When malignant tumour cells infiltrate the skin and break through a fungating wound develops. Managing fungating wounds can be challenging for nurses, especially in terms of implications for patients and of quality of care. These wounds can spread rapidly, either as a primary, metastatic or recurrent malignancy, and are often associated with breast or head and neck cancers.
Approximately 5-10% of people with metastatic cancer develop malignant/fungating wounds. [1] These wounds rarely heal fully, and the focus is often on comfort and reducing the impact on quality of life. The physical and psychological impact of the wound on day-to-day living can be enormous, with subsequent quality of life issues. Malodour, offensive exudate, pain and discomfort, infection, and bleeding are some of the problems experienced by patients. Oozing wounds cause anxiety about seepage. They can prevent women from wearing feminine clothes and can affect some people's need for physical closeness and sexual intimacy. Holistic psychosocial support of patients and families is required along with physical care.
Some nurses have experience in the management of these types of wounds, but others may have to seek expert help. This help may come from specialist palliative care nurses or from wound management specialists. Effective wound assessment, use of appropriate dressings and symptom management are vital, and care should aim to minimise symptoms in line with patient preferences. In many cases a range of approaches is available, and choice will depend on the wishes of the person and available resources.
Working to develop a care plan with the person and their family is important. Key symptoms requiring management include:
Pain: Use of an opioid is widely recommended for pain management including prior to changing a dressing. Establishing if pain is due to infection or the wound dressing is an important first step. [1]
Infection: Wounds are often contaminated with bacteria. Management of local infection includes taking a swab to identify the organisms involved and use of antimicrobial agents to control signs of infection (inflammation, systemic signs of infection, or increased odour, pain, or discharge). [1-3]
Bleeding: Causes of bleeding include changes in blood clotting capacity or blood vessel structure. Medications being taken by the person such as anticoagulants could be contributing to bleeding and should be discussed with prescribers. [4] Wound dressings themselves can also contribute to bleeding through physical abrasion or adhesion. [3]
Exudate: As the tumour grows changes to the blood vessels and disruption of the lymphatic system often leads to a large volume of exudate at the wound site. This can degrade the extracellular matrix and affect healing. Management to remove saturated dressings is important and if very moist may require specialist input. [1,2]
Odour: Malodour is in part due to bacterial infection and can be distressing for the person. It may affect their relationships and interaction with others and cause psychological distress. There are many approaches to addressing this including dressings containing charcoal, medical-grade honey, or silver. If debridement to remove necrotic tissue is considered then an assessment of how this might impact on the person’s quality of life is essential. [1-3] Masking environmental odours using air fresheners, or an infuser or similar can also be helpful. [4]
Psychosocial well-being: The person’s comfort and quality of life remains the goal in managing fungating wounds. This includes finding the dressing that best suits them while minimising any symptoms. It also includes support for quality of life and social interaction if this is important to the person.