metastatic wounds
TRANSCRIPT
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.
Skin Cancer Foundation
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.
Skin Cancer Foundation
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
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
Skin Cancer Foundation
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.
Skin Cancer Foundation
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.
Skin Cancer Foundation
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.
Skin Cancer Foundation
Squamous Cell Treatment
Cryosurgery
Chemotherapy Topical or Injections
Ecisional surgery
Mohs Micrographic Surgery
Radiation therapy
Photodynamic therapy
Laser therapy curettage - electro dessicationSkin Cancer Foundation
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
National Cancer Institute, US National Institutes of Health
LymphomaEstimated new cases and deaths from non-Hodgkin
lymphoma in the United States in 2007:
New cases: 63,190
Deaths: 18,660
National Cancer Institute, US National Institutes of Health
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.
National Cancer Institute, US National Institutes of Health
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.
National Cancer Institute, US National Institutes of Health
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.
National Cancer Institute, US National Institutes of Health
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).
National Cancer Institute, US National Institutes of Health
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.
National Cancer Institute, US National Institutes of Health
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?