How to assess a malignant wound

➔ Conduct a holistic patient assessment with a focus on patient quality of life, social and family support/environment.



➔ Conduct a wound assessment using a validated assessment tool, with the following special considerations:

• Watch for tunnelling or undermining.
• Assess odour, from the patient’s perspective, which can be caused by infection, necrotic tissue or exudate.
• Amount and type of exudate.
• Percentage of devitalised tissue.
• State of surrounding skin.
• Watch for bleeding and potential for haemorrhage.
• Effects of location (obstruction of airways, near major arteries, restriction of movement, restriction of eating or basic body functions, etc.).

Conduct a pain assessment and complete physical exam

➔ Conduct a detailed pain assessment to determine the nature and type of pain, duration, severity and impact of daily living, etc. using a validated pain assessment tool.



➔ Include a complete physical exam to check for other injuries/complications (i.e. pressure injuries, skin failure, etc.), including a nutritional assessment as patients with malignant fungating wounds often have significant problems with appetite due to odour.

➔ Examples of patient care goals

• Be able to visit with family and friends (i.e. clarity of thought and odour control).
• Live to see birth of grandchild (life extension).
• Being able to attend a family wedding (mobility).
• No pain.
• Etc.

How to develop a treatment and care plan

➔ Management of malignant wounds is complex and requires a multidisciplinary approach to care. 



➔ Putting together a multidisciplinary/integrated care team is critical. 



➔ The patient and their family/caregivers must be considered full and active members of the care team. 



➔ The team should include everyone with a role in the patient’s clinical, psychological and spiritual care.

➔ Developing treatment goals

• Achieving realistic, patient and family-centred measurable goals are the cornerstone of effective care.⁵
• Treatment goals must be patient driven, help alleviate social isolation and manage pain. It is critical that clinicians ask the patient before undertaking any treatment or assessment and respect the patient’s decision-making.
• Patient and family centered care (PFCC) is increasingly linked to improved communication, care quality, and patient decision making.⁶
• Patient centred care involves understanding the patient as a person, the patient-healthcare professional relationship, and coordination of care across the healthcare system.⁷


➔ SMART goals

➔ Treatment planning


• The treatment plan must be in keeping with the care goals of the patient and their family, which may change over time.⁴
• Overall goals should include patient comfort, confidence and sense of wellbeing, prevent social isolation and maintain or improve overall QoL.⁸
• Pain management is a critical part of the treatment planning. If pain is not being adequately managed refer.
  • Patient reported pain can include pain due to the underlying condition and specific pain related to the wound site.
  • It is important that a distinction be made between pain caused by stimulation of nerve endings (nociceptive pain), pain caused by nerve dysfunction (neuropathic pain) and pain caused by treatments or dressing changes as they all require different treatments.^2,9
  • Pain experienced during dressing changes can be mitigated by advising patients to take their oral medications 45 minutes prior to the nursing visit to ensure the pain medication is at full strength prior to any wound care treatments, or by using a “booster” dose of analgesia prior to treatment. Some studies have also demonstrated a positive effect from the use of topical opioids applied directly to the wound bed.²
  • A pain specialist can help tailor the care to suit the evolving needs of the patient^.2,4,10

• Pruritus or itchy skin can be a side effect of the tumour or of the treatment. Moisturisers, use of neutral soaps, topical anesthetics, localised temperature control, cortisone and antihistamines may help.¹⁰
• Treatment and control of exudate, odour and bleeding are often of immediate importance to optimise patient quality of life.
  • Malodour is recognised as having a major physical and psychological impact on patients and families/caregivers. Determining the cause of the malodour can help in developing a realistic management plan.¹¹
  • There are some reports of success using off-label treatments such as: charcoal dressings, administration of chlorophyll tablets, use of antibiotics, silver dressings, medical honey, sugar, green tea bags and NPWT palliative therapies.
  • There is some agreement that metronidazole gel administered topically and the use of oral metronidazole can reduce odour.
  • Other typical strategies to control odour include

                    -  Use of aromatherapies (some scents may cause nausea for patients. A trial- and error approach to                                               determining which if any scents help may be required).

                    -   Keeping room well ventilated. 


                    -   Kitty litter under the bed. 


• • For all odour reducing dressings, follow manufacturers’ instructions closely to ensure the most effective outcomes.



➔ WHO Analgesic Ladder

How to manage a malignant wound

➔ Cleansing & Debridement: 


• Therapeutic cleansing/irrigation and debridement may be necessary to remove necrotic tissue and reduce odour.
• Self showering is a viable cleansing technique based on the patient’s abilities and preferences.
• Aggressive or sharp debridement is not recommended on malignant wounds. Autolytic debridement can be achieved using hydrating dressings or honey.⁵ Debulking tumours to remove necrotic tissue and reduce odour should only be done by a specialist.
• Mild wound cleansing is recommended to reduce the incidence of bleeding. Use of potable water, saline or mild antiseptic solutions at room or body temperature are recommended. Therapeutic irrigation and wound cleansing may not be appropriate if deep tunnelling is present.⁵

➔ Infection management


• Only swab if you are planning to treat for infection and where it is necessary to control bacteria where resistant organisms require special infection control measurements.¹²
• Controlling bacteria can decrease exudate, pain and odour and help stabilise a non healing wound.¹³
• If unexpected infection is persistent, spreading or if systemic infection is suspected refer.

How to choose dressing and additional therapy

➔ Dressing choice should always take into account current treatment and procedures that may impact dressing type and change frequency, such as radiotherapy. 



➔ A dressing should manage exudate, prevent infection, protect periwound skin, allow the patient maximum mobility, comfort and security and be non-traumatic on application and removal. 



➔ Non-adherent soft silicone dressings have been shown to cause less pain upon removal.²

➔ Choose a dressing that:

• Is comfortable and allows patient maximum mobility.
• Is convenient for patient and caregiver.
• Has a long wear time, to reduce painful dressing changes.
• Is non traumatic on application and removal.Absorbs excess exudate, bleeding and protects periwound skin. 


• Reduces infection risk and odour. 



➔ Avoid the use of petroleum impregnated dressings and occlusive hydrocolloid dressings in fungating wounds.⁵

➔ Malignant wounds are often highly exudating and irregular in size and shape, which makes them difficult to dress and may require an unorthodox approach. A multiple layered dressing approach may be required. Dressing selection should be based on patient needs and preferences and local policy/protocol/formularies. The following chart (see below) breaks down some of the basic theory around dressing types and how they can help manage symptoms for patients with malignant fungating wounds.

Monitor patient's progress towards care goals

➔ Care must be flexible and focused on the patient’s priorities, as well as management and control of symptoms. 



➔ Assess progress towards care goals and acknowledge that the patient’s goals may change as their condition progresses. 



➔ Taking photos of the wound at dressing changes can help assess progression and will allow other members of the care team to “see the wound” without disturbing the patient. Always ask patient permission before taking the photo and also ask patient if they would like to see the image. 



➔ Monitor environment of care and openly discuss care options with patient and family/caregivers.

➔ Patient and care giver education and communication:


• Malignant wound care must always focus on the needs and wishes of the patient.
• Continuous open communication between all members of the multidisciplinary team, the patient and the patient’s family/caregivers is crucial to ensure effective coordinated care and to manage expectations.
• Clinical and psychological support for the patient and their family/ caregivers should be part of every interaction with the patient.
• Preparing the patient and family/caregivers for future stages of care is important (i.e. if wound is near a major artery and there is a possibility of a large or fatal bleed, suggest keeping dark towels on hand to decrease the stress and anxiety from the sight of blood).
• Providing written instructions to patients and families will often help with information retention.
• Connecting patients and family/caregivers to community resources can often assist in education and communication efforts and offer additional support.



➔ Caregiver support


• Clinicians who treat patients with malignant wounds and end-of-lifewounds often face complex challenges of care and additional factors such as moral distress, burnout, compassion fatigue and death anxiety.¹⁴
• Clinician self-care should be prioritised and include extended supervision, reflective practice, access to on-the-spot debriefs, and other support services.
• Patients found that they felt isolated and cut off by nurses who struggled to acknowledge their own distress.⁸