Principles of Malignant Wound Care: Part 2

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A palliative approach to malignant wound care requires assessment of common related symptoms.

Part 1 of this series reviewed malignant wound pathophysiology, the importance of wholistic malignant wound care, and critical thinking points about wound bed preparation, dressing choices and peri-wound care.

Assessment:

Malignant wounds are very different from other types of wounds.  The Malignant Wound Care Tool – Clinical (MWAT-C) is a validated assessment tool developed in Canada. (4-6)

The tool assists clinicians by organizing the wholistic assessment of malignant wounds in a meaningful way that can be compared over time and communicated with team members.

Symptom Management

Effective malignant wound care requires proper symptom assessment and management by the patient’s entire team.  Health care providers specialized in palliative care, enterostomal therapy, and wound care can provide consultation to your team for effective management of symptoms related to malignant wound care:

Manage Moisture Use critical thinking when considering treatments (topical gels or ointments) that add moisture to the wound bed in fungating malignant wounds. Maintaining skin integrity, by preventing maceration and tissue breakdown, helps to reduce infection and bleeding risk.  (1, 3)

Manage Drainage If the wound is producing a lot of drainage, adding high absorbency layer(s) that can be changed more frequently than the base layer in contact with the wound bed, can be very beneficial. In some circumstances, ostomy products can be beneficial for collecting drainage and protecting peri-wound skin. (1,3)

Manage Infection The goal of malignant wound care is not to cure infection but to take measures to prevent new or worsening infection, and manage the side effects of infection, like drainage, pain and odour

  • Topical agents may be useful to control local wound infection. Only use preparations intended for topical use like metronidazole gel, sterile medical honey or Flamazine® on the wound- Do Not Use Oral medications on the wound.
  • Wound care products with antimicrobial properties can also assist in curbing infection (i.e. silver).
  • Systemic antimicrobial therapy may be helpful, depending on the location and extent of the infection as well as the patient’s goals of care. (1,3)

Manage Odour The combination of tissues breaking down and bacterial colonization can result in odour from malignant wounds. Choice of wound care products can make a significant impact on wound odour and should always be a first consideration:

  • Moisture-wicking wound products can assist to reduce moisture that causes maceration and breeds infection.
  • Active charcoal dressings may be effective for some malignant wounds.
  • Treatment aimed at managing or reducing infection like antimicrobial wound products, and topical or oral medications, may be considered. (1, 3)

Environmental changes can also be helpful to reduce odours.

  • Improving ventilation with fans or opening windows might be appropriate.
  • Consider adding deodorizers (i.e. cat litter, coffee grounds, shaving cream, diffused essential oils) in a container in the patient’s room. (1,3)

Manage Pain Wound-care products may also add to pain in the wound.

  • Choose dressings with non-adherent or silicone contact layers to reduce damage to the wound surface and peri-wound tissue. Do not use dry dressing products.  If a dressing becomes stuck in the wound, soak the dressing with sterile water or saline before removing. (1-3)
  • Limit the use of adhesive dressings; instead consider soft, flexible netting/clothing to hold dressings in place. (1)
  • After comprehensive pain assessment, provide appropriate analgesia for around the clock wound pain, and anticipate breakthrough pain during wound care. (1-3)
  • In some cases, palliative radiation or palliative chemotherapy are used as adjuvants to malignant wound care to slow tumour growth or reduce tumor size and associated pain. (1,3)

Sources:

  1. BC Cancer Agency. (2015 Mar). Symptom Management Guidelines: Care of Malignant Wounds.  Available at bccancer.bc.ca.
  2. Canadian Association of Wound Care. (2018). Chapter 2: Best Practice Recommendations for the Prevention and Management of Wounds in Foundations of Best Practice for Skin and Wound Management. Available at woundscanada.ca.
  3. Pallium Canada. (2018). The Pallium Palliative Pocketbook: A peer-reviewed, referenced resource. 2nd Cdn Edition.  Ottawa, Canada: Pallium Canada.
  4. Schulz, V. (2001). The development of a malignant wound assessment tool.  [Masters thesis].  University of Alberta: Edmonton, AB.  Accessed at https://www.collectionscanada.ca/obj/s4/f2/dsk3/ftp04/MQ60406.pdf.
  5. Schulz, V., Kozell, K., Biondo, P.D. Stiles, C., Tonkin, K., Hagen, N.A. (2009). The malignant wound assessment tool: a validation study using a Delphi approach.  Journal of Palliative Medicine, 23, p 266-273.
  6. Savage, P., Murphy-Kane, P, Lee, C., Chung, C.S., Howell, D. (2019). Validation of the Malignant Wound Assessment Tool – Research (MWAT-R) using cognitive interviewing.  Canadian Oncology Nursing Journal, 29(2), p 97-102.

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