Transcript 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?
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
Malodor
Tissue
Necrosis
Anaerobic
Bacterial
Colonization
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)
Anaerobes only – Binds their DNA
gel - .75% -displacement
tablets crushed in gel
oral tablets (200-500 mg. TID)
IV/irrigation
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
Cloudy
Serous
Amber Exudate
Purulent
Hemopurulent
Sanguinous
THE 5 C’S OF EXUDATE
MANAGEMENT
CAUSE
CONTROL
COMPONENTS
CONTAINMENT
COMPLICATIONS
CAUSE
Lymphedema
Drug-related
Infection
Heart Failure
Decreased se
albumin
CONTROL
Is systemic and or local control
possible?
COMPONENTS
VISCOSITY?
BACTERIA?
NECROTIC
MATERIAL?
CONTAINMENT
Collection
Devices
VAC
Capillary
Action
Dressings
Bacterial
Control
Dressings
Absorptive
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
Sucralfate
Topical
Adrenaline
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?