| Problem | Causes | Management strategies |
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| Odor | Nonviable, necrotic tissue and excessive drainage create an ideal environment for bacterial growth. In turn, this produces a foul odor. Polymicrobial bacteria are responsible for causing odor. Odor-causing bacteria can be aerobic such as, Klebsiella, Proteus, Pseudomonas, and Staphylococcus, or they can be anaerobic such as Clostridium and Bacteroides fragilis. Odor can cause nausea, vomiting, and loss of appetite for the patient. | - Change dressings and gently irrigate the wound with tap water or normal saline solution at frequent intervals.
- Apply topical antibiotics to reduce the amount of bacteria.
- Foam, calcium alginate, hydrofiber, composite, and occlusive dressings may be used based on wound characteristics. See chapter 11 for more on dressings.
- Use other topical antimicrobials, such as metronidazole gel or crushed metronidazole tablets, Iodoflex or Iodosorb, or silver-containing products, as indicated.
- Antiseptic solutions such as acetic acid or sodium hypochlorite can reduce odor but might sting and require at least daily dressing changes.
- Use charcoal dressings, such as Carbonet, CarboFlex, and Actisorb Plus.
- Room deodorizers and odor masking techniques can be helpful such as:
- Peppermint, lavender, or lemon scents.
- Apply Mentholatum (Vicks VapoRub) near the patient's or caregiver's nostrils to minimize the perception of odor.
- Place a tray of kitty litter, baking soda, or charcoal under the patient's bed to absorb odors.
- Room ventilation.
- Apply a pouching system to the wound to help control odors.
| | Bleeding | Malignant cells stimulate angiogenesis. Thrombocytopenia and disseminated intravascular coagulopathy and malnutrition are factors common in cancer patients, leading to increased vascular permeability and promote a loss of protein and fibrinogen. This causes the blood vessels surrounding a malignant wound to become friable and fragile, and the blood to have an impaired ability to clot. | - Use nonadherent or low adhesive dressings (such as silicone dressings) to minimize tissue trauma and reduce the risk of bleeding.
- Avoid frequent or unnecessary dressing changes.
- For small bleeding areas, consider using alginate dressings and/or hemostatic agents (such as Gelfoam, Surgicel, Spongostan, silver nitrate, and Oxycel)
- For larger areas, epinephrine soaked gauze can be applied in layers
- Assist with surgical intervention (cauterization) or the application of topical epinephrine (Adrenalin) 1:1,000 to control profuse bleeding.
- Administer oral antifibrinolytics (such as tranexamic acid [Cyklokapron] or aminocaproic acid [Amicar]), as prescribed, to control severe bleeding.
| | Exudate (drainage) | The leakage of fibrinogen and plasma colloids by vessels in the wound causes exudate to form. Bacteria in the wound release enzymes that liquefy tissue, producing additional exudate. | - Use highly absorbent dressings (such as calcium alginate, foam, and hydrofiber) in wounds with moderate to large amounts of exudate.
- Administer topical or systemic antimicrobials, as prescribed, to reduce bacterial load and exudate.
- Use a wound drainage system, such as a pouch, on wounds with large amounts of exudate. (Avoid using a negative pressure system.)
- Protect the surrounding skin from maceration and irritation.
- Use stockinette, tube sleeves, and binders when possible to secure dressings and minimize tape to skin.
| | Pruritus (itching) | Edema, bacteria, and tumor all cause cellular inflammation and destruction. This causes the skin to stretch and the peripheral nerves become irritated, commonly resulting in pruritus. Fungal infections may also cause pruritus. | - Chill emollients, hydrogel sheet dressings, and other topically applied agents in the refrigerator and then apply to the wound.
- Apply menthol creams to the affected area.
- Advise the patient to use cool or lukewarm water to bath or shower, rather than hot water.
- Advise the patient that antihistamines may only have a limited effect on the pruritus associated with malignant wounds.
- Administer oral medications such as gabapentin, doxepin, or mirtazapine as ordered.
- Topical agents such as tacrolimus, lidocaine applied before capsaician (to reduce stinging), and topical cannabinoid agonist agents can offer temporary relief.
| | Pain | Pressure on nerve endings from edema and the tumor as well as exposure of the dermis to air may cause chronic pain. Dressing changes and other procedures may also worsen pain. | - Use a reliable and valid pain assessment tool—such as the visual analog, numeric pain intensity, or FACES pain-rating scales—to accurately assess the patient's level of pain.
- Determine triggering and relieving factors.
- Administer prescribed pain medication (oral or parenteral) or topical anesthetics as ordered and before changing dressings or performing procedures.
- Allow for ‘time-out’ if dressing change is too painful.
- Nonadhesive dressings may be more comfortable.
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