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Little information seems to be available on this aspect of fungating wounds. Ivetic and Lyne (1990) have reviewed the literature and found no significant research. There seems to be some evidence that fungating lesions of the breast are less common than they once were, but it is not conclusive. Thomas's survey (1992) found that breast lesions were most commonly seen, followed by head and neck lesions. However, the survey did not attempt to assess incidence.

5.4.3 The management of fungating wounds

Management of the patient

This is a vital part of the management of these wounds. Many factors within the patient can affect the progress of the wound. Chapter 2 discusses patient care in greater detail. Factors that need to be considered are:

Communication patients may find it too difficult to discuss their condition and its implications. Pain may also be a problem that needs to be addressed. Eating and drinking nutritional status may be affected by the disease process or by treatment such as radiotherapy or chemotherapy.

Elimination poor nutrition may result in constipation. Some analgesia may also have the same effect. Ultimately, constipation will cause loss of appetite. Mobility poor mobility may affect the patient's ability to be self-caring. Expressing sexuality most patients are greatly distressed by their altered body image.

Sleeping this may be disturbed because of anxiety and/or pain.

Dying the prognosis for these patients is generally poor. Patients and their family are likely to need help in coming to terms with this.

Medical intervention radiotherapy treatment may be given to reduce the size of the lesions and resolve some of the symptoms.

Psychological assessment the patient may show signs of grief, fear or loss of self-respect. Some patients may talk of feeling 'unclean' or show embarrassment, especially when the wound is being dressed. Fitzgerald (Sims & Fitzgerald, 1985) describes how one lady talked of herself as 'leprous' and felt ashamed of her wound because it must be her fault. Patients who feel like that may not want others to dress their wound because they, the patients, believe that the wound would horrify them. Spiritual assessment the patient may question the meaning of life or express feelings of guilt and see the lesion as a form of punishment.

Management of the wound

Chapter 3 covers the general principles of wound management. This section will address the specific problems related to fungating wounds.

When assessing the wound the following need to be considered:

(1) Fungating lesions are often necrotic, sloughy or infected.

(2) There are usually copious amounts of exudate, which may have an offensive odour.

(3) Many of these wounds become malodorous as a result of bacterial invasion. It causes distress to the patient, relatives and visitors, and may be very difficult to control.

(4) The position of the wound obviously depends on the type of cancer. However, it may spread along the trunk or limbs, sometimes in the form of isolated nodules. Plate 27 shows a fungating lesion which has spread under the axilla to the patient's back. Applying a dressing to protect such a widespread lesion can be very difficult and requires considerable nursing skill.

(5) Capillary bleeding may occur as the cancer increases in size and erodes blood vessels, and may be sufficiently heavy or frequent to cause anaemia. Removal of the old dressing must be done with great care in order to avoid loosening any clots.

(6) Lymphoedema may be present with cancers of the breast, cervix or vulva. This is a chronic swelling of the adjacent limb(s) due to a failure of lymph drainage, and may be associated with loss of function of the affected limb. Logan (1995) reviewed studies of the prevalence of lymphoedema associated with breast cancer and reported that it affects around 25-28% of patients. A small study by Werngren-Elgstrom and Lidman (1994) of patients with cancer of the cervix found that 40% had some limb swelling and 22% of women had symptoms of lymphoedema.

It is essential to identify patient problems rather than nurse problems. Although in many instances they may be the same, they are not always. The following is an extreme example encountered by the author.

Mrs B. was admitted to hospital with a severely swollen leg due to lymphoedema. The ulceration in her groin was relatively small, but there was an ulcer on her leg which constantly poured lymph fluid. Despite being dressed by the district nurses three times a day, her leg was constantly wet and very painful. Initially, the problem of a painful wound was addressed by applying an extra absorbent hydrocolloid dressing. Within 48 hours, the pain had gone and Mrs B. looked a different person. The dressing was being changed daily. The nursing staff decided that the next problem to tackle was the lymphoedema, which would have the effect of reducing the fluid flowing from her leg. When Mrs B. was approached, she categorically said she was not interested. She wanted to go home as she had 'things to sort out' and she knew the district nurses would come and change her dressing when she needed them to do so. Mrs B. went home having had her problem resolved.

Once the specific problems have been identified, the treatment options have to be planned in the light of the patient's condition. If the expected outcome is very poor, then totally palliative care with the minimum need to dress the wound must be the treatment of choice. For others, a more aggressive approach can be used. A course of radiotherapy may be prescribed to help reduce the size of the lesion. It should be remembered that many patients find dressing change a major ordeal which leaves them feeling very tired.

Odour is probably the problem that causes the greatest distress to patients. It is mostly due to bacterial invasion, although exuding necrotic wounds may also be offensive. A wound swab will identify the invading bacteria, so that appropriate systemic antibiotics can be prescribed. Topical agents can also be used. Hampson (1996) reviewed the use of metronidazole for malodorous wounds. To date the studies have been poor with inadequate numbers. However, it is widely used to reduce odour. Silver sulphadiazine cream can be used for Pseudomonas aeruginosa infections.

If the odour cannot be reduced, or even while action is being taken to reduce odour, other steps can be taken. The aim is to mask the smell. This can be achieved in a variety of ways. Activated charcoal dressings can be effective in absorbing odour (Lawrence et al., 1993). They are often used in conjunction with other dressings. Air fresheners can help and stoma therapists can give advice on the use of deodorant solutions used by ostomists.

Copious exudate is another problem that concerns patients. Very absorbent dressings are necessary to provide comfort and dryness for the patient. Alginates and hydrocellular foams can be effective in controlling exudate. Grocott (1997, 1998) has undertaken a longitudinal multiple case design study to monitor the outcomes when using different dressings to manage exudate. She considers that the factor of greatest importance is fitting conformable dressing materials to the wound, thus reducing the risk of leakage. Dressing bulk can be reduced by the use of outer dressings with high moisture vapour transfer rates.

When aggressive treatment is suitable, wound debridement is a treatment option. Removal of necrotic or sloughy tissue can reduce odour and exudate. The quickest method is surgical debridement. This must be done by a skilled surgeon because of the distorted anatomy and the risk of capillary bleeding. Surgical debridement is not a suitable option for patients with a history of capillary bleeding into the wound. A variety of wound management products can be used, depending on the amount of exudate. Alginates and beads can be used on heavily exuding wounds. When there is moderate to low exudate, an amorphous hydrogel and occasionally hydrocolloids can be used. The position, size and spread of the lesion can affect dressing choice.

Capillary bleeding can be frightening for both the patient and the nurse. When there is a history of capillary bleeding, great care should be taken when removing the old dressing. If the dressing is adherent, it should be soaked with saline before removal is attempted. It may also be necessary to remove the dressing slowly in stages. It is better to take a long time to remove a dressing than to start bleeding which is difficult to control.

To control profuse bleeding, adrenaline can be applied directly to the wound. However, it should be used with caution, under medical supervision. Alginate dressings are useful when there is oozing. They can be removed easily by washing away with saline. If there is persistent bleeding, the haemoglobin should be checked regularly. Blood transfusions may be necessary to treat anaemia.

If radiotherapy treatment is being given to the lesion, attention must be paid to dressing selection. A range of dressings have been found to be suitable, including charcoal dressings, alginates and an amorphous hydrogel.

Dressing retention may be a problem. Ideally, the dressing should not be too bulky because it makes the wearing of clothes difficult and the patient becomes very self-conscious. Bandages and tubular net and tubular gauze are probably the most versatile means of dressing retention. Tape should be used with care as the skin may become sore with repeated dressing change. If the patient is undergoing a course of radiotherapy to the lesion, it may be necessary for the outer dressing to be removed for treatment. Again, the skin may become sore. 'Garments' made from tubular net allow easy access to the wound and will not further damage the skin.

Patients with lymphoedema may have been told that nothing can be done to reduce the swelling. This is not true. Although it is not possible to cure lymph-oedema, it can be controlled. Management of lymphoedema involves a four-fold plan and considerable commitment from the patient and, possibly, a member of the family. It is possible to reduce a severely swollen limb to a reasonable size and so improve the quality of life of the patient (Badger, 1987). Regnard et al. (1997) describe the cornerstones of treating lymphoedema as skin care, exercise and movement, truncal massage and support bandaging or hosiery.

Skin care is a vital aspect of overall care. Williams and Venables (1996) describe the need for daily washing and careful drying, especially between the digits. Creams should be applied to prevent the skin drying out and cracking. Over time, untreated lymphoedema will result in deep skin folds and ultimately hyperkeratosis. Emollients can help to prevent this occurring. Care should be taken to prevent the swollen limb getting burnt by the sun. Cuts and scratches can be a source of infection. They should be treated with antiseptic cream. Gloves should be worn for protection when working in the kitchen or garden. Jeffs (1993) has reviewed the effects of infection in lymphoedema. She suggests that Streptococcus is generally the causative organism. The infection should be treated with appropriate antibiotics.

Exercise assists in improving drainage of lymph from the limb. Muscle movement alters tissue pressure and has a massaging effect on the lymph vessels. The best effect is obtained if the exercises are carried out when the patient is wearing compression bandages or hosiery. Exercise also prevents or reduces stiffness of the joints. Passive movements should be carried out if the limb is paralysed. All patients should be encouraged to move as much as possible, but lifting and carrying heavy weights should be avoided.

Massage encourages the flow of lymph away from the limb. Occasionally, the swelling may have spread beyond the limb into the trunk. Massage should start on the trunk, which should be free of lymphoedema, before moving to a lymphoe-dematous limb (Regnard et al., 1997); this creates a space for the lymph in the swollen limb to flow into. The massage then continues down the affected limb. The massage technique should be gentle, so that it does not stimulate blood flow into the limb and increase congestion. It may need to be a little firmer when tissue fibrosis is present. Ko et al. (1998) monitored the effects of treatment for 299 patients over a 12-month period. They found a 59.1% reduction in size in arms and 67.7% reduction in size in legs after initial treatment averaging 15.7 days. This was maintained in 88% of compliant patients. The noncompliant patients regained 33% of the initial reduction.

Compression can be provided by bandages or compression hosiery, such as a sleeve. In the initial stages of treatment, bandages assist in reducing limb size. In severe cases the digits as well as the hand and arm, or foot and leg, should be bandaged. Once the limb has been reduced to a reasonable size, compression hosiery can be used to maintain limb reduction.

Intermittent pneumatic compression may be helpful for some patients. It is used in addition to massage and not as an alternative. The type of compression that is most effective is the multichamber sequential pump. The best effect is obtained by clearing fluid from the trunk before commencing treatment.

It is important to provide encouragement to the patient to persevere with all aspects of this plan. None of these treatments is effective in isolation. Significant reduction of a swollen limb can only be achieved when all aspects of the treatment plan are implemented. Carroll and Rose (1992) demonstrated that this type of treatment regime reduced pain in the limb as well as limb volume. Williams et al. (1996) described the benefits of a lymphoedema service accessible to all.

Evaluation of the management of fungating wounds should always consider whether the predetermined goals have been attained. Good documentation can be used to maintain a record of effective care, thus providing guidelines for the management of other patients. Managing a fungating wound and providing care for the patient require considerable nursing skills. More research is needed in order to be able to identify the most effective care.

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