MALIGNANT WOUNDS

1. MALIGNANT WOUNDS Connie Sarvis RN, BN, MN, CON(C), IIWCC, CWS Skin and Wound Consultant Seven Oaks General Hospital

2. Malignant Wound?Fungating Wound?Cutaneous Malignancy?Malignant Cutaneous Ulcer?Tumor Necrosis?

3. How Common Are They? 5-10% of patients with metastatic cancer will develop a malignant wound! Wound Care Designed to afford Relief without Cure

4. Most Common Sites • Breast • Head/Neck • Back/Trunk/Abdomen • Groin/Axilla • Genital

5. How do they develop?

6. From a Primary Skin cancer left untreated. Ie. Basal cell ca Squamous cell ca

9. A Primary Tumor invading up into and through the skin. Ie. Breast tumor

11. Tumor has invaded blood or lymph vessels – small skin capillaries trap malignant cells

14. During Surgery – seeding of malignant cells in the dermis occurs

18. Conversion: Malignant wound develops in another chronic ulcer/scar tissue

20. 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

21. Tumor very disorganized! – poor skin perfusion, edema and necrosis occurs • Tumors often extend into deeper structures – sinus and fistula formation

22. TREATMENT

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

24. Chemotherapy • Can decrease tumor mass • Depends on tumor response

25. RADIOTHERAPY • Can reduce the size of mass – controlling exudate, bleeding and pain • Adding radiotherapy reactions to wound

29. 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

30. ASSOCIATED PROBLEMS WHAT DOES THE PATIENT THINK IS THE MOST IMPORTANT?

31. ODOR!! • Anaerobic Bacteria infecting or colonizing necrotic tissue-Putrescine, Cadaverine • Klebsiella, Pseudomonas & Proteus • Necrotic Tissue Odor • Stale Exudate

32. Presence of Infection Tissue Degradation Malodor Tissue Necrosis Anaerobic Bacterial Colonization

33. Debridement Remove necrotic tissue where bacteria are • Sharp? • Mechanical? • Autolytic?

35. SYSTEMIC ANTIBIOTICS • Control Odor from Bacteria’s Metabolic End Products • Bacterial Resistance • Adverse Effects

36. FLAGYL (Metronidazole) Anaerobes only – Binds their DNA • gel - .75% -displacement • tablets crushed in gel • oral tablets (200-500 mg. TID) • IV/irrigation

37. SILVER/IODOSORB • Reaches the Gram positive cocci and gram negative rods – Pseudomonas • No bacterial resistance • Longer to control odor

39. CHARCOAL DRESSINGS • Absorbs volatile malodorous chemicals from wound before they pass into air • Needs to be an airtight seal

40. Pouching? • Increase Frequency of Drsg. Changes • Room Sprays – Nausea!! • Mentholatum applied to Nostrils • Kitty Litter, Charcoal, Baking Soda, Vinegar • Distraction Techniques

41. EXUDATE

42. Tumor Cells can secrete Vascular Permeability Factor – vessels become more permeable to plasma colloids and fibrinogen • Inflammatory reaction - Histamines

43. Cloudy Serous Amber Exudate Purulent Hemo-purulent Sanguinous

44. THE 5 C’S OF EXUDATE MANAGEMENT • CAUSE • CONTROL • COMPONENTS • CONTAINMENT • COMPLICATIONS

45. CAUSE Drug-related Lymphedema Infection Decreased se albumin Heart Failure

46. CONTROL Is systemic and or local control possible?

47. COMPONENTS VISCOSITY? BACTERIA? NECROTIC MATERIAL?

48. CONTAINMENT Collection Devices VAC Capillary Action Dressings Bacterial Control Dressings Absorptive Dressings

49. COMPLICATIONS

50. BLEEDING