Download Although fungating wounds do not usually heal, there are a number

Wounds-PG/AM
19/03/2008
11:57
Page 1
Clinical
Making it better
Although fungating
wounds do not usually
heal, there are a number
of treatment options
available to help patients
cope, writes
Anne Murphy
FUNGATING wounds are caused by the
infiltration of the skin by a local tumour or
by recurrent or metastatic spread of the
primary tumour.14
These wounds do not generally heal
unless the malignancy is receptive to anticancer treatment and are therefore more
likely to deteriorate over time.32 The actual
incidence is however difficult to establish
due to the nature of the wound and the
time in the life of the individual that presents with the wound usually during the
last six months of life.
It is however thought that approx 5%10% of patients with metastatic cancer
will develop a malignant wound occurring
most frequently in the 60-70 year age
group. 19,15
It is important to note though that
although fungating wounds occur more
frequently in people with advanced cancer, it is possible for people to live for years
with a fungating wound if the disease is
localised.13,15
As fungating wounds rarely heal, their
management is based on symptom control, promoting comfort and maintaining
or improving quality of life. Treatment is
generally palliative in nature and often
involves the use of dressings or other topical products to control symptoms. 31
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WIN April 2008 Vol 16 Iss 4
There are several physical symptoms
associated with fungating wounds
including:
• Pain
• Malodour
• Exudate
• Bleeding
• Infection
• Slough
• Itching
• Oedema.
Fungating wounds can cause several
psychological issues for the patient
including:
• Fear and guilt
• Embarrassment
• Poor self image
• Social isolation and depression.
Odour
Malodour is a common symptom from
fungating wounds. Odour is caused by tissue necrosis and infection, usually
anaerobic bacterial infection.40 Stale exudate and soiled saturated dressings may
also contribute to wound odour.4,2
Treatment
There are various treatment modalities
for the management of fungating wounds
such as:
• Radiotherapy
• Chemotherapy
• Hormone therapy
• Surgery.17
Radiotherapy is effective for some
wounds in that it can control bleeding and
exudate, may reduce tumour bulk and
may be given prophylactically to prevent
fungation. Chemotherapy (palliative low
dose) may also help in tumour control.
Hormone therapy may also be considered
a treatment option where the primary
tumour is hormone sensitive for example
oestrogen- receptive- positive breast
tumour.
Palliative surgery may also be an option
for tumours that can be completely
excised and repaired with a flap or skin
graft but this option is not used very
often.34 Appropriate wound dressings are
also essential in their overall management
and this is an area where nurses’ knowledge and experience can make a
significant difference in the patient’s quality of life.
The management of fungating wounds
poses many challenges for nursing staff, is
rarely straightforward and requires a great
deal of sensitivity and flexibility from
those involved in the patient’s care.40
A wound care intervention, based on
evidence based practice and psychosocial
support can reduce the symptoms and
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Clinical
increase a patient’s overall sense of wellbeing.24
Assessment
Assessment of fungating wounds is a
very important aspect of care. Assessment
should involve a holistic approach that
includes the physical, psychological and
social status of the patient as well as local
wound factors.15,39
These assessments will form the base
line against which to measure the outcome of any nursing intervention and
plan further care for the patient and
his/her wound.11 Accurate wound assessment is based on:
• Wound location and size
• Amount of exudate wound produces
• Odour from the wound
• Has the patient pain and how is the surrounding skin
• How does it impact on the patient’s psychosocial needs?
Assessment tools
Two disease specific measurement tools
are identified in the literature that can be
used to assess and measure the outcomes
of fungating wound management
together with the impact of the condition
on the individual:
• The Wound and symptoms Self Assessment Chart (WoSSAC)
• The Treatment Evaluation by LE Roux’s
method (TELER).32,13
Management of the most common
symptoms: pain, exudate, odour and
bleeding.
Pain
Pain management of fungating wounds
is complex. Effective management of
wound care may be compromised by
inappropriate or non-existent pain assessment, the inefficient use of analgesia and
confusion about the appropriate wound
care product to use.30
It is important that these patients be
referred to the local palliative care team
and that nurses involved in their management liaise with this team particularly in
relation to pain management.
Causes of pain may include pressure
form the tumour pressing on nerves and
blood vessels, inflammation, infection, skin
maceration of surrounding tissue,
oedema, trauma on dressing removal.25,18,20
Patients may need adjuvant analgesics
such as non-steroidal anti inflammatory
drugs, steroids, antidepressants, or anticonvulsants. Topical opiates have been
recommended in the management of
pain in fungating wounds and local anaesthetic gel may also help relieve pain
caused by skin maceration and skin excoriation.1,23,38,26
Consider the need for analgesia pre
dressing changes. Irrigate with warm normal saline rather then cleaning with gauze
swabs.19
Consider also using complementary
therapies as these can play a significant
role in pain management. 8 From a dressing perspective dry dressings will nearly
always increase pain because of the
osmotic ‘pull’ that is created by the wound
environment.
Non adherent dressings should be used,
maintaining the wound in a moist environment will protect exposed nerve
endings and reduce dressing adherence
therefore minimising pain (during dressing changes).18 Pain assessment tools are
invaluable for measuring interventions
and evaluating outcomes. A Visual Analogue Scale is an easy to use assessment
tool.
Conclusion
Management of fungating wounds is
certainly challenging to healthcare staff.
However effective management can have
a significant impact on the quality of life
patient. It is for this reason that each individual is assessed and the choice of
treatment and dressing are tailored to the
individual.
Anne Murphy is oncology nurse education facilitator
at St Luke’s Hospital, Rathgar, Dublin 6
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