be vaporized in the room or drops applied to the dressing
Care should be taken as strong scents may induce nausea | Mercier and Knevitt ([95]) chose an essential oil that was only present during dressing changes. The oil was vaporized in the room before and after the dressing change. If odour was detectable when the dressing was in place, a few drops were applied to the dressing. Eucalyptus, tea tree and lemon myrtle were found to be the most promising scents in the trial
Oils have been blended into creams and applied directly to a wound; however the safety of this practice cannot be recommended without discussion with a pharmacist and must only be used by healthcare professionals with the relevant skills and knowledge (Gethin [48]) |
External odour absorbers, i.e. cat litter/activated charcoal | Can be placed under the patient's bed | The use of such methods should be discussed with patients and their families and friends to avoid causing distress or offence (EONS [38]) | The use of cat litter or charcoal in an open tray under the bed, which may assist in absorbing odour, has been written in anecdotal evidence
There are also reports of an open dish of shaving foam or coffee beans being used to successfully manage wound odour |
Wound cleansing
Wound cleansing is extremely important in the management of malignant wounds to remove surface contaminants, micro‐organisms and excess exudate and loosen debris. However, cleansing is not appropriate for all wounds; if the aim of the management of the wound is to keep the area dry, it may be contraindicated (Jones [73]). Stagnant exudate within the wound or dressing can lead to an increase in malodour (Collier [25]).
If appropriate, patients with malignant wounds can remove their dressing and shower the open wound with warm water. This can be beneficial psychologically for the patient and help them to feel clean and refreshed (Fairbairn [40]). NICE guidelines ([106]) recommend that when a clean technique is required, warm tap or shower water is the preferred choice. If a sterile technique is required in circumstances such as a patient being immunocompromised, exposed bone within the wound or prior to taking a microbiology swab, sterile 0.9% sterile saline should be used, preferably warmed to body temperature prior to use.
The use of antiseptic solutions is not recommended by NICE ([106]) because they may be detrimental to the healing of wounds and toxic to tissues (Sibbald et al. [129]). Body fluids also quickly inactivate the solution (Naylor [101]). If there is a biofilm present in the wound the use of sodium chloride and tap water may be ineffective as biofilms may be resistant to irrigation and antibiotics (Jones [73]). The use of a wound irrigation solution or gel which contains polyhexamethylene biguanide such as Prontosan was found to be effective in eliminating biofilms in an evaluation by Horrocks ([69]). The study showed a significant improvement in wounds over a 3‐week period and a reduction in the level of exudate.
A study by Bale et al. ([12]), looking at the efficacy of metronidazole gel on malignant wounds, interestingly found that 76% of patients in the placebo arm reported an elimination in malodour. This was attributed to the fact that while the patients were on the study their wounds were thoroughly cleaned and their dressings changed on a regular basis. These findings support the need for regular cleansing and redressing of wounds to be carried out according to the requirements of the wound and the severity of the symptoms (Draper [36]).
Debridement
The management of malodour in a wound requires the odour to be contained and the cause to be treated. Debridement of devitalized tissue may be appropriate to reduce the concentration of the bacteria. The method of debridement should be based on the assessment of the wound, and guided by treatment goals and patient preference (Gethin [48]). Care should be taken with debridement as the wounds are often friable and tend to bleed; surgical or sharp debridement is therefore often contraindicated (Grocott [54]). It is also suggested that surgical debridement may ‘seed’ the malignant cells (Hampton [61]). Autolytic or enzymatic debridement is usually the preferred method (EONS [38]). However, consideration should be given to the impact on the patient of any form of debridement that may increase the exudate level while the necrotic tissue is liquefying.
Metronidazole
If an infection is suspected a wound swab should be taken and microbiology results obtained for a specific antibiotic to be prescribed.
There are several anecdotal reports affirming the effectiveness of metronidazole and the relief that is expressed by patients within a few days (Alexander [6]). Metronidazole is a synthetic drug which prevents the replication of bacteria by binding to their DNA, thereby reducing the bacterial burden in a wound (Draper [36]).
NICE guidelines ([106]) recommend oral metronidazole for deep tissue infections which are causing odour, with a dosage of 400 mg three times daily for 5–7 days. If a partial response is seen, consider continuing the drug for a further 7 days. However, patients may experience side‐effects such as nausea and neuropathy and the reduction of odour may only be effective for a few days (Grocott [53]). The effect may be reduced if the blood supply to the wound is compromised (EONS [38]).
The use of topical metronidazole may avoid the effects associated with the oral drug. It is traditionally thought to be effective against anaerobic bacteria; however, Thomas et al. ([133]) reported that it is also effective against aerobes. There can be limited effect when the wounds are extensive and penetration of the deep tissue to reach the anaerobic bacteria is not possible (Grocott [53]). It has also been questioned how therapeutic levels can be maintained when the drug is diluted with exudate in highly exuding wounds and can be absorbed in the dressings (Grocott [53]).
Topical metronidazole 0.75% gel can be applied directly onto the wound and can be more effective than oral metronidazole when excess necrotic tissue is present (NICE [106]). The gel should be applied liberally to the ulcer once or twice daily for 7 days. If there is a partial response, consider continuing for a further 7 days (NICE [106]). The contents of metronidazole capsules have also been sprinkled directly onto wounds; however, this may act as an irritant on the wound bed. The practice is unregulated and has only been documented through anecdotal evidence (EONS [38]).
Metronidazole gel can be used alone or with systemic therapy to manage malodorous wounds. The gel may also expedite debridement within the wound, through the facilitation of autolysis of the necrotic tissue and slough (Gethin [48]).
Dressings and agents for the management of wound malodour are summarized in Table 25.5.
Bleeding
Tumour‐induced angiogenesis and coagulopathy can result in thin‐walled blood vessels that bleed easily and have reduced coagulation (Lotti et al. [83]). As a tumour progresses, blood vessels may be eroded from the tumour or from the surrounding necrotic tissue, which can increase the risk of episodes of spontaneous bleeding or bleeding from trauma when a dressing is removed (Lloyd [80]).
The overall health conditions of the patient can increase the risk of bleeding, such as abnormal platelet function and vitamin K deficiency (Woo and Sibbald [147]). Systemic coagulopathy from existing co‐morbidities can exacerbate the fragility of a malignant wound (Alexander [4]).
The bleeding can be small or a significant bleed which is hard to control and may potentially necessitate the patient's admission to hospital. This can be extremely frightening for the patient and their family and can also be challenging and cause anxiety and apprehension for nursing staff managing their dressings (Lloyd [80]). A patient may be anxious and frightened about even the slightest leakage of blood from a wound (Lund‐Neilson et al. [85]).
The tumour may erode through a major vessel, which can result in a catastrophic fatal bleed. It is rare for a fatal haemorrhage to occur; however, it is most likely in head and neck tumours adjacent to the carotid artery or tumours in the groin adjacent to the femoral artery (EONS [38]). This can be extremely distressing for everyone involved. If it is thought to be a possibility, preparation should be made in advance. If possible a strategic plan should be developed with the patient and family, using dark sheets and having dark towels available (Watson and Hughes [139]). Medication to sedate the patient, such as subcutaneous benzodiazepine, should be available and prescribed in advance (EONS [38]).
Management of bleeding wounds
Much of the literature on the management of bleeding in malignant wounds is prescriptive with minimal empirical evidence on interventions (Alexander [5]).
- Consider antibiotics if signs or symptoms of infection are present – infected wounds are more prone to bleeding.
- The patient's bloods should be monitored to ensure they are not becoming anaemic due to bleeding from the wound (Benbow [14]).
- Consider the appropriateness of radiotherapy, chemotherapy, cauterization or embolization (Yorkshire Palliative Medicine Clinical Guidelines Group [152]), electrochemotherapy (Gehl and Geertsen [46]) or surgery, depending on the palliative care goals for the patient (Seaman [128]).
- If dressings are adherent to the wound, gently soak them off and review the dressing regimen to include non‐adherent dressings.
- If required, wounds should be gently irrigated with warmed normal saline as opposed to swabbing to avoid further trauma.
- If bleeding occurs the initial intervention should be to apply direct pressure to the area for 10–15 minutes (Watson and Hughes [139]).
Dressings appropriate for the management of bleeding wounds are listed in Table 25.6.
Table 25.6 Dressings and agents for the management of bleeding wounds
| Dressing/agent | Description | Application | Comments |
|---|---|---|---|
| Non‐adherent/soft silicone dressings or moist wound products, e.g. NA Ultra/Mepitel | Specifically designed to be non‐traumatic and enable pain‐free removal from the wound | Apply with secondary dressing
If silicone dressing used can be left in situ and secondary dressing changed – refer to specific manufacturer's guidelines | To reduce the risk of trauma to the wound and subsequent bleeding, a non‐adherent dressing should be used that maintains a moist surface between the dressing and the wound (EONS [38]) |
Alginate dressing, e.g. Kaltostat/Sorbsan (for mild–moderate bleed) | Some alginate dressings have haemostatic properties; however, they are not licensed as haemostatic dressings
The calcium ions within the dressings are released into the wound, activating platelets and leading to haemostasis (Yorkshire Palliative Medicine Clinical Guidelines Group [152]) | Available as flat non‐woven pad, ribbon for packing narrow wounds or sinuses and rope for packing cavities
Requires a secondary dressing
Forms a gel when in contact with wound exudate
Contraindications: dry/low exuding wounds, or hard necrotic tissue | Alginates can adhere to the wound between dressing changes and then cause further trauma and bleeding on removal. A silicone non‐adherent dressing may be placed directly onto the wound bed and left undisturbed and the secondary dressings changed as required (Watret [138]) |
Silver nitrate sticks (for mild–moderate bleed) | Works by coagulating proteins, leading to tissue necrosis and eschar formation, which leads to thrombus formation and haemostasis (Glick et al. [51]) | Apply to specific small bleeding points within a wound
Can cause permanent skin pigmentation
Surrounding skin should be protected prior to use | Small bleeding points can be managed with silver nitrate sticks (Seaman [128])
Creates a thin eschar that sloughs off within several days |
Sucralfate paste (for mild–moderate bleed) | For a slow capillary ooze | Sucralfate paste (1–2 g sucralfate crushed with a water‐soluble gel) can be applied to the bleeding point 1–2 times a day (Yorkshire Palliative Medicine Clinical Guidelines Group [152]) | |
Haemostatic surgical dressings, e.g. Surgicel (for moderate–heavy bleed) | Absorbable haemostat composed of oxidized cellulose polymer, absorbable knitted fabric that is flexible and adheres to bleeding surfaces (Keshavarzi et al. [76]) | For heavier bleeding, haemostatic surgical dressings (e.g. Surgicel) can provide rapid capillary haemostasis. They can be left in place on the wound and covered with a secondary dressing (Naylor [101]) | |
Topical adrenaline (for moderate–heavy bleed) | Adrenaline is a vasoconstrictor that makes capillaries smaller, limiting blood flow to the wound | Topical adrenaline (1:1000, 1 mg in 1 mL) in the form of a gauze soak should be applied with pressure for 10 minutes (EONS [38]) | There can be rebound bleeding when the effect of the adrenaline has worn off (Yorkshire Palliative Medicine Clinical Guidelines Group [152])
|
Topical tranexamic acid (for moderate–heavy bleed) | Tranexamic acid is an antifibrinolytic that stops the conversion of plasminogen to plasma, preventing the degradation of fibrin and the breakdown of clots (Noble and Chitnis [109]) | Tranexamic acid 500 mg in 5 mL soaked into gauze can be used as an alternative and applied with pressure for 10 minutes | Topical tranexamic acid is thought to have a lower incidence of developing thrombotic complications than oral route (Emara et al. [37]) |
Oral fibrinolytic antagonists, e.g. tranexamic acid (for moderate–heavy bleed) | See specific medication guidance for dosage | Oral fibrinolytic antagonists such as tranexamic acid can be given to stop bleeding and prevent further bleeding (Yorkshire Palliative Medicine Clinical Guidelines Group [152]) |
Pain
This section will concentrate on the management of acute non‐cyclic and acute cyclic pain particularly relating to malignant fungating wounds.
Patients consistently report pain as having a major impact on their quality of life and as one of the worst parts of living with a chronic wound (Price et al. [113]). It is recognized that pain is not only physical; it can also affect the psychological, social and spiritual well‐being of a patient and can limit their physical activities and social contact and contribute to an increase in anxiety and depression (Wounds International [151]).
Patients may experience the following types of physical pain with malignant fungating wounds:
- non‐cyclic acute pain – occurs when a procedure such as sharp debridement is being carried out
- cyclic acute pain – occurs on a regular basis and can be related to wound care, such as cleansing or dressing removal (procedural pain), or to movement and activity (incident pain) (Naylor [102])
- chronic pain – consistent pain that is not related to the actual management of the wound (World Union of Wound Healing Societies [149]).
The physical sensation of pain in malignant wounds can be due to several different factors such as: pressure from the tumour on other body structures; damage to nerve endings from the tumour; exposure of nerve endings; recurrent infections; impaired lymphatic and capillary drainage; trauma from wound care procedures and inappropriate dressings (Alexander [4], Naylor [102]).
A study conducted by Woo ([146]) found that 80% of patients experienced persistent pain between their dressing procedures. Szor and Bourguignon ([131]) found that 87.5% of the patients they studied reported pain at dressing change; Sibbald et al. ([130]) identified that pain is often at its worst during removal of the dressing.
A full and accurate assessment of the pain a patient is experiencing and the impact it has on their quality of life is crucial in understanding the correct management required. A valid and reliable assessment tool, such as a visual analogue scale, should be used to provide an accurate assessment of the type, frequency and duration of pain to identify aggravating and relieving factors and to allow implementation of an appropriate management plan. This should be an ongoing process so that the effectiveness of the analgesia can be monitored and adjusted as required to ensure that the patient is offered the maximum relief for any wound‐related pain (Day [27]).
A compassionate caring approach by the healthcare professional, and providing patients with an explanation of what to expect through dressing changes and details of the strategies in place to minimize their pain can help to reduce a patient's fear and anxiety. Increased levels of stress and anxiety have been shown to lower a patient's tolerance to pain, and a cycle can develop where pain, stress and anxiety worsen the patient's experience of pain (Woo [146]). Anticipatory pain is a significant problem. If there is a high level of anxiety a patient will anticipate more pain and can consequently experience more intense pain (Woo [146]). If there is inadequate pain management at the first dressing change that a patient experiences, it can have an impact on future management and the patient may lose confidence in the team managing their care (Latarjet [78]).
Patients should be encouraged to participate in their own care, where appropriate, by removing their dressings themselves, giving them some control and autonomy (Day [27]). They should be aware that they can request regular breaks during the dressing change if required and be encouraged to express when they are in discomfort.
Management of pain
Dressing changes should be kept to a minimum to avoid distress to the patient and trauma to the wound.
The inappropriate use of dressings can cause or increase pain for patients. Care should be taken when removing any dressings and the manufacturer's instructions should be consulted to avoid trauma, for example film dressings should be lifted at the edge then stretched up and away from the wound. A medical adhesive remover should be considered when removal of the dressing is painful or traumatic to the skin. Traditional dressings such as gauze and paraffin tulle should be avoided as they have the tendency to dry out and adhere to wounds and can become incorporated into tissues when the granulation tissue grows through the mesh pores. Soaking to remove these dressings is rarely effective (Naylor [99]). Products with an overall layer of adherence, such as hydrocolloids, foams and films, should be used with caution as they can be painful on removal (Hollinworth and Collier [68]). Honey dressings can cause a stinging or burning sensation for patients. This could potentially be due to the acidity level or the osmotic pull that they exert. See Table 25.7 for appropriate dressings and agents to manage wound pain.
Table 25.7 Dressings and agents to manage wound pain
| Dressing/agent | Description | Application | Comments |
|---|---|---|---|
| Soft silicone dressing/non‐adherent dressings, e.g. Mepitel | Soft silicone dressings reduce pain at dressing changes as they do not adhere to the wound surface. There is therefore no trauma, pain or stripping of skin on removal (Benbow [15]) | Soft silicone dressings may be left in situ and secondary dressings changed as required | The use of soft silicone dressings together with appropriate analgesia has been shown to lead to a dramatic improvement in a patient's pain levels and emotional state (Naylor [99]) |
| Alginate dressings, i.e. Sorbsan/Kaltostat | Alginate dressings transform to a gel when in contact with wound exudate. This provides a moist environment and facilitates pain‐free removal of dressings | Alginate dressings should not be applied to wounds with low levels of exudate as they dry out, adhere to the wound and cause trauma on removal | Moist wound healing is advocated in malignant fungating wounds to provide an environment where exposed nerve endings are bathed in fluid, preventing stimulation of the nerve receptors through dehydration and minimizing pain levels (White [142]) |
| Skin protector/barrier film, e.g. Cavilon | Liquid barrier film that dries quickly to form a breathable, transparent coating on the skin. Designed to protect intact, damaged or at risk skin from exudate and adhesive trauma (3M [1]) | Consult manufacturer's guidelines for application | Patients can develop contact and allergic dermatitis in the periwound area from corrosive exudate and dressing materials, leading to erythema, oedema and blistering around the wound edges
Macerated periwound skin can cause high levels of background pain. The application of a skin barrier film can prevent trauma to periwound skin |
| Topical opioids | Topical opioids can provide effective relief for up to 24 hours following application (Ashfield [10]) and can significantly improve the patient's comfort in between dressing changes | When using topical opioids, several factors should be taken into consideration such as the wound aetiology and size, the monitoring of the patient and their previous experience of treatment, the dose concentration and formulation (Graham et al. [52])
Treatment is usually a mixture of morphine and hydrogel, with a dosage of 1 mg morphine per 1 g of hydrogel (Naylor [102]) | The use of topical opioids is thought to be safe due to the low doses used and the minimal systemic absorption of topically applied opioids (EONS [38])
It is thought that topical opioids can relieve inflammatory pain without causing systemic side‐effects
Metronidazole can be used as a carrier for the opioid to combine pain and odour control (Grocott [53]) |
| Topical anaesthetics, e.g. lidocaine | Topical anaesthetic works by causing temporary numbness to the area of skin | Topical preparations may be suitable for use prior to a painful procedure under medical guidance
Use with caution due to potential increased absorption (Maier [88]) | Can reduce pain during wound manipulation and it is thought that patient anxiety may be reduced as they are aware that an anaesthetic is being applied (Sibbald et al. [130]) |
| Entonox | Entonox is a gas mixture of 50% nitrous oxide and 50% oxygen used to manage procedural pain | Appropriate training is required for healthcare professionals prior to the administration of Entonox | It can be used for rapid short‐lasting pain relief such as dressing changes with no lasting side‐effects (Hollinworth and Collier [68]) |
| Transcutaneous nerve stimulation (TENS) | Produces effect by stimulating the large diameter nerve fibres that carry the signals to the spinal cord and then inhibit the transmission of pain signals (James [72]) | Someone with expertise in the area should apply the TENS machine as the electrodes should be applied to receptor sites in areas of intact skin (Grocott [54]) | |
| Complementary therapies, e.g. relaxation, distraction or visualization | Visualization and imagery focus a patient's attention away from painful stimuli by creating images. Visualization is consciously selected images, and imagery is spontaneously occurring images from the unconscious (Van Fleet [137])
Distraction draws attention away from pain using an actual physical stimulus such as conversation, music or television
Aromatherapy – pleasant familiar smells can increase the production of endorphins | The use of relaxation and massage can help to reduce tension and anxiety, improving pain tolerance by breaking the cycle of anxiety and pain (Naylor [99])
Aromatherapy can create a relaxing atmosphere and help with wound odour. A combination of techniques can be used to provide optimal care for a patient, such as breathing techniques, relaxation and music during dressing changes (Naylor [99]) | |
| Acupuncture, acupressure and hypnosis | Acupuncture – needle inserted into the median that runs through the area of pain to interrupt it (James [72])
Acupressure – exact mechanism unknown; believed it allows endogenous opioids to be released into the body and improves local circulation (James [72])
Hypnosis – induced state of consciousness where patient loses power of voluntary action and is responsive to suggestion or direction | All administered by appropriate skilled healthcare professionals | Hypnosis – thought to alter thoughts and feelings, behaviour or psychological states. Can help alleviate sensory or effective components of a pain experience (James [72]) |
Appropriate treatment should be provided for any signs of infection. An increase, unexpected pain or change in the nature of the pain could indicate that there is an infection present in the wound (Gardner et al. [45]). There may be an increase in pain from a high bacterial load which can occur prior to any signs of an infection being observed.
To reduce discomfort wounds should be irrigated or showered with an appropriate temperature solution and not swabbed unnecessarily (EONS [38]). (See Chapter c18: Wound management.)
Analgesia should be given at least 30–60 minutes prior to dressing changes to allow for maximum effect and can be systemic, local or topical (Lloyd‐Jones [81]).
Pruritus
Pruritus can be one of the most troublesome symptoms of advanced cancer and may be so severe that patients scratch their skin until it bleeds (Alexander [4]). Itching can often be disabling and is difficult to treat as the active tumour is often the cause of the itch. A patient's quality of life can be impaired with the resulting anxiety, depression and loss of sleep (Upton et al. [136]). The itching can be intense and is often described as creeping by patients. It can be caused by the stretching of the skin over the active tumour which irritates the nerve endings at the dermo‐epidermal border, leading to a biochemical reaction (Zylicz et al. [153]). See Table 25.8 for appropriate dressings and agents for the management of pruritus.
Procedure guideline 25.2
Dressing a malignant fungating wound
Table 25.8 Dressings and agents for the management of pruritus
| Dressing/agent | Description | Application | Comments |
|---|---|---|---|
| Tricyclic antidepressants and paroxetine | Pruritus from malignant wounds generally does not respond to antihistamines
Tricyclic antidepressants and paroxetine can be beneficial, although their use may be limited due to their toxicity (Zylicz et al. [153]) | ||
| Bedlinen and clothing | Garments and bedlinen that reduce pruritus in conditions such as eczema may be beneficial for patients with malignant fungating wounds (EONS [38]) | ||
| Hydrogel sheets, e.g. Novogel | Hydrogel sheets keep the skin well hydrated and can have a cooling effect (EONS [38]) | The dressing should be covered with a semi‐permeable film to prevent the dehydration of the dressing. If the wound is exuding, cover with a dry dressing and secure in place (Naylor et al. [103]) | Dressings such as Novogel have a cooling effect which is enhanced if cooled in a non‐food refrigerator prior to use |
| Menthol in aqueous cream | Pre‐prepared lotion such Levomenthol cream | Can be applied to an itchy area 1–2 times a day
This should be applied to surrounding skin and not directly onto an open wound | Menthol in aqueous cream can have a cooling effect and the cream does not dry on the skin as calamine lotion would |
| TENS (transcutaneous electrical nerve stimulation) | TENS machines stimulate the nerves that carry non‐painful messages to the brain which then overrides the pain messages and can also be beneficial in the treatment of pruritus (Grocott [54]) | Someone with expertise in the area should apply the TENS machine as the electrodes should be applied to receptor sites in areas of intact skin |
Post‐procedural considerations
Ongoing care
Dressings need to be changed when ‘strike‐through’ occurs; that is, the dressing becomes soiled and damp at the surface or edge or leakage of wound exudate occurs (see individual dressing packs for instructions to guide practice). The medical team may take the dressing down to view the wound and the nurse should be present to monitor this and reapply an appropriate dressing. Record any changes and/or instructions in the patient's notes or wound care plan (NMC [107]). Included in the notes should be the amount and appearance of exudate, any signs of inflammation, infection or odour, and appearance of the wound bed. The condition of the periwound skin should be recorded as should any pain at dressing change. The management plan for the next dressing change should be amended accordingly.
Complications
Malnutrition and dehydration
Patients with a malignant fungating wound often have additional nutritional requirements that may be due to the loss of protein through wound exudate, often combined with a poor appetite due to nausea from their disease process or the odour from their wound (EONS [38]).
The patients have a high metabolic demand and may require regular meals and snacks during the day and consideration to be given to nutritional supplements. Exudate from malignant fungating wounds can be up to one litre per day which puts an increased demand on the patient for proteins and additional fluid intake to reduce the risk of dehydration (EONS [38]).
A nutritional specialist or dietician should be involved in the care of the patient for a comprehensive nutritional assessment.
For further nutritional information please refer to Chapter c27.
