metastatic wounds

Metastatic Wounds

More than One PersonWith More than a Wound

EmotionsAnger

IsolationEmbarrassment

FearDenial

Psychologicalwound Care

Only the Beginning

Cancer Names

Melanoma

Basal Cell

Squamous cell

Lymphoma

Sarcoma

Kaposi's Sarcoma

Melanoma is the most serious type of Skin Cancer. Often the first sign of melanoma is a change in the size, shape, colour or feel of a mole. Most melanomas have a black or black-blue area. Melanoma may also appear as a new mole. It may be black, abnormal or "ugly looking."

Superficial SpreadingMelanoma

NodularMelanoma

LentigoMalignaMelanoma

MedLine Plus -Cancer

MelanomaMelanoma can appear anywhere on the body — soles,

palms, inside the mouth, genitalia, and underneath nails. However, it is most commonly found on the back, buttocks, legs, scalp, neck, and behind the ears.

ABCDs of Melanoma Detection

Asymmetry.

If you could fold the lesion in two, the two halves would not match.

Border.

Melanomas often have uneven or blurred borders.

American Academy of Dermatology

MelanomaABCDs Colour

Melanoma typically is not one solid colour; rather it contains mixed shades of tan, brown, and black. It can also show traces of red, blue or white.

Diameter While melanomas are usually greater than 6

millimetres (about the size of a pencil eraser) when diagnosed, they can be smaller. If you notice a mole different from others, or which changes, itches, or bleeds even if it is smaller than 6 millimetres, you should see a dermatologist.

American Academy of Dermatology

Melanoma

Four Types of Melanoma

Superficial Spreading Melanoma(about 70% of diagnosed cases)

Nodular Melanoma (about 15% of diagnosed cases)

Lentigo Maligna Melanoma (about 10% of diagnosed cases)

Acral Lentiginous Melanoma (about 5% of diagnosed cases)

Basal Cell

Basal cells line the deepest layer of the epidermis. Basal cell carcinomas are malignant growths--tumors--that arise in this layer.

Basal cells line the deepest layer of the epidermis. Basal cell carcinomas are malignant growths--tumors--that arise in this layer.

occur most frequently on the sun-exposed areas of the body: face, ears, neck, scalp, shoulders and back.

Skin Cancer Foundation

Basal CellFive most typical characteristics of basal cell carcinoma

An Open Sore that bleeds, oozes or crusts and remains open for a few weeks. A persistent, non-healing sore is a very common sign of an early basal cell carcinoma.

A Reddish Patch or irritated area, frequently occurring on the chest, shoulders, arms or legs. Sometimes the patch crusts. It may also itch or hurt. At other times, it persists with no noticeable discomfort.


Typical Characteristics of Basal Cell Carcinoma

A Shiny Bump or nodule that is pearly or translucent and is often pink, red or white. The bump can also be tan, black or brown, especially in dark-haired people, and can be confused with a mole

A Pink Growth with a slightly elevated rolled border and a crusted indentation in the centre As the growth slowly enlarges, tiny blood vessels may develop on the surface.

Scar-Like Area which is white, yellow or waxy, and often has poorly defined borders. The skin itself appears shiny and taut. This warning sign can indicate the presence of small roots, which make the tumor larger than it appears on the surface.


Basal Cell TreatmentsCurrent methods of treating BCC are: Curettage-electro dessication

Cryosurgery

Chemotherapy Topical or Injections

Excitional surgery Mohs Micrographic Surgery

Radiation therapy

Photodynamic therapy

Laser therapy

http://www.skincancer.org/skin-cancer/surgical-excision.html

Squamous Cell

Squamous cell carcinoma (SCC) is the second most common form of skin cancer, with over 250,000 new cases per year estimated in the United States. It arises in the squamous cells that compose most of the upper layer of the skin


Squamous CellTumours appear most frequently on the sun-exposed face, neck, bald scalp, hands, shoulders, arms and back. The rim of the ear and the lower lip are especially vulnerable to these cancers.


SCCs may also occur where skin has suffered certain kinds of injury: burns, scars, long-standing sores, sites previously exposed to X-rays or certain chemicals (such as arsenic and petroleum by-products). In addition, chronic skin Inflammation or medical conditions that suppress the immune system over an extended period of time may encourage development of the disease. Skin Cancer Foundation

Squamous Cell

Squamous cell tumors are thick, rough, horny and shallow when they develop. Occasionally, they will ulcerate, which means that the epidermis above the cancer is not intact. There will be a raised border and a crusted surface over a raised, pebbly, granular base. See photos below for examples.


Squamous Cell

Warning Signs:

A wart-like growth that crusts and occasionally bleeds.

A persistent, scaly red patch with irregular borders that sometimes crusts or bleeds.

An open sore that bleeds and crusts and persists for weeks

An elevated growth with a central depression that occasionally bleeds. A growth of this type may rapidly increase in size.


Squamous Cell Treatment

Cryosurgery

Chemotherapy Topical or Injections

Ecisional surgery

Mohs Micrographic Surgery

Radiation therapy

Photodynamic therapy

Laser therapy curettage - electro dessicationSkin Cancer Foundation

http://www.skincancer.org/skin-cancer/surgical-excision.html

LymphomaLymphoma is a cancer of a part of the

immune system called the lymphatic system. There are many types of lymphoma. One type is called Hodgkin's disease. The rest are called non-Hodgkin's lymphoma.

National Cancer Institute, US National Institutes of Health

Lymphoma

Non-Hodgkin's lymphomas begin when a type of white blood cell, called a T cell or B cell, becomes abnormal. The cell divides again and again, making more and more abnormal cells. These abnormal cells can spread to almost any other part of the body. Most of the time, doctors can't determine why a person gets non-Hodgkin's lymphoma


LymphomaEstimated new cases and deaths from non-Hodgkin

lymphoma in the United States in 2007:

New cases: 63,190

Deaths: 18,660


What Is Non-Hodgkin Lymphoma?

Non-Hodgkin lymphoma is cancer that begins in cells of the immune system. The immune system fights infections and other diseases.

The lymphatic system is part of the immune system.


What Is Non-Hodgkin Lymphoma? The lymphatic system has a

network of lymph vessels. Lymph vessels branch into all the tissues of the body.

The lymph vessels carry clear fluid called lymph. Lymph contains white blood cells especially Non-Hodgkin's Lymphoma cells - Lymphocytes such as B cells and T cells.


What Is Non-Hodgkin Lymphoma?

Lymph vessels are connected to small, round masses of tissue called lymph nodes. Groups of lymph nodes are found in the neck, underarms, chest, abdomen, and groin. Lymph nodes store white blood cells. They trap and remove bacteria or other harmful substances that may be in the lymph.


Other parts of the lymphatic system:

the tonsils, thymus, and spleen.

Lymphatic tissue is also found in other parts of the body including the stomach, skin, and small intestine.

Non-Hodgkin

Lymphoma?

Non Hodgkin's StagingStage I: The lymphoma cells are in one lymph node group (such as in the neck or underarm). Or, if the abnormal cells are not in the lymph nodes, they are in only one part of a tissue or organ (such as the lung, but not the liver or bone marrow).


Stage II: The lymphoma cells are in at least two lymph node groups on the same side. Or, the lymphoma cells are in one part of an organ and the lymph nodes near that organ. There may be lymphoma cells in other lymph node groups on the same side of the diaphragm

Stage III: The lymphoma is in lymph nodes above and below the diaphragm. It also may be found in one part of a tissue or an organ near these lymph node groups.

Stage IV: Lymphoma cells are found in several parts of one or more organs or tissues (in addition to the lymph nodes). Or, it is in the liver, blood, or bone marrow.

Recurrent: The disease returns after treatment.

Staging (cont'd)

In addition to these stage numbers, your doctor may also describe the stage as A or B:

A: You have not had weight loss, drenching night sweats, or fevers.

B: You have had weight loss, drenching night sweats, or fevers.


Hodgkin Lymphoma

Hodgkin Lymphoma Cells

Hodgkin lymphoma begins when a lymphocyte (usually a B cell) becomes abnormal.

National Cancer Institute,US National Institutes of Health

Staging

The Reed-Sternberg cell divides to make copies of itself. The new cells divide again and again, making more and more abnormal cells. The abnormal cells don't die when they should. They don't protect the body from infections or other diseases. The build-up of extra cells often forms a mass of tissue called a growth or tumor.

Abnormal B cells

Stage I. The cancer is limited to one lymph node region or a single organ.

Stage II. In this stage, the cancer is in two different lymph nodes, but is limited to a section of the body either above or below the diaphragm.

Stage III. When the cancer moves to lymph nodes both above and below the diaphragm, but hasn't spread from the lymph nodes to other organs, it's considered stage III.

Stage IV. This is the most advanced stage of Hodgkin's disease. Stage IV Hodgkin's disease affects not only the lymph nodes but also other parts of your body, such as the bone marrow or your liver.

Additional definitions of the cancer

doctor may use the letters A, B, E and S to help define the extent of your cancer and the treatment needed:

The letter A means that you don't have any significant symptoms as a result of the cancer.

The letters B, E and S indicate potentially more serious disease

The letter B indicates that you may have significant signs and symptoms, such as a persistent fever greater than 100 F with no other known cause, unintended weight loss of more than 10 percent of your body weight or severe night sweats.

The letter E stands for extra nodal, which means that the cancer has spread beyond your lymph nodes.

The letter S designates a cancer that has spread into your spleen.

Many initial signs and symptoms may be similar to those of the flu, such as fever, fatigue and night sweats. Eventually, tumors develop.

Hodgkin Lymphoma

Hodgkin's disease symptoms may include:

Painless swelling of lymph nodes in your neck, armpits or groin Persistent fatigue Fever and chills Night sweats Unexplained weight loss — as much as 10 percent or more of your body weight Loss of appetite Itching

Cause

The exact cause of Hodgkin's disease is unknown.

There are five types of Hodgkin's disease

all among a group of cancers called lymphomas

cancers of the lymphatic system.

Commonly begins in lymph nodes located in the upper part of your body

Some lymph nodes are in areas more readily noticed, such as in your neck, above your collarbone, under your arms or in your groin area.

Enlarged lymph nodes in the chest cavity also are common.

Eventually, Hodgkin's disease may spread outside your lymph nodes to virtually any part of your body.

Risk Factors for Hodgkin's disease:

Age. People between the ages of 15 and 40, as well as those older than 55, are most at risk of Hodgkin's disease.

Family history. Anyone with a brother or a sister who has the disease faces an increased risk of developing Hodgkin's, though this may be due to similar environmental exposures rather than genetic factors.

Sex. Males are slightly more likely to develop Hodgkin's.

Past Epstein-Barr infection. People who have had illnesses caused by the Epstein-Barr virus, such as infectious mononucleosis, are more likely to develop Hodgkin's disease than people who haven't had a past Epstein-Barr infection.

Compromised immune system. Having a compromised immune system, such as from HIV/AIDS or from having an organ transplant requiring medications to suppress your immune response, also appears to put you at a greater risk of Hodgkin's disease.

Risk Factors for Hodgkin's disease:

Screening and DiagnosisSymptoms of Hodgkin's are similar to those of other disorders, such as influenza, the disease can be difficult to diagnose. Some distinctive characteristics help diagnose Hodgkin's disease, and these include:

Orderly spread. The pattern of spread is orderly, progressing from one group of lymph nodes to the next. Only rare 'skipping.' The disease rarely skips over an area of lymph nodes as it spreads.

Biopsy Can Reveal Changes

A tissue sample (biopsy) of an enlarged lymph node is needed to make the diagnosis

X-ray Computerized tomography (CT) scan Magnetic resonance imaging (MRI) Gallium scan, which uses a radioactive substance

given intravenously that indicates areas in your body where Hodgkin's disease may be present

Positron emission tomography (PET) scan Bone marrow biopsy Blood tests

Other factors affecting decisions about treating this disease include:

Your age

Your symptoms

Whether you're pregnant

Your overall health status

Treatment options include:

Radiation

Chemotherapy

Bone marrow transplant

Treatment

The most important factor in Hodgkin's disease treatment is the stage of the disease. The number and regions of lymph nodes affected and whether only one or both sides of your diaphragm are involved also are important considerations.

Soft Tissue Sarcoma

Soft tissue sarcomas can occur anywhere in your body, but the largest number — about 60 percent — occur in the arms, legs, hands or feet. Another 20 percent occur in the chest and abdomen. About 10 percent are found in the head and neck.

Soft tissue sarcomas usually produce no signs and symptoms in their early stages. As the tumor grows, it may produce a lump or swelling. Later it may cause pain if it presses on nerves or muscles. If the tumor is located in the abdomen, it may cause blockage or bleeding of the stomach or intestines. Mayo Clinic

Locations of sarcomas and their names include:

Muscle - Sarcomas that arise from skeletal muscles include rhabdomyosarcomas, which most commonly occur in your arms and legs. There are multiple subtypes of rhabdomyosarcoma, and

Leiomyosarcomas, which are more common in adults, arise from the smooth muscles, most commonly in the uterus, gastrointestinal tract or lining of blood vessels.

Blood vessels

Hemangiosarcomas, which most commonly occur in blood vessels of your arms, legs, head and trunk;

Infantile hemangiopericytomas, which generally occur in blood vessels of the arms, legs, trunk, head and neck of children ages 4 and younger; and

Kaposi's sarcomas, which occur in blood vessel walls, most commonly in people with immune deficiencies such as HIV/AIDS.

Lymph vessels -

Lymphangiosarcomas, this type occurs in lymph vessels, most commonly in your arms. These sarcomas are sometimes seen in tissue that's been exposed to radiation, such as the arm on the same side as a breast treated for breast cancer.

Synovial tissue -

Synovial sarcomas occurs in the tissue around joints such as your knees and ankles. Synovial sarcomas typically occur in children and young adults.

Nerves -

Neurofibrosarcomas occur in the peripheral nerves, most commonly in the arms, legs and trunk.

Fat -

Liposarcomas occur in the fatty tissues, often in your legs and trunk.

Fibrous tissue

Fibrosarcomas, which usually occur in your arms, legs or trunk; malignant fibrous histiocytomas, which tend to occur in your arms or legs; and Dermatofibrosarcoma, which grow in the tissue beneath your skin and typically occur in your trunk or limbs.

Possible Causes

Inherited retinoblastoma. This rare form of childhood eye cancer may increase a child's risk of soft tissue sarcoma and is due to inheritance of a mutated retinoblastoma gene.

Li-Fraumeni syndrome. This condition is characterized by an increased risk of many cancers, including sarcomas, Leukaemia, breast cancer, ovarian cancer and others.

Gardner's syndrome. This hereditary disease leads to precancerous and cancerous growths in the intestines and abdomen.

Neurofibromatosis. This condition results in developmental changes in the nervous system, causing nerve sheath tumors. About one in 20 people with neurofibromatosis develops malignant tumors.

Radiation exposure

Chemical exposure

Vinyl chloride, used in making plastics

Dioxin, an unwanted byproduct of incineration

Herbicides that contain the chemical phenoxyacetic acid

Possible Causes

When to seek medical advice

Talk to your doctor if you develop a lump that persists or if you have signs or symptoms that may indicate a soft tissue sarcoma, such as worsening abdominal pain or blood in your stool. Some soft tissue tumors are noncancerous (benign). However, the only way to determine whether a tumor is cancerous or not is for a doctor to examine a sample of the tissue

Screening and diagnosis

Needle biopsy

Surgical biopsy

Imaging tests, X-rays,

Computerized Tomography (CT) scans,

Ultrasound,

Magnetic Resonance Imaging (MRI)

Positron Emission Tomography (PET)

With soft tissue sarcomas, tumors can grow large, press on normal tissue, and cause soreness or pain. If the cancer spreads to other organs, complications include dysfunction of the affected organ, such as shortness of breath if it spreads to your lungs.

TreatmentSurgery

Radiation therapy

Chemotherapy

Eliminate all cancer cells in your body, even when cancer is widespread

Prolong your life by controlling cancer growth and spread

Relieve symptoms and enhance your quality of life

Malignant WoundsTreat the Patient Concerns

Manage Pain

Provide Psychological, Emotional, and Financial Support

Patient/Family Education, Family Involvement and readiness to participate in wound care

Enhance Patient Management at home

Reduce Suffering and quality of Life

Causes of Wounds in Malignant DiseasePressure Ulcers

Primary Skin Tumor

Invasion of skin structures by underlying tumour

Metastatic spread of distant tumour

Lesion on forearm d/t Metastatic breast cancer

Other Causes of Malignant Cutaneous Wounds

Oral Lesions

Lymphedema

HIV - Karposi's sarcoma

Type of Cancer Incidence Location and Presentation

Lung Most common in Chest wall, men 24% posterior back or abdomen, clusters of painless nodules

Breast 69% Anterior chest wall, plaques, nodules or inflammatory telaniectasis

Colorectal Male 19% Abdomen or Female 95 perineal area

Type of Cancer Incidence Location and Presentation

Ovarian 4% Umbilicus, vulva or upper thigh with a herpetiform pattern or erysipleus like features

Cervix 2% Abdominal wall, vulva or anterior chest wall, plaques, nodules or inflammatory telangietasia

Melanoma Female 51% Heavily pigmented men 13% or subcutaneous nodularities

Assessment & Diagnosis

Complete History

Underlying Etiology – cancer type

past and current treatment of cancer and wounds

Impact of disease (process and burden) and treatments

Co morbidities\; Diabetes, immunosuppression,peripheral vascular disease (extremity wounds), coagulation therapy, and clotting problems

Allergies/sensitivities to dressing products and/or tape

Physical Status

Capabilities

Functional limitations and compromise for wound location: blindness, deafness, difficulty walking, eating and drinking

Medications: NSAIDS, steroids, chemotherapy

Psychological and Quality of Life Concerns

Cosmetic affect of dressings

Body image alterations

Attitudes and feelings regarding wound, cancer and treatment, depression, anxiety, denial, anger, shock, embarrassment, fear, guilt, lack of respect or self esteem

Coping strategies

Beliefs and values

Cultural issues/marginalization

Alterations in life related to wound and dressings – family, career, social activities

Impact on family and partner -relationship problems, sexual intimacy

Financial issues

Spiritual issues

Communication difficulties

Informational needs

Psychological and Quality of Life Concerns

Psychological and Quality of Life ConcernsSupport and support networks

Identification with person who will do wound care

Determine expectations and needs

Determine short and long term goals of the client – may differ from professionals

Nutritional Assessment

Poor nutrition impairs ability to heal, essential in success or failure of treatment plan

Nutritional screening is necessary to identify patients at risk and should include the following risk factors:

Recent significant weight loss: measure height & weight at regular intervals – consultDietitian if weight loss of 4.5Kg or more

Impaired oral intake due to decreased appetite, swallowing problems, nausea and vomiting, taste changes, poor appetite and mucositis

Impaired absorption due to infection, malabsorption, medication and pancreatitis

Increased metabolic demand caused by cancer, trauma or infection

Decreased serum Albumin

Decreased serum pre-albumin – predictor of recent changes in nutritional status

Decreased serum transferrin

Decreased total lymphocyte (WBC) count

Decreased hemoglobin < 100 poor healing

Nutritional Assessment

Possible Investigations/diagnostic TestsCBC – hemoglobin, WBC including Neutrophils, S-transferrin, PT, PTT, INR

Albumin. Total protein

Glucose

C&S and Fungus tests – if signs & symptoms of infection

Viral Swab if Herpes suspected

Suspected Osteomylitis – bone scan, erythrocyte sedimentation rate/ C-reactive protein, X-rays

Possible Investigations/diagnostic Tests

CT Scan – assessment of disease progression

Cardiac and Respiratory functions -P02 level, ABI, capillary refill, vital signs, peripheral pulses if a extremity is involved

Risk Factors for Pressure Ulcers

Radiation

Surgery

Chemotherapy

Pain

Anorexia/Cachexia syndrome

Immobility

Moisture

Treat the Cause

Pressure

Shear

Friction

Poor Nutrition

Incontinence

Risk Factor – Pain

Poor pain control may lead to immobility and skin breakdown

Control is essential through monitoring, ongoing assessment, continual revision of treatment plan

Anorexia/CachexiaCommon in Palliative patients

Weight loss, appetite, & increasing weakness

Nutritional imbalance – skin breakdown, inhibit wound healing

Risk Factors – Immobility

Due to: Shortness of breath, fatigue, generalized weakness,

sleep disorders, anxiety and depression,

anorexia/Cachexia, pain/edema, neurological complications

Moisture (maceration) incontinence, excessive wound drainage, diaphoresis, edema

Goal of Malignant Wound Care

Comprehensive care plan

Prevent wound development

Prevent wound progression (not necessarily healing)

Minimize distressing symptoms - Malodour - Exudate - Pain - Bleeding - Altered cosmetic appearance

Malodour Due To:

Saturated dressings

Destruction of blood vessels & reduced oxygen supply

Necrotic tissue with bacterial invasion

Chemotherapy – increased risk of infection

Anaerobic organisms (bacteroids) and Staphlococcus aureus, E-coli, pseudomonas

Malodour Management

Saline irrigation – adequate removal of exudate

Debridement – remove necrotic tissue and bacteria

If clinical signs of infection swab for C&S

Treat increased bacterial burden or infection

Metronidazole (Flagyl) -systemic, oral - Topical (Metrogel), gel, cream - IV preparation (cleansing)

gel or cream can be nixed with hydrogel

Treatment of increased bacterial burden or infection

Silver Sulfadiazine (Pseudamonas) Flamazine Antibiotic therapy

Antimicrobial dressings ( slow release Iodine, Silver)

Activated charcoal dressings

Dressings (primary & secondary dressings to absorb odour & exudate) alginates, hydorfibers, foams, gauze

Malodour Management

Ventilation

Mentholatum (nostrils)

Remove solid linens/dressings

Deodorizers – odour antagonizing room spray - eucalyptus leaves - cedar chips - kitty litter (clay type) baking soda, charcoal

Diversional Therapies

Exudate

Increased permeability of tumour

secretion of vascular permeability factor by tumour cells

Inflammatory response – infection

Can result in :

Psychosocial problems

Further skin breakdown

Exudate Management

Cleanse with saline using 30ml syringe 7 18 gauge venous access device

Debride bacteria laden necrotic tissue using autolytic or surgical process

Select dressings to cover the area & prevent external contamination

Scant Exudate

Use dressings with low absorbency so as not to dry out the wound (hydrocolloids, semi-permeable films and low adherent dressings – silicone coated)

Exudate – Copious

Use dressing to absorb excess exudate, while maintaining moist wound environment (alginates, hydrofiber, foams, hypertonic saline gauze, combination dressings)

Protect peri – wound skin (prevent lateral migration of exudate – skin protectors, foams, gauze)

Exudate

Where exudate is copious 7 wound opening small consider stoma appliance

Drainage contained, measured, evaluatedPain from irritated skin relievedSkin integrity restoredOdour containedreduced time for wound care

Exudate ManagementAnti-inflammatory medications

Chemotherapy

Radiotherapy may help to reduce tumour bulk & draining

Eliminate/reduce microorganisms, necrotic tissue, debris (wound antiseptic)

Wound culture if clinical signs of infection

Suspect Osteomylitis if probes to bone

Treat if infected (if consistent with overall goals)

Fistulas

abnormal communication from one internal organ to an other or through to the skin surface

Neck

Abdomen

Perineal Area

PainDue to:

Tumour pressing on nerves and blood vessels

Exposure of the dermis

Procedures (inappropriate cleansing technique or removal of a dressing which adheres to the wound bed)

Neuropathic involvement

Inflammatory process

Pain Management Assess Pain Type

Duration Intensity Specific Characteristics

Non- Cyclic

Acute

Cyclic

Acute

Chronic

Types of Wound PainNoncyclic Acute Wound Pain

- Occurs during intermittent manipulation of wound (e.g. Debridement)

- provide analgesic 60-90 minutes prior to wound manipulation

Cyclic Acute Wound Pain

- Accompanies regular procedures (e.g. Dressing changes, repositioning)

-May require around the clock dosing with option for breakthrough

Pain Management

-Treat cause of pain (pressure,edema, infection)-Use analgesics, opioid analgesics for nociceptive pain-Consider tricyclic antidepressants, anti-epileptics for neuropathic pain-Patients with cyclic wound pain must receive pain -medications just before wound care (Fentanyl/Sufenta)-Use non-adherent dressings which maintain a moist wound environment (silicone, vaseline impregnated)-Avoid mechanical debridement & use of antiseptics if possible-Irrigate with saline (rather then gauze cleansing)- Try complementary therapies (distractions, visulization, relaxation) www.palliative.info

Prevention is Better

than

Treatment

3 Strong Opioid

+/- adjuvant

2 Weak Opioid

+/- adjuvant

1 Non-Opioid

+/- adjuvantWHO

Analgesic

Ladder

Non-OpioidParacetamolNSAIDS

Opioid

Codeine (weak)

Morphine (strong)

Adjuvant

Corticosteroids NMDA- receptor channel blockersAnti-spasmodic Antidepressantsmuscle relaxant Anti-epilepticsBisphosophonates

LONG – ACTING OPIATES Morphine sulfate (MS Contin)

Sustained Release, Parenteral Short Acting

Oral Short Acting

Oxycodone (OxyContin)Sustained Release

Oral Short Acting

Methadone

Oral Oral Long Acting Parenteral Short Acting

Adjunctive DrugsStool softeners, Laxatives

Antihistamines – sedative, antagonize histamine, potentiate analgesia

Antidepressants – reduce pain perception, induce sleep, treat depression

Antipsychotics – reduce pain perception, induce sleep, counter delirium

Anxiolytics – reduce anxiety, induce sleep, provide amnesia

anticonvulsants – stabilize neuronal membranes, analgesic

NSAIDS

Ketorolac,Aspirin, Acetaminophen, Ibuprofen,Sodium |Salisylate, Fenoprophen Calcium

World Health Organization

Non-Pharmaceutical Pain Management

TENS ChemotherapyAcupuncture/Acupressure RadiationMassage Heat/coldOT/PTProgressive muscle relaxationMeditationGuided imageryHypnosisBio FeedbackIndividual/ family psychotherapy

BleedingCommon in fungating wounds

Can be distressing and life threatening

Malignant cells eroding blood vessels

leakage for tumour

Infection

Damage to fragile tissue during dressing changes

Bleeding Management

non- adherent dressings which maintain a moist wound environment

use gels to rehydrate

reduce frequency of dressing changes

remove necrotic material by autolysis

cleanse by irrigation or moist compress

oral antifibrinolytics may help

Bleeding Management Active Bleeding

Alginate dressings

Haemostatic surgical sponges – promote rapid haemostasis and can be left in place covered with appropriate dressing

Topical Adrenaline (may cause ischemic necrosis due to lack of circulation)

Silver Nitrate (cauterize)

Excessive, uncontrolled bleeding may need referral to a vascular surgeon for cautery or ligation

Bleeding Management

Review overall management

Medications which are vasodilators or alter viscosity

Dietary factors (vitamin V,K)

Feasibility of radiation

Cosmetic Appearance

Wound management should take into account the patients outward appearance by:

Manage odour and exudate

Restore body symmetry

Discretely conceal affected areas (foams, hydrocolloids, silicone)

Wrap difficult areas with flexible supportive device

Utilize clothing to support dressings

Oral Lesions

Burning

Intolerance to hot, spicy or acidic food

Halitosis

Inflammation

Changes in salivary production

Altered taste

Speech changes

Oral Care

Goals of Treatment

Maintain oral health, moist, clean mucosa

Remove food debris & dental plaque

Alleviate pain & discomfort

Prevent Halitosis

Enhance oral intake

Oral Lesion management

-Soft toothbrush

-Rinse with normal saline or & biocarbonate solution (8oz. Lukewarm water / 1 tsp baking soda)

-Avoid alcohol based mouthwashes, lemon and glycerine swabs, chlorhexidine, hydrogen peroxide

-Lip moisturizers (avoid petroleum jelly and mineral based products – may be harmful if aspirated)

Oral Lesion management

-Remove dentures for at least 8 hours

- Avoid hot,spicy foods, tobacco & alcohol

- Cover oral ulcers with topical anaesthetics

- Treat Candiasis rigorously

-Resistant halitosis can be treated with Metronidiazole

Oral Candidosis

Responsible for most oral infections – thrush

Thick white patchy spots on the mucosa can be rubbed off to reveal a granular, reddened base

Treatment -topical Nystatin, systemic Fluconazole, Ketoconazole, Itraconazole, Clotrimazole

Lymphedema

Definition: caused by Lympho-venous stasis and is an excess of fluid in the subcutaneous layer

Goal of Treatment reduce the edema and protect skin from breakdown and maceration

Management elevate and support edematous and dependent limbs protect skin, diuretics, fitted and applied compression, remove exudate with tepid water,use absorbent dressings

Treat the Cause

Fungating Cancers:

Surgery to remove tumour mass and debridement Malignant wound would need to be amendable to complete excision and repair

Chemotherapy – decrease mass and symptoms

Radiotherapy – decrease mass, decrease exudate,bleeding and pain

Hormonal Blocking Agents -if hormonal sensitive cancer

Treat the Wound

Based on moist wound healing

Gauze and Paraffin not recommended

Optimal dressing wear time according to exudate, manufacturers guidelines, clinical setting, and activity level of patient

Absorbent moisture -retentive dressings and a secondary venting material that is flush to the wound and body contours to prevent leakage

Pharmacological TreatmentsSystemic antibiotics can cause side effects – nausea and vomiting

Topical and oral Metronidazole – odour and aerobic infections (Metrogel 0.75% or 0.8% 1-2 x/day)

If cavities or vaginal tumour try gauze soaked in Metronidazole IV solution (10 mls solution on gauze)

Metronidazole powder that can be sprayed

Silver Sulfadiazine for pseudomonas if wound dry

Avoid antiseptics, povidone iodine, sodium hydrochlorite

Pharmacological Treatments

Consider slow release Iodine (Iodasorb) discontinue as soon as the infection is under control ( do not use with Thyroid Disease or Iodine sensitive)

Consider specialized antimicrobial dressing to control infection

Did We?Manage pain

Cleanse & debride

Manage infection

Manage odour & exudate

Control bleeding

Prevent trauma

Reduce edema

Improve aesthetics

Address psychological concerns

Case Study

80 year old married femalemain caregiver for spousehome care HCA was not allowed toreport covered breast until client agreed

wound fungating, mastectomy in 3 daystumour reappeared at surgical site 3 months later

Psychosocial considerations?

Denied any pain

Did not allow dressing to be done with spouse home or to tell him diagnosis

How do you assist this lady?

Wound care options?

End of life concerns?

metastatic wounds

Documents