Keywords: fungating wounds, palliative care, hospice, dressings, malodour, carcinoma cervix
Fungating wounds with the associated malodour, disfigurement, and discharge are distressing to patients and caregivers, and are a leading cause for hospice admission in our centre. Although many new wound care materials and dressings have been developed, most are very expensive. Essentially, dressings for fungating wounds need to contain the wound, drainage and odour thus reducing social isolation and improving quality of life. Over the past ten years in Jeevodaya hospice we have used low cost methods for managing fungating wounds and discharge. These are outlined below.
The continued use of commercially sold sterile cotton pads and bandages can be expensive. At Jeevodaya we make dressing pads using old cotton sarees/ dhotis which are collected as donations. The sarees are cut into different lengths depending on the sizes of pads required. A thin layer of cotton is placed within to make dressing pads which are are then autoclaved and used. This method can be taught to the family caregivers who can prepare the pads at home and sterilize them by steaming them for 15 minutes in a pressure cooker. An indirect advantage of using coloured material is that minor bleeding or oozing will not be as obvious. Vaseline gauze is also prepared in house and autoclaved.
Sufficient time and privacy are allowed for the cleaning and dressing of wounds. The first dressing of the day is done after the patient has had his morning wash or bath. If there is excessive discharge dressings will need to be repeated during the day and possibly before the patient retires to bed.
Patients who find the procedure painful are given an extra dose of morphine half an hour before the dressing. This would generally be one sixth of the daily dose or 5- 10 mg if opioid naοve. Anxiolytics such as lorazepam or midazolam my be needed for extremely anxious or restless patients.
The dressing material, instruments, antiseptic lotions, irrigation solutions, rubber sheets, kidney trays, buckets and waste basket are assembled before starting the procedure. Universal precautions are followed. Gloves are always worn and where there is excess discharge or risk of splashing, masks and aprons may be necessary
We prefer to have patients lying down for dressings, for some may feel faint. The wound is exposed. For wounds on the trunk, we keep rubber sheets on the bed to prevent soiling. For wounds on the extremities, the limb is brought away from the edge of the bed and a bucket placed underneath.
The wound is then well irrigated. We use normal saline as the irrigating fluid. Patients who cannot afford normal saline at home are advised to use boiled and cooled water. Hydrogen peroxide is sometimes used for wounds with profuse discharge, in the inpatient setting. The solution is poured over the wound and allowed to act for 3-5 minutes. The excess is mopped off with dry gauze or swabs on sticks. Wounds must never be "rubbed" dry.
We use topical metronidazole to reduce malodour. Since metronidazole gel is expensive we prefer to use crushed metronidazole tablets or intravenous metronidazole solution spread on gauze.
Cotton must never be placed directly on the wound. A layer of vaseline gauze can prevent dressings from adhering to the wound. The wound is then covered with locally prepared gamgee pads which are secured using bandage or micropore tape.
Malodour is a major cause of social isolation- as Mrs.R a patient with carcinoma cervix explained, "I personally find the smell from my body so nauseating that I am unable to eat, how can I expect others to tolerate this smell?" Some patients in the hospice are social outcasts, rejected by their family and the community.
Oral and topical metronidazole reduce the malodour caused by anaerobes. We use topical metronidazole regularly for dressing wounds. Some patients benefit from protracted courses of oral metronidazole- 400 mg thrice daily for two weeks, and then maintained on 200 mg twice daily. Honey, and activated charcoal have been suggested for combating malodour. We find that the key to minimizing malodour especially in resource poor settings, is the frequent change of dressings. Some of our patients require a change of dressings 5-6 times in a day. Any malodour or seepage would warrant a prompt change of dressings.
It is essential to have good cross ventilation and fans. Room fresheners can be used, and some use incense but this must be used with discretion as a combination of smells can be even more sickening. At Jeevodaya we have found that a few drops of ginger grass oil dabbed near, (not on), the wound, masks the malodour and provides a pleasant smell within the room. Anecdotal reports suggest that coconut shell ash kept within the room can help adsorb foul smells.
Sowani et al, have described the management of maggot infested wounds in an Indian hospice. Turpentine is used to draw the maggots to the surface of the wound. They can then be picked out using forceps. The procedure will have to be repeated daily till all the eggs have hatched and buried larvae have emerged.
Management of bleeding ulcers
Bleeding from fungating ulcers can either be diffuse and superficial or a massive hemorrhage due to arterial blowout or erosion of major vessels. The former can be managed by using local pressure or compression dressings. We have used powdered sucralfate tablets and sucralfate solution with variable results. A short course of palliative radiotherapy can help in controlling bleeding.
For penetrating ulcers situated on major vessels. in the inguinal region, axilla and the neck, anticipation is the key word, for erosions of these vessels cause fatal haemorrhage.
Compression may help temporarily. It is important to have coloured towels or old bedsheets available to mop up the blood should massive haemorrhage occur. Sedating the patient should be considered.
Wound care in cancer cervix
The nursing care of patients with cancer cervix is challenging. Regular vaginal douches with warm water, or dilute betadine solution are necessary for patients with vaginal discharge. The final irrigation is done with metronidazole solution. We use vaginal douche pumps with an attached catheter. The irrigation catheter is gently introduced as far back into the vagina as possible. A course of systemic antibiotics helps when there is secondary infection. Patients with fungating wounds of the vagina, perineum and anus benefit from twice daily Sitz baths.
Surgical diversion procedures should be considered for patients with rectovaginal and vesicovaginal fistulae. If this is not possible, some patients with a vesicovaginal fistula may benefit from an indwelling urinary catheter to reduce dribbling. For patients with rectovaginal fistulae keeping the stools solid with frequent evacuation of the rectum with suppositories may help. Adult diapers are expensive, cloth pads are a cheaper option. If such patients have significant seepage, layers of newspaper placed under the draw sheet increase absorbency and reduce odour.
Disfigurement, trismus and oro-cutaneous fistulae pose special problems in the care of patients with oral cancers. Soft tooth brushes or cotton swabs on sticks are used to clean the teeth. We use dilute potassium permanganate solution or dilute lime juice as mouthwash. When trismus is a problem, a catheter attached to a syringe can be introduced in the gap between the teeth or behind the molars. This can be used for gentle irrigation and dependent drainage. This is especially useful for patients with oro-cutaneous fistulae.
Fungating and disfiguring wounds lead to a loss of self esteem and social withdrawal., This is especially true of patients with disfiguring lesions of the face. Dressings, and cosmetically covering the affected area with a saree, dupatta, shawl or scarf can help to some extent. Such patients may also have difficulty in phonation. When they find that others find it difficult to understand their speech, they often withdraw. It is important that carers take extra trouble to communicate with them, perhaps through writing to help them express their needs and thoughts. Family and professional caregivers have to share their efforts and resources to infuse a sense of worth and hope in patients with fungating and disfiguring wounds.