Malignant Wound Management

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Malignant fungating wounds: managing pain, bleeding and psychosocial issuesManagement of these non-healing wounds typically involves practices that

diverge from those used in other settings. The fi nal article of this four-part series

explores the holistic approach required in dealing with the complex symptoms

pain; bleeding; psychosocial issues; non-healing wound; management; malodour

T his is the fourth and fi nal part of a series of articles summarising the available lit-erature on malignant wounds. The epide-miology, aetiology, presentation and assessment of these wounds were explored

in the fi rst article,1 and the proceeding article looked at key symptoms and their psychosocial effects.2 This article discusses how these psychosocial effects can be managed, and also explores the manage-ment of pain and bleeding. The management of malodour and exudate were covered in the third article.3 As in the previous articles, this fourth part takes a holistic approach to the literature, which practitioners can use to inform their decisions when caring for people with these devastating wounds.

Literature reviewThe fi rst article outlined the search strategy used for this series, and described the state of the evi-dence base for the management of malignant wounds.1 In summary, currently the strength of evidence for management of malignant wounds is weak — based chiefl y on case studies, anecdotal reporting and expert opinion.4-6 Although the lit-erature base is growing, there are as yet no formal guidelines or robust evidence on which to base practice. Given the unique and complex nature of malignant wounds, available evidence (including that presented in this paper) must be interpreted with caution when considering application to prac-tice in specifi c cases.

ManagementPart three of the series discussed the general princi-ples of management of malignant wounds.3 It was noted that an individualised and multi-faceted approach provided through a multidisciplinary team is considered best practice, given the unique and complex nature of these wounds.7-8 The typical non-healing status of malignant wounds generally requires a focus on management of the wound and

comfort for the patient,9-12 rather than healing as the primary goal. Most care plans will therefore be formulated within a palliative care framework focus-ing on maximising quality of life while minimising the impact of the wound.9,13

PainPain is a signifi cant aspect of many malignant wounds and practitioners must have a sound under-standing of its causes and impact to ensure that management strategies are appropriate. In particu-lar, the concept of ‘total pain’ is important when assessing and managing pain; this recognises that the total pain experience is affected by all dimen-sions of a patient’s existence, rather than the physi-cal sensation related to tissue pathology alone.14-16

An example of the impact of contributory fac-tors was described in part two of this series,2 in which a case study found a decrease in pain scores recorded by participants once the malodour asso-ciated with their wounds had been resolved.17 Consequently, the management team will need to assess what other factors might also be contribut-ing to the pain experience.

Managing painIn keeping with all aspects of the management of malignant wounds, developing an individualised pain management protocol is crucial and must be based on a comprehensive assessment.14,15,18 The World Health Organisation (WHO) guidelines for the control of cancer pain provide a sound starting point for developing a protocol for physical pain management.19 The possibility that the doses of analgesia suffi cient to manage pain can adversely affect mental and cognitive functions should also be explained to the patient. This conversation will pro-vide the patient with the opportunity to express her/his preferences and assist the clinician to achieve the appropriate balance in accordance with the patient’s wishes.20

S. Alexander, Bachelor of Health (Nursing) (Hons), RN, MRCNA, Researcher, CQ University, Bundaberg, Australia.Email: [email protected]

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Attention should also be paid to the dressing regi-men which may be contributing to the patient’s pain experience. Pain during dressing changes can be reduced through pre-medication with short-act-ing opioids,9 but care should be taken to ensure they are administered in suffi cient time before the proce-dure to enable maximum effectiveness. Pain may also be reduced through the use of appropriate dressings, including non-adherent dressings and those that facilitate a moisture balanced wound healing environment and may be left in situ for longer periods.9

Topical analgesiaA small number of articles that discussed the use of topical analgesia in chronic wound management have included malignant wounds21,22 but the evi-dence is still minimal. Accordingly, fi ndings of other studies investigating the use of topical analgesia in chronic wound management have been included in this review. With careful extrapolation, these sup-plementary fi ndings may bolster the evidence cur-rently available on the use of topical analgesia in malignant wounds.

Some authors have reported empirical success in the use of topical opioids (diamorphine, morphine, meperidine or oxycodone in a carrier gel), to allevi-ate pain in chronic wounds both during dressing changes and in the intervening periods.23-27 Recom-mendations included a composition of 0.1% w/w (weight for weight) which would equal 1mg mor-phine to 1g hydrogel;28 or 20mg of diamorphine in 30g of hydrogel.29 Other authors discussed the use of a 2.75% topical lidocaine cream prepared by blending one 454g jar of zinc oxide cream with 35.44g of lidocaine 5% ointment.18 There have also been reports on the successful blending of diamor-phine with metronidazole gel to alleviate infection, pain and malodour.26,30

Three patients with malignant wounds were included in one small (n=16) crossover, randomised controlled trial (RCT) of topical analgesia on chronic wounds.22 It is not possible to comment on the ade-quacy of methodological processes because the reporting of this trial was brief and the trial was halt-ed early for administrative reasons. However, the researchers reported their preliminary fi ndings in the hope that they would be informative for practi-tioners. Patients in the study arm (morphine in Intrasite gel, Smith & Nephew) reported signifi cantly lower pain scores compared with pre-treatment and the control arm. The authors reported that the topi-cal morphine appeared to be safe and well tolerated by participants. They acknowledged the limitations of their study, particularly the small sample size, and recommended that further research be conducted.

One potential advantage of topical analgesia is the possible reduction or elimination of systemic

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analgesia, thereby avoiding the adverse effects often associated with these medications.29 Although it is possible that topical analgesia might be absorbed systemically when applied to large ulcerated areas, one study reported that the bioa-vailability was unlikely to result in excessive sys-temic adverse effects, particularly in view of the small doses applied daily.31 This study reviewed six patients with painful cutaneous ulcers; however, only one was a malignant wound. One article rec-ommended that EMLA cream be used with caution in malignant wounds because of its propensity to exaggerate the infl ammatory response, damage the host defences and increase the risk of infec-tion.32 However, the evidence on which this rec-ommendation was based was minimal and outdat-ed, indicating yet again the need for more research.

Non-pharmacological pain reliefNon-pharmacological or complementary therapies which reduce anxiety or the sensation of pain, or that distract the patient may also be helpful in man-aging pain. Suggested therapies included: ● Relaxation● Music● Massage● Visualisation● Imagery ● Aromatherapy.14,15,18

Treatment of pruritisAlthough not strictly categorised as painful, pruritus is capable of causing discomfort to such an extent that some authors have recommended that it deserves the same degree of attention as pain.33

The unpleasant itch associated with pruritus may be widespread or restricted to certain areas and can be caused by a variety of pathogenicities, ranging from dehydrated skin to the complex array of fac-tors present in uraemia. In the absence of broad spectrum anti-pruritic drugs,33 non-pharmaceutical methods of alleviating the discomfort associated with pruritus were noted. These methods included: ● Cooled hydrogel sheets● Menthol in aqueous cream (for unbroken skin only)● Transcutaneous electrical nerve stimulation (TENS)● Paroxetine● Calamine● Capsaicin● Local anaesthetics● Systemic corticosteroids● H-receptor antagonists● Anti-convulsants● Antidepressants● Ultraviolet B therapy

● Histamine receptor blockers (doxepin)● Hydroxyzine● Ondanestron.8,30,33-37

The majority of these articles provided only generic information on the aetiologies and treat-ment of pruritus; however, two articles also pro-vided anecdotal information on the successful treatment of pruritus in malignant wounds. Gro-cott provided an anecdotal report on the use of TENS to relieve pruritus in a malignant wound30 and Holme et al. reported the success of a number of interventions in a case study of a patient with cutaneous metastases from breast carcinoma.35 Of the interventions trialled by Holmes et al, TENS was successful but was impractical due to the lim-ited amount of unaffected skin. Greater relief was achieved through twice-weekly doses of narrow-band ultraviolet B phototherapy concurrent with topical Crotamiton 10% cream (Eurax, Novartis) in a hydrogel carrier.35

BleedingProtection of the fragile tissue surrounding the blood vessels is vitally important in malignant wound management and includes gentle techniques during dressing changes to prevent trauma. If a dressing has adhered to the wound, it must be soaked to facilitate easy removal, and consideration must then be given to reviewing the dressing regi-men. Where cleansing of the wound is considered necessary, it should be done gently with warmed normal saline to avoid further trauma to the fragile peri-wound tissue.38 Some authors recommended the use of an 18–20 gauge angiocath on a 30–60ml syringe to create a pressure of 8–15 pounds per square inch (psi) which will effectively clean the wound without causing further trauma.32,39 Although rarely mentioned in the malignant wound litera-ture, careful use of sodium chlorine ampoules or aerosols may also be helpful in irrigating the wound40 as it is possible to vary the delivery pressure to suit wound conditions. In addition, this method is less expensive and requires less equipment than the syringe method.41,42

Much of the literature on bleeding events in malignant wounds is prescriptive in nature, and suggests what interventions might be appropriate. However, very little is based on empirical evidence of interventions. Some of these suggestions which might be helpful, depending on individual circum-stances, are discussed below.

Minor bleedingSuggestions of measures to control minor bleeding included:9,23,43,44

● Local pressure● Ice packs● Haemostatic alginates

References1 Alexander, S. Malignant fungating wounds: epidemiology, aetiology, presentation and assessment. J Wound Care 2009; 18: 7, 273-280.2 Alexander, S. Malignant fungating wounds: key symptoms and psychosocial issues. J Wound Care 2009; 18: 8, 325-329.3 Alexander, S. Malignant fungating wounds: managing malodour and exudate. J Wound Care 2009; 18: 9, 374-382.4 Wilkes, L., White, K., Smeal, T., Beale, B. Malignant wound management: what dressings do nurses use? Journal of Wound Care 2001; 10; 3, 65-69.5 Noblet, M. Assessment of a fungating breast wound. Practice Nursing 2008; 19; 6, 282, 284-286.6 Lazelle-Ali, C. Psychological and physical care of malodorous fungating wounds. Br J Nurs 2007; 16; 15, S16, S18, S20, S22, S24.7 Wilkes, L., Boxer, E., White, K. The hidden side of nursing: why caring for patients with malignant malodorous wounds is so diffi cult. J Wound Care 2003; 12; 2, 76-80.8 Grocott, P. Care of patients with fungating malignant wounds. Nurs Standard 2007; 21; 24, 57-66.9 Naylor, W. A guide to wound management in palliative care. Int J Palliat Nurs 2005; 11; 11, 572-579.10 Wollina, U., Liebold, K., Konrad, H. Topical treatment for malignant wounds. Eur J Geriatr, 2001; 3; 3, 118-121.11 Grocott, P. A Review of Advances in Fungating Wound Management since EWMA 1991. EWMA J 2002; 2; 1, 21-24.12 Adderley, U., Smith, R. Topical agents and dressings for fungating wounds. Cochrane Database Syst Rev 2007; 2: CD003948. 13 Grocott, P., Browne, N., Cowley, S. Quality of life: assessing the impact and benefi ts of care to patients with fungating wounds. Wounds 2005; 17; 1, 8-15.14 Naylor, W. Assessment and management of pain in fungating wounds. Br J Nurs 2001; 10: 22, S33-S56.

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● Sucralfate paste (1g dispersed in 5ml of water solu-ble gel)● Ostomy adhesive or other hydrocolloid powders containing carmellose, sodium, gelatin and/or pec-tin which promote haemostasis.

Moderate bleedingFor moderate bleeds, some practitioners recom-mended alginates because of their haemostatic properties.45,46 However, Grocott recommended that only non-fi brous alginates should be used because of the possibility of alginate fi bres irritating the fri-able tissue.47

A number of authors have suggested the use of haemostatic surgical sponges as an emergency meas-ure, but only one author has reported its use.47 According to the prescriptive advice, surgical spong-es can be left on the wound and covered with a sec-ondary dressing once the bleeding is under con-trol.28,32,47 An additional advantage of this approach is that sponges can be applied by patients or carers in the home setting, which may reduce the need for emergency referral and the associated anxiety. According to Grocott, surgical sponge is a natural gelatine which absorbs some of the blood. The sponge is then either ‘naturally absorbed, or remains as a soft gelatinous structure which slides off with the next dressing change’.47

Heavy bleedingHeavier bleeding events require more urgent meas-ures. In instances where it is possible for interven-tions to be arranged before the blood loss becomes too severe, options outlined in the literature includ-ed: ● Antifi brinolytics (tranexamic acid)● Vasoconstrictors● Radiotherapy,● Ligation ● Cauterisation.39,44

Oxidised cellulose or collagen to promote clotting has also been suggested.18 The use of gauze saturated with adrenaline 1:1000 (1mg/1ml) has been recom-mended but caution is required as ischaemia and consequent necrosis could result from injudicious use.32,48 Less commonly used haemostatic agents included: somatostatin analogues; acetone; thrombin/thromboplastin; topical cocaine; prostag-landins; formalin and fi brin sealants; aminocaproic acid; ethamsylate; ornipressin (Por 8, Sandoz); 1% alum solution; and vitamin K treatment to resolve disrupted clotting mechanisms.43,44,49-51 Despite the wide range of interventions discussed in the litera-ture, few were supported by empirical evidence. However, Carville reported on the successful use of Por 8 to control bleeding43 and Jones reported on the use of tranexamic acid syrup and adrenaline-soaked (1:1000) pads to control bleeding.52

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Catastrophic bleedingA catastrophic bleed is clearly very distressing for the patient and family, not only because of the copi-ous outfl ow of blood but because it signifi es immi-nent death. However, even in cases where the risk of a catastrophic bleed has been identifi ed, there is often little warning of the actual event and carers are frequently ill-equipped to deal with the emer-gency. Accordingly, a strategic plan should be devel-oped in conjunction with the patient and family when such an event is considered to be a possibility. Following careful assessment of the patient’s cir-cumstances and depending on whether the plan was developed for the hospital or home setting, such a plan might include:9,29,50

● Caregivers and family members being informed about the possibility of a catastrophic bleeding event, what is likely to happen in this event and what they should do● Dark towels and a basin being kept close to the patient’s bedside● The preparation of an emergency pack, including a sedating drug such as midazolam in a prefi lled syringe to be administered subcutaneously● Access to emergency services and transport● Open lines of communication with appropriate specialist centres where emergency control of bleed-ing could be easily and rapidly facilitated.

Psychosocial issuesThe dearth of information on the lived experience and associated psychosocial issues of living with or caring for a malignant wound was discussed in part one.1 This lack of knowledge affects the prac-titioner’s ability to care for patients holistically, particularly when it is often the psychological issues associated with an illness that cause more distress than physical issues. Given the limited evidence base in this area, this section will review some of the general psychosocial issues associated with chronic wounds, and suggest how they might be addressed.

Research into the lived experience of chronic wounds, predominantly leg ulcers, suggested that practitioners do not often understand the profun-dity of the life-changing nature of the experience and the day-to-day challenges involved. Participants in one study felt that they had ‘become the wound’, as it became the focal point of their existence and took over their lives.53 Because of the wound, the participants considered they had a different way of being in the world than those who were healthy and wound-free.53

Lawton introduced the concept of ‘unbounded-ness’ to describe those people whose bodily contents spilled uncontrollably into the external world.54 She described how unbounded people suffered from diminished personhood, both from their own per-

spective and that of a society that harboured revul-sion for uncontrolled body fl uids and only granted full personhood to those in possession of a sanitised, deodorised, hygienic, somatically bounded body. Some of these unbounded individuals were observed to withdraw from social interaction and undergo a form of ‘social death’ even though physical death was still some weeks away.54

The huge impact of psychosocial issues on patients with malignant wounds has been illustrated in the literature. People have been found to be reluctant to seek medical assistance because they are embar-rassed by the appearance or location of the wound.6,38,52,55,56 Often these people only seek medi-cal advice when the wound is advanced, by which time palliative care is the only realistic treatment option.57,58 For these people, coping with the physi-cal problems unassisted is less burdensome than coping with the psychosocial anxieties.

However, it is not only patients who struggle to manage psychosocial issues; authors have discussed tendencies among health-care professionals to avoid these issues because they do not know how to han-dle them.59-61

Psychosocial interventionsIn view of the inter-relatedness of physical and psy-chosocial domains, it is likely that alleviating the physical symptoms of malignant wounds will also help alleviate the psychosocial burden. However, there are some interventions recommended specifi -cally for psychosocial issues.

A simple and cost-effective way of helping people to manage their condition is to listen to their sto-ry.57,62,63 Knowing that their story has been heard and their diffi culties acknowledged can be both therapeutic and cathartic for the patient, and so lead to improvements in treatment.59-61,64 Once the practitioner understands the challenges being faced by patients, he/she will be better placed to help them overcome their diffi culties.

For example, a Danish study reported the con-cerns of women with malignant breast wounds.62

The participants expressed their anxieties about leakage and malodour, not being able to wear femi-nine attire and having to refrain from physical or sexual intimacy or any form of social interaction. As a result of their discussions with a clinical nurse advisor, dressing regimens were developed for each participant that enabled them to dress in feminine clothes once again and resume social interaction without fear of seepage or malodour. Because the women had been able to discuss the wider implica-tions of their wounds with nurses, they were able to enjoy a new sense of freedom.62

Neal provided a useful maxim for practitioners to remember in such instances: ‘Don’t just do some-thing, sit there’.63

15 Ngugi, V. Managing neuropathic pain in end-stage carcinoma. End of Life Care 2007; 1: 1, 38-46.16 Strasser, F., Walker, P., Bruera, E. Palliative pain management: when both pain and suffering hurt. J Palliative Care 2005; 21: 2, 69-79.17 Bale, S., Tebble, N., Price, P. A topical metronidazole gel used to treat malodorous wounds. Br J Nurs 2004; 13: 11, S4-S11.18 Alvarez, O., Kalinski, C., Nusbaum, J. et al. Incorporating wound healing strategies to improve palliation (symptom management) in patients with chronic wounds. J Palliat Med 2007; 10: 5, 1161-1189.19 World Health Organisation. WHO’s pain ladder. WHO 2009. http://www.who.int/cancer/palliative/painladder/en/index.html20 Hughes, R.G., Bakos, A.D., O’Mara, A., Kovner, C.T. Palliative wound care at the end of life. Home Health Care Management & Practice 2005; 17: 3, 196-202.21 Back, I.N., Finlay, I. Analgesic effect of topical opioids on painful skin ulcers. J Pain Symptom Manag 1995; 10: 7, 493.22 Zeppetella, G., Ribeiro, M.D.C. Morphine in Intrasite Gel applied topically to painful ulcers. J Pain Symptom Manag 2005; 29: 2, 118-119.23 Seaman, S. Management of malignant fungating wounds in advanced cancer. Semin Oncol Nurs 2006; 22: 3, 185-193.24 Wilson, V. Assessment and management of fungating wounds: a review. Br J Community Nurs 2005; 10: 3, S28-34.25 Flock, P. Pilot study to determine the effectiveness of diamorphine gel to control pressure ulcer pain. J Pain and Symptom Management 2003; 25: 6, 547-554.

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The benefi ts of a strong social support network for people living with chronic illness have been report-ed extensively in the literature.65,66 Such relation-ships are of vital importance in reducing stress levels and infl uencing wellbeing and coping processes. However, as the discharge and malodour associated with a malignant wound continue to breach social boundaries, individuals tend to withdraw from social contact, while at the same time friends and family — not knowing how to handle the situation — decrease the duration and frequency of vis-its.57,67,68

In these instances, cognitive behaviour therapy can be helpful in reminding patients that, although they cannot infl uence the reactions of others, they can control their own responses to them.69 It is clearly never easy to discount the unthinking responses of others but Clarke has shown that those who were able to maintain self-esteem despite dis-fi gurement fi rmly believed that the unkind reac-tions of others refl ected more harshly on the per-ceiver than the perceived.69

Finally, and most importantly, practitioners must never lose sight of the personhood of the people in their care. It takes very little to recognise somebody as a person but that small act can reap huge rewards for both the practitioner and patient.

Emerging treatmentsThe third and fourth articles in this series have dis-cussed mainstream approaches to the management of malignant wounds. It is hoped that ongoing research will discover more interventions. Two emerging treatments that have demonstrated an ability to palliate the symptoms of cutaneous metas-tases are miltefosine and electrochemotherapy.

Miltefosine is a topical cytostatic treatment that was found to be superior against placebo in extend-ing the time to treatment failure in a sample of breast cancer patients (n=52) with cutaneous metas-tases.70 However, the lesions in the study sample were all superfi cial, being <1cm in depth, which is signifi cantly less than many of the malignant wounds encountered in clinical practice.

Electrochemotherapy combines the administra-tion of a cytotoxic chemotherapeutic drug (com-monly bleomycin) with electrical pulses applied to the tumour to enhance the permeability of the tumour cells, thus increasing the cellular uptake of the drug.71 However, as the majority of reports of its clinical applications included patients with nodular involvement only, its usefulness in the larger malig-nant wounds appears to be limited.

It remains to be seen whether the ability of these or other new interventions to successfully treat malignant cutaneous lesions will result in a reduc-tion in the incidence of ulcerating malignant wounds.

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Box 1. Areas for further research

Research questions

What causes malodour in malignant wounds?

Metronidazole appears to be effective in reducing malodour in malignant wounds, but why?

Is the effectiveness of metronidazole reduced (diluted) in heavily exuding wounds?

Is the effectiveness of systemic metronidazole reduced if the circulation proximating the tumour is compromised?

How do we assess the appropriate amount of metronidazole gel to apply?

Which dressings are the most suitable for malignant wounds?

Are charcoal dressings (with silver and without silver) effective in controlling the malodour associated with malignant wounds?

Do some (fi brous) alginates exacerbate bleeding incidents in friable malignant wounds?

Exploration of patients’ measurement of malodour; are there issues such as shame and embarrassment associated with them accurately measuring the odour?

Do patients, lay caregivers and/or practitioners become accustomed (desensitised) to the malodour of malignant wounds over time?

Is there a role for analgesia-impregnated dressings in malignant wound management?

How effective is topical analgesia in alleviating pain in malignant wounds and are there any adverse effects?

Development areas

Development of an objective tool for measuring malodour

Development of an objective tool for measuring exudate

Implications for researchThis series of review article has shown that much of the literature on malignant wounds is based on prescriptive advice with some anecdotal reports and case studies. However, undertaking RCTs on malignant wounds is problematic because of meth-odological problems in studying individuals with unstable disease, where there is little homogeneity and where variables cannot be controlled.48 The Cochrane Collaboration has recognised that RCTs might not be feasible for malignant wounds and that ‘less robust designs such as multiple case study design may be the highest level of evidence available’.12 In any event, there has been little research of any methodology into malignant wounds. As a result, there seem to be more ques-tions than answers, and topics for future research abound. A good place to start might be the inci-dence of malignant wounds, but other topics are suggested in Box 1.

ConclusionGiven the complexity and overwhelming nature of malignant wounds for patients, it is recommended that these wounds be managed by a multidiscipli-nary approach within a palliative care framework. This will facilitate the provision of comprehensive and individualised care, which is of vital importance if quality of life is to be maximised.

There is a clear need for research into the man-agement of malignant wounds as most of the exist-ing literature is based on prescriptive advice, some-times generalised from the management of other chronic wounds, anecdotal reporting and case studies. One area where the lack of research is par-ticularly evident is psychosocial issues. Although lack of information on psychosocial issues has hampered discussion of management options, some simple interventions that will be of use have been highlighted here. These include acknowledg-ing that the patient has been heard and never los-ing sight of their personhood. It is hoped that fur-ther research will contribute to the existing knowledge base, thereby enhancing the practition-er’s ability to provide holistic care for patients with this challenging condition. ■

26 Flock, P., Gibbs, L., Sykes, N. Diamorphine-metronidazole gel effective for treatment of painful infected leg ulcers. J Pain Symptom Manag 2000; 20: 6, 396-397.27 Zeppetella, G., Paul, J., Ribeiro, M.D.C. Analgesic effi cacy of morphine applied topically to painful ulcers. J Pain Symptom Manag 2003; 25: 6, 555-558.28 Naylor, W. Malignant wounds: aetiology and principles of management. Nurs Standard 2002; 16: 52, 45-56.

29 Grocott, P. The Palliative Management of Fungating Malignant Wounds. Paper presented at the Evening Hosted by South Australian Wound Management Association and Association of Stomal Therapy Nurses, Queen Elizabeth Hospital 2003.30 Grocott, P. Palliative management of fungating malignant wounds. JCN Online 2000; 14; 3. http://www.jcn.co.uk/journal.asp?MonthNum=03&YearNum=2000&Type=backissue&ArticleID=221

31 Ribeiro, M.D.C., Joel, S.P., Zeppetella, G. The bioavailability of morphine applied topically to cutaneous ulcers. J Pain Symptom Management 2004; 27: 5, 434-439.32 McDonald, A., Lesage, P. Palliative management of pressure ulcers and malignant wounds in patients with advanced illness. J Palliative Med 2006; 9: 2, 285-295.33 Twycross, R., Greaves, M.W., Handwerker, H. et al. Itch: scratching more than the surface. Quality J Med 2003; 96: 1, 7-26.34 Rhiner, M., Slatkin, N.E.

Pruritus, fever, and wweats. In: Ferrell, B.R., Coyle, N. (eds.). Textbook of Palliative Nursing. Oxford University Press, 2006.35 Holme, S.A., Pease, N.J., Mills, C.M. Crotamiton and narrow-band UVB phototherapy: novel approaches to alleviate pruritus of breast carcinoma skin infi ltration. J Pain Symptom Manag 2001; 22: 4, 803-805.36 Lovell, P., Vender, R.B. Management and treatment of pruritus. Skin Therapy Letter 2007; 12; 1. http://www.medscape.

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com/viewarticle/554692_print37 Fleck, C. Ethical wound management for the palliative patient. Extended Care Product News 2005; 100: 4, 38-46.38 McMurray, V. Managing patients with fungating malignant wounds. Nurs Times 2003; 99; 13, 55.39 Haisfi eld-Wolfe, M.E., Rund, C. Malignant cutaneous wounds: a management protocol. Ostomy/Wound Management 1997; 43: 1, 56-66.40 Davis, V. Goal-setting aids care. Nurs Times 1995; 91: 39, 72-76.41 Williams, C. Irriclens: a sterile wound cleanser in an aerosol can. Br J Nurs 1996; 5: 16, 1008-1010.42 Young, T. Common problems in wound care: wound cleansing. Br J Nurs 1995; 4: 5, 286, 288-289.43 Carville, K. Wound Care Manual (Vol. 5). Silver Chain Foundation 2005.44 Pereira, J., Phan, T. Management of bleeding in patients with advanced cancer. Oncologist 2004; 9: 561-570.45 Nazarko, L. Malignant fungating wounds. Nursing Residential Care 2006; 8: 9, 402-406.46 Thomas, S., Vowden, K.R. Controlling bleeding in fragile fungating wounds. J Wound Care 1998; 7: 3, 154.47 Grocott, P. Controlling bleeding in fragile fungating

tumours. J Wound Care 1998; 7: 7, 342.48 Grocott, P. An Evaluation of the palliative management of fungating malignant wounds, within a multiple-case study design. King’s College, 1999.49 Saunders, J., Regnard, C. Management of malignant ulcers - a fl ow diagram. Palliat Med 1989; 3: 153-155.50 Gagnon, B., Mancini, I., Pereira, J., Bruera, E. Palliative management of bleeding events in advanced cancer patients. J Palliat Care 1998; 14: 4, 50-54.51 Walton, A., Broadbent, A. Radiation-induced second malignancies. J Palliat Med 2008; 11: 10, 1345-1352.52 Jones, S. Easing the symptoms. Nurs Times 1998; 94: 24, 74, 77.53 Neil, J.A., Munjas, B.A. Living with a chronic wound: the voices of sufferers.Ostomy Wound Manage 2000; 46: 5, 28-38.54 Lawton, J. The Dying Process: Patients’ experiences of palliative care. Routledge, 2000.55 Mekrut-Barrows, C. Softening the pain of cancer-related wounds. Ostomy Wound Manage 2005; 52: 9.56 Haller, S.M. A large ulcerated fungating breast lesion. Clin J Oncol Nurs 2004; 8: 1, 76-78.57 Queen, D., Woo, K., Schulz, V.

N., Sibbald, R.G. Chronic wound pain and palliative cancer care. Ostomy Wound Management 2002; 49; 10. http://www.o-wm.com/article/211758 Davies, A. Nursing a patient with a malodorous fungating non-healing wound. Nurs Times 2003; 99; 13, 58-60.59 Bredin, M. Mastectomy, body image and therapeutic massage: a qualitative study of women’s experience. J Adv Nurs 1999; 29; 5, 1113-1120.60 Price, B. Altered body image: managing social encounters. Int J Palliat Nurs 2000; 6: 4, 179-185.61 Piff, C. A patient’s perspective: living with facial cancer. J Tissue Viability 2000; 11: 2, 64-66.62 Lund-Nielsen, B., Muller, K., Adamsen, L. Malignant wounds in women with breast cancer: feminine and sexual perspectives. J Clin Nurs 2005; 14: 56-64.63 Neal, K. Treating fungating lesions. Nurs Times 1991; 87: 23, 84, 86.64 Hack, A. Malodorous wounds: taking the patient’s perspective into account. J Wound Care 2003; 12: 8, 319-321.65 Karnell, L.H., Christensen, A.J., Rosenthal, E.L. et al. Infl uence of social support on health-related quality of life outcomes in head and neck cancer. Head Neck, 2007; 29; 2, 143-146.

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Online learning to reduce wound pain

A global education programme aimed at

supporting pain reduction strategies in wound care has been launched.

Less-Pain Academy is an online resource that provides access to new research, therapies, protocols and best practice for health-care practitioners involved in dressing changes.

The initiative, which

is endorsed by the European Wound Management Associa-tion (EWMA), will focus on pain awareness, management, quality of life and wound healing, as well as providing practical tools to improve outcomes. The website will also screen a series of live seminars (web-based lectures) by renowned specialists, which will then be available to download as podcasts.www.less-pain.com

Stockings gain Sigel certifi cation

A brand of compression stockings has

achieved independent certifi cation in their use against deep vein thrombosis (DVT).

Mölnlycke Health Care’s Brevet tx anti-embolism stockings gained independent accreditation for their compliance with international compres-sion standards.

The stockings follow

the international Sigel standards at the measuring points of ankle, mid calf and upper thigh, as set by the National Institute for Health and Clinical Excellence (NICE).

‘That this product adheres to an interna-tionally recognised standard ensures that patients receive the best possible care’, said Nick Howard, International Product Manager at Mölnlycke Health Care.www.moInlycke.com

Documents

Malignant Wound Management