Malignant wounds can be complex to assess and manage. You or your community nursing team may need help from the local tissue viability service and possibly a futher opinion from the oncology team (as to whether radiotherapy may help). A care plan and regular supply of dressings is key.
The CNWL woundcare flow chart (see downloads) gives an approach to managing these complex wounds.
Key objectives in wound management according to symptom:
Exudate
Light irrigation of wound if needed with normal saline or tap water
Commence a barrier product to wound margins and surrounding skin
1st line – Absorbent pad, 2nd line – Foam adhesive, 3rd line – Super absorbent
If itchiness is an issue consider allergy to dressing. Also consider topical steroid and/or antihistamines
Malodour
Topical treatment is with antimicrobial gel e.g. Octenillin or Prontosan gel X
Flaminal® Hydro ointment for low to moderate exudate or Flaminal® Forte ointment for moderate to high exudate
Oral or topical antibiotics may help especially in anaerobic infections e.g. metronidazole
Increase dressing changes if needed and consider odour control dressings e.g. charcoal dressing
Infection
A broad spectrum antibiotic e.g. Co-amoxiclav, metronidazole
Dressing with Flaminal® should be applied and can remain in place as long as the gel structure is intact (1 to 4 days, depending on the amount of exudate)
If a high exudate level is present use Flaminal® Forte
If a low to moderate exudate level use Flaminal® Hydro
Pain
Consider a treatable cause of wound pain e.g. infection
To reduce pain at dressing change use a low adherent contact layer such as a silicone wound contact layer e.g. Adaptic touch. Cleansing can be carried out over the top to help reduce trauma. Then the outer dressings are changed
Consider an analgesic prior to each dressing change or a medication review of background analgesia
Bleeding
Light bleeding: Apply pressure for 10-15 mins with moist non-adherent dressing. Alginate dressing should be considered for haemostatic properties e.g. Kaltostat
Topical adrenalin 1:1000 or topical tranexamic acid 500mg/5ml soaked on gauze may help
Severe bleeding - see related article Haemorrhage from malignant wounds
Top Tips:
- Remember the social impact of malignant wounds in terms of self esteem and embarrassment. Do ask about this
- The anaerobic odour of malignant wounds can often be masked by dishes of absorbent material in the room or under the bed e.g. ground coffee or cat litter
- Several international hospices are finding nebulised metronidazole held close to the wound can really help odour