Wound Care
An approach to symptom management to guide decision-making in the management of patients with life-threatening illness
Consider disease-specific treatment
Non-pharmacological treatment of malodour
Pharmacological treatment of malodour in wounds
Involve the interdisciplinary team
In palliative care we mainly deal with chronic wounds. Chronic wounds are characterised by ischaemia, lengthened inflammatory processes, increased protease concentration and reduced level of growth factor activity.
Appropriate assessment
A comprehensive history and physical exam should be performed keeping in mind the local and systemic factors that influence wound healing.
Assess systemic factors:
- Nutrition –
- Deficiency in the following macro-nutrients may delay healing: albumin, carbohydrates, fats and dehydration.
- Deficiency in the following micro-nutrients may delay healing: Vitamins A, B, C, E, K, Copper, Iron and Zinc.
- Medication –
- Steroids inhibit wound closure
- NSAIDs – may delay healing
- Chemotherapeutic agents slow wound healing
- Immunosuppressive drugs impair the inflammatory phase of healing, inhibit immune response and predispose to infection
- Other: Beta blockers, anticoagulants and phenytoin may delay healing.
- Radiotherapy depletes dermal fibroblasts locally and total body irradiation depresses bone marrow which causes minimising of wound macrophages.
- Drug and Alcohol abuse cause vascular injury and reduce the immune response.
Assess Body Systems:
- Respiratory system – decreased blood oxygen supply.
- Circulatory system – poor circulation at wound site or anaemia causing a reduction in the oxygen carrying capacity of the blood
- Endocrine system – diabetes causes circulatory impairment, peripheral neuropathy, impaired inflammatory response and an increased risk of infection.
- Digestive system – malabsorption may lead to deficiencies in macro and micro-nutrients.
- Renal system – incontinence and/or renal failure may cause skin irritation, increased susceptibility to infection.
- Central nervous system – impaired sensation results in no pain signals to warn of tissue damage, impaired movement facilitates pressure ulcers.
Assess psycho-social circumstances
- Giving accurate information and explanation will lessen the sense of isolation and enhance confidence and morale in patients
Assess pain
- Ensure that pain is caused neither by infection nor the dressing itself! Limit the frequency of dressing changes.
Assess wound
- Classification
- Mechanical (surgical)
- Burns and chemical (thermal, radiological)
- Chronic ulcerative wounds (pressure sores, leg ulcers, radiotherapy or malignancies)
- Post-operative
- Location:
- Pressure sores commonly on heel, sacrum and buttocks
- Peripheral areas with poor local circulation
- Position affects vascularity e.g. wounds over joint areas tend to heal slower.
- Wound circumference and depth – ruler based measurement
- Wound margins – redness could indicate infection, red/grey could be the result of undermining, white typifies maceration (excess moisture)
- Exudate –
- Amount: A sudden increase may indicate infection but the presence of exudates is a necessary part of the healing process and varies during the different phases.
- Appearance: serous, haemo serous, sanguineous, purulent
- Odour – an offensive odour usually indicates the presence of high levels of bacteria.
- Wound base –
- Dry and necrotic
- Moist and sloughy
- Granulating
- Epithelialising
Explain to patient and family
- Involve patients in all the decisions
- When working through the assessment, pinpoint factors which may be detrimental to the care of the wound.
- Set realistic goals aimed at quality of life.
Treat reversible factors
The focus in palliative care is quality of life for the patient. Reversible factors include oedema, malnutrition, anaemia, diabetes and medication. Treatment of these factors may involve hospitalisation, transfusion of blood and withdrawing medication which may benefit the patient as far as other symptoms are concerned. A balance is needed between reversing systemic factors and improving wound healing in palliative care patients.
Wound specific treatment
- Remove Necrotic Tissue
- surgical – tweezers, scissors or a scalpel
- enzymatic debridement – in dressings
- autolytic debridement – hydrogel dressings can be used for this method
Note: Match the treatment objective to the appropriate dressing.
- Bleeding
- Gauze soaked in adrenaline 1:1000 or kaltostat may be used
- Gentle removal of dressing with normal saline spray or irrigation using a syringe containing warm NS 0.9% to prevent trauma at dressing changes.
- Odour
- See below guidelines on malodorous wounds
- Infection
- Irrigate wound with warm NS 0.9% or under running water.
- Use antibiotics if there is spreading inflammation, not just a red rim.
- Fucloxacillin or trimethoprim or erythromycin should cover most common infections.
- Choosing a dressing
- To maintain moisture - films, hydrocolloids, hydrogel sheets
- to add moisture (no or low exudates) - hydrogels
- to absorb moisture - foams, alginates, super-absorbents
- protect wound surface - contact layers, impregnated gauze, Bactigras
- control bacteria - silver sulphadiasine cream, ichthammol glycerine, activated charcoal ± silver dressings
- control odour - activated charcoal, see separate guidelines below
Choosing a dressing
| Type of dressing | Wound care goal | Advantages | Disadvantages |
| Films (Opsite, Tegaderm) | Protection. Not for exuding wounds. As cover dressing | Permit visibility. Good secondary dressing, conformable to contours, can promote autolytic debridement | No absorbency, may be difficult to apply or remove, can cause skin tears, may adhere to surface |
| Foam dressings (Allervyn, Biatain Coloplast), adhesive and non-adhesive | Moist wound healing via absorption, protection. As cover dressing | High absorbent, remove drainage from wound surface, provide cushioning | May not conform well to wounds with depth, could potentially dry out the wound and adhere to surface |
| TIELLE hydro-polymer adhesive dressing | Flow low to moderate exuding wounds, including pressure sores and venous ulcers | Provides moist wound healing environment, easy to handle, can be left on wound for up to 7 days, waterproof, moisture and gas permeable, skin friendly adhesive, can be used under compression bandage, reduces leakage and odour | |
| Hydrocolloid dressings (Comfeel Plus, Granuflex, Replicare Ultra) | Moist wound healing for minimally to moderately exuding wounds, protection, debridement | Minimally absorbent, can adhere to moist skin, stay in place for long periods, can promote autolytic debridement | Can macerate wound edges, may promote hypergranulation, may not conform to depth, stick edges |
| Amorphous hydrogels (Intrasite Gel) hydrogel + hydrocolloid (Granugel) | Debridement via rehydration, use in minimally exuding wounds, fill in dead space | Add moisture to dry wound, can assist in autolytic debridement, can maintain moisture longer than saline | Can macerate wound edges, should only coat the wound surface, not fill up a wound |
| Hydrogel with alginate (NuGel) | Sloughy and necrotic wounds and to create a moist wound healing environment | Effective rehydration of necrotic and sloughy wounds, ideal moist wound healing environment, maintains consistency, easy to use, non traumatic |
Remember that the aim is to contain problems and improve quality of life. Be prepared to change and experiment. The simplest products may be the best and the most cost effective.
Re-evaluate: Continually re-evaluate. The criteria are comfort, acceptability and availability.
Refer to a nurse with specialist experience of wound management.
Malodourous wounds
The wounds seen in palliative care patients are often a result of their advanced illness and/or poor physical or social state. Wound malodour can be a significant and distressing symptom for the patient, his/her family and care givers. Patients may experience embarrassment, disgust, guilt and shame, which can lead to social isolation and relationship problems.
Appropriate assessment
The wound itself may be a small part of the problem for patients with cancer, HIV or other chronic illnesses. Accurate assessment includes:
- Nutritional assessment
- Medication (corticosteroids slow rate of epitheliasation)
- Cytotoxic chemotherapy and radiotherapy reduce wound strength
- Diabetes control
- Immune system assessment (HIV, Leukaemia, treatments)
- Find out what the patient perceives as the major problem.
Assessing the wound: (for complete assessment see guidelines on ‘wound care’)
- Surface area – size
- Base of the wound – slough, pus, necrosis
- Discharge – amount, colour, odour
- Pain
PRINCIPLES OF PALLIATIVE WOUND MANAGEMENT (Naylor 2005)
1. Prevent wound development and/or deterioration
2. Correct or treat underlying cause
3. Control wound-related symptoms (pain, malodour, bleeding, discharge)
4. Utilise patient self-assessment
5. Provide psychosocial support
6. Promote independence
7. Improve quality of life
Correct reversible factors
Malodour is often caused by anaerobic bacterial infection of the necrotic tissue within a fungating wound. Metronidazole has been shown to be effective.
Consider disease-specific treatment
Treatment of lesions depends on the stage of the wound, size and the patient’s general health:
- Surgery (debulking) of large fungating tumours
- Chemotherapy
- Palliative radiotherapy
- Hormone therapy for responsive tumours
Explain to patient and family
Involve patients in all the decisions
When working through the assessment, pinpoint factors which may be detrimental to the care of the wound.
Set realistic goals aimed at quality of life. Healing may be an unrealistic goal, but getting rid of the odour can be achieved.
Note: Patients are quick to pick up adverse non-verbal reactions.
A professional’s reaction to a wound is very important for the patient.
Non-pharmacological treatment of malodour
- Good hygiene:
- Regular wound cleaning
- Regular bedding and clothing changes
- Adequate disposal of soiled dressings
- Adequate ventilation
- Dressings:
- Use highly absorbent dressings to contain a high level of exudate to control odour.
- Preferably use non-adherent dressings (to make regular changing less painful)
- Debridement:
- Mechanical/surgical (only if physical condition allows)
- Chemical
- Auto-debridement (hydrocolloid, hydrogel dressings provide suitable environment)
- Burning candles/incense
- Vanilla or lavender sprigs in room
Note: The use of perfumes and air fresheners does not always help to reduce smell and may result in their fragrance being thereafter associated with the odour.
Pharmacological treatment of malodour in wounds
TOPICAL (For mildly infected wounds without cellulitis):
- Metronidazole solution for cleaning a wound: 2l saline + 13 (400mg) crushed metronidazole tablets
- Metronidazole gel: KY jelly or intrasite gel mixed with crushed metronidazole tablets applied to the wound
- Metronidazole cream: aqueous cream mixed with crushed metronidazole tablets
- Metronidazole powder: crushed metronidazole tablets applied directly on to the wound
- Silver sulphadiazine (flamazine)
- Bacitracin, Fucidin or antifungal ointments where appropriate
- Charcoal dressings
- Honey and yoghurt
SYSTEMIC antibiotics for significant infections (preferably after obtaining a wound swab if possible)
- Metronidazole 400mg b.d PO until good effect is obtained. (Side-effects: nausea and alcohol intolerance)
- Other antibiotics: amoxicyllin, erythromycin, trimethoprim sulphametoxazole
PAIN: Treat pain appropriately
Involve the Interdisciplinary team
The psychosocial impact of malodour is significant and may cause patients to withdraw from social contact, fear the stigma associated with cancer or AIDS and have an altered body image. It is important for the IDT to be the social support for such a patient alongside family and friends.
Review
Refer to a wound care specialist in the area if you are not happy with the progress or if you are unsure.