Wound Management - Easing the pain

Wound management takes on additional dimensions in the care of cancer patients, writes Patricia O’Regan

CANCER causes a large range of distressing and traumatic problems to the individual, which are due both to the disease itself and the subsequent treatments. Many of these symptoms as well as implications of treatments have a deleterious effect on wound care management and on the individual.

Wounds can cause extreme pain and discomfort, thus affecting daily activity. They can be disfiguring, foul smelling and appear repulsive to the patient, which can result in self esteem, body image and quality of life being severely affected. Cancer wounds can result in major irreversible skin damage to the extent of tissue necrosis and problematic long-term care can ensue.

Radiotherapy
Radiotherapy cannot differentiate between normal cells and cancer cells. Therefore normal cells will be affected within the path of the radiation beam, causing the patient to experience side effects,1 including skin problems. Skin reactions may be mild such as dry skin but can also vary from slight erythema to, at worst, moist desquamation.

Treatment of dry desquamation is similar to erythema. Care of the skin should focus on preventing skin breakdown and relieving symptoms of burning and itching. The skin should be moisturised daily with an emollient cream. If pruritis or pain are present topical steroid creams and cooled hydrogel sheets should be applied.2 Skin folds, moist areas and opposing skin surfaces subject to friction are likely to develop more intense reactions.3

The chances of developing a moist skin reaction increases as higher doses of radiotherapy are given. The management of moist desquamation can pose somewhat of a challenge as reactions often develop in awkward places, such as the axilla, neck and perineum where dressings cannot be easily applied.4

The care of moist desquamation skin reactions is based on the principles of moist wound healing. Management should include the following issues:

Dressings
The type of dressing depends on the amount of exudate. Common dressings include hydrogel and a secondary dressing; foam sheets or alginate if there is bleeding present.2

Patients may need additional antibiotics if infection and a lot of exudate are present. Dressings should also be changed daily.

Delayed wound healing is a potential serious complication of radiotherapy. The long-term effects include skin atrophy, soft tissue fibrosis and microvascular damage, leading to a higher risk of developing problematic, non-healing wounds which are unamenable to surgical repair.5

Chemotherapy
Chemotherapy drugs affect both normal and malignant cells by altering cell activity. The administration of specific chemotherapy agents may result in an inflammatory reaction in tissue that has been previously irradiated. This can result in erythema, blisters, hyperpigmentation, oedema, vesicle formation, exfoliation and ulcer formation.6

Chemotherapy can adversely affect wound healing by inhibiting cell division and protein synthesis. Many chemotherapy drugs can also cause immunosuppression. This can inhibit the inflammatory response in the early stages of wound healing.7 This reduces the activity of neutrophils and macrophages, thereby increasing the risk of wound infection and delaying the removal of dead tissue and foreign bodies through phagocytosis.8

In relation to fungating wounds, chemotherapy may decrease the size of the wound by destroying malignant cells and in turn reduce pressure on nerves and blood or lymph vessels. This can positively influence wound healing by reducing exudate production and the tendency of wounds to bleed.6

Surgery
Similar to non-malignant patients, cancer patients experience a number of complications post surgery. To reduce the risk of cancer wound complications careful
continuous assessment should be carried out. There are a number of areas that should be focused on:

Radical surgery often causes major
deformities to the individual as well as loss of function. This can have major psychological implications for the individual as well as a severe impact on their body
image.

Lymphoedema
Cancer surgery, radiotherapy and cancer metastasis can produce lymphatic injury that progresses to lymphoedema. Lymphoedema can develop at any time
following a diagnosis or treatment for cancer and has been reported to occur many years later.

Both infection and thrombosis are two common factors that can precipitate lymphoedema. Other factors that can cause lymphoedema include postoperative wound complications including infection/ seroma or radiodermatitis, infection of soft tissue of the arm, a tumour on the side of the dormant hand and obesity.9

Skin care is an extremely important management issue of lymphoedema and the overall goal of care should be to promote skin integrity and prevent complications from decreased oxygenation of tissues.

Skin care should include factors such as: good daily hygiene; regular inspection of the skin; avoiding sources of skin damage such as sun, razors, needles; reducing the risks of cuts and grazes by prompt cleaning; wearing comfortable loose clothing; daily application of bland emollients (non-perfumed); and the use of specific
dermatological products.9

Lymphoedema can cause traumatic disfigurement to the cancer patient as well as pain and disablement. Lymphoedema can severely impact on their quality of life as it can have detrimental effects on the cancer patient’s physical, psychological and sexual functioning.

Fungating wounds
Fungating cancer wounds could be considered the most potential distressing lesion for cancer patients. These wounds are frequently strongly odorous with exudate that may be serous or bloody, which can seep onto clothing, causing extreme distress.10

A fungating wound develops from the extension of a malignant tumour into the structure of the skin, producing a raised or ulcerating necrotic lesion.11 Fungating wounds frequently have many associated symptoms including: exudate, infection, slough/necrosis, bleeding, pain at wound site, itching, irritation and malodour.12

Exudate is considered the most common and embarrassing problem. It is very important to select the correct dressing due to the different absorbent properties present. The dressing should have minimal bulk, while preventing leakage and creating an acceptable cosmetic appearance.13

Cancer patients can generally present with a number of symptoms as fungating cancer lesions generally do not heal. Many of these symptoms can be long term,
which present a major challenge. The priority in management of fungating cancer wounds, especially in advanced cancer, should be optimum patient comfort.

The priority of dressing should be:

Psychological issues
The psychological impact of a chronic cancer wound varies according to the patient’s coping mechanism, the effect on their quality of life and the individual patient’s own perception of the wound.

A fungating wound can have a devastating psychological effect on an individual, especially when it is in an area where it is visible. This could cause the patient to withdraw from their normal social and daily activities and become isolated. Close relationships may also be severely affected. Symptoms such as odours and excessive exudate may lead to reluctance to share a bed with their partner due to the likelihood of leakage and staining of the patient’s clothes or bedding during the night.2

Chronic wounds can negatively impact a cancer patient’s body image and sense of self worth. Caring for a cancer patient with a chronic wound should encompass
an individual holistic perspective. Assessment and management should involve the psychological, social, emotional and spiritual aspect of the individual patient.

Implications for nursing practice Nursing care of the cancer patient with a chronic or fungating wound should not just focus on the physical aspects of care but encompass general advice on how to adapt and promote optimum quality of life.

Nurses face many challenges in caring for cancer patients with associated wounds. Their remit can involve the physical management of the wound, including constant reassessment, psychosocial support and general advice on how to live as full a life as possible.

Within the context of care delivery the role of the nurse centres on supporting, educating and encouraging the patient to consider the impact of lifestyle and behaviour on the disease process. The nurse is thus in a unique position to deliver holistic care and optimise quality of independent life in cancer patients.

Patricia O’Regan is a college lecturer in the School of Nursing and Midwifery,UCC References on request (quote O’Regan P.WIN 2006; 14(11): 48-49)


 Wound Management - Easing the pain

 


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