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Skin disorders: Malignant wounds, fistulas, and stomas 

Skin disorders: Malignant wounds, fistulas, and stomas
Chapter:
Skin disorders: Malignant wounds, fistulas, and stomas
Author(s):

Susie Seaman

and Barbara M. Bates-Jensen

DOI:
10.1093/med/9780199332342.003.0018
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The drainage and odor are so bad, I am embarrassed to go out in public, and I feel like my family does not want to be around me because of it. …I don’t want to be around me either.

A palliative care patient

I feel so helpless. I don’t know how to help her, and I feel nauseated whenever I see or smell her wound.

A loved one

Key points

  • Management of drainage, odor, bleeding, and pain are key components of palliative care for malignant wounds.

  • Palliative cares for the person with an ostomy is focused on maintenance of an efficient management plan and provision for optimal functional capacity.

  • It is essential to involve caregivers and family members in the plan of care.

Malignant wounds

Definition

Malignant wounds, also known in the literature as fungating tumors, tumor necrosis, ulcerative malignant wounds, or fungating malignant wounds, present both a physical and an emotional challenge for the patient, caregiver, and clinician. These wounds are frequently associated with pain, odor, bleeding, and an unsightly appearance. They may be a blow to self-esteem and may cause social isolation just when the patient needs more time with loved ones. The goals in the care of patients with malignant wounds include managing wound exudate, odor, bleeding, and pain; preventing infection; and promoting the emotional welfare of the patient and family.

Malignant cutaneous lesions occur in up to 5% of patients with cancer and 10% of patients with metastatic disease. To date, the largest study examining the incidence of cutaneous involvement of internal malignancies was performed by Lookingbill and colleagues,1 who retrospectively reviewed data accumulated over a 10-year period from the tumor registry at Hershey Medical Center in Pennsylvania. Of 7316 patients, 367 (5.0%) had cutaneous malignancies. Of these, 38 patients had lesions as a result of direct local invasion, 337 had metastatic lesions, and 8 had both. A secondary analysis from the same registry found that 420 patients (10.4%) of 4020 with metastatic disease had cutaneous involvement.2 In women, the most common origins of metastasis were breast carcinoma (70.7%) and melanoma (12.0%). In men, melanoma (32.3%), lung carcinoma (11.8%), and colorectal cancer (11.0%) accounted for the most common primary tumors. In a 10-year retrospective review of 677 patients with lung cancer, Ambrogi et al.3 found that 26 (3.8%) patients had cutaneous metastasis. Mueller et al.4 performed a meta-analysis of eight studies examining cutaneous metastasis of internal malignancies. Out of 81,618 primary visceral cancers, they identified 2369 (2.9%) cases of metastasis to the skin. Wong et al.5 found that in 401 patients with skin metastasis cared for over a 25-year period at a single cancer center, the primary tumor sites, starting with the most common, were breast (32.7%), bronchus and lung (13.2%), skin (melanoma; 9.5%), lymph nodes (7.5%), mouth/pharynx/larynx (6.2%), blood and bone marrow (5.5%), and colorectal (4.2%). Although breast, lung, gastrointestinal tract, and melanoma account for the majority of cutaneous metastases, these lesions may arise from any type of malignant tumor.6,7,8,9 In some cases, the tumor of origin may not be identified.10

Pathophysiology of malignant wounds

Malignant wounds may occur from infiltration of the skin by local invasion of a primary tumor or by metastasis from another site.6,11 Local invasion may initially manifest as inflammation with induration, redness, heat, tenderness, or some combination of these features. The skin may have a peau d’orange appearance and may be fixed to underlying tissue. As the tumor spreads and further tissue destruction occurs, the skin eventually ulcerates. The presentation may differ in metastatic cutaneous infiltration. Tumor cells detach from the primary site and travel via blood or lymphatic vessels, or tissue planes, to distant organs, including the skin.8,12,13 In general, cutaneous metastasis occurs in the region of the primary tumor, most commonly on the chest, head, neck, abdomen, and groin.6,8,9,13 These lesions may initially manifest as an erythematous rash or plaque, known as carcinoma erysipelatoides, which is due to the presence of malignant cells in the dermal lymphatics.8 More commonly, they present as well-demarcated, painless nodules ranging in size from a few millimeters to several centimeters. Their consistency may vary from firm to rubbery. Pigmentation changes may be noted over the lesions, from deep red to brown-black. Both locally invasive and metastatic lesions may initially be misdiagnosed as rashes, plaques, cellulitis, epidermal cysts, lipomas, or other benign conditions. However, unlike many benign skin problems, these lesions will not resolve and over time may ulcerate, fungate, drain, and become very painful.

As these malignant lesions extend, changes in vascular and lymphatic flow lead to edema, exudate, and tissue necrosis.14 The resulting lesion may be fungating, in which the tumor mass extends above the skin surface with a fungus or cauliflower-like appearance, or it may be erosive and ulcerative.15,16 The wound bed may be pale to pink with very friable tissue, completely necrotic, or a combination of both. The surrounding skin may be erythematous, fragile, and exceedingly tender to touch. The skin may also be macerated in the presence of excessive wound exudate. The presence of necrotic tissue is an ideal culture medium for bacterial colonization, which may result in significant malodor.17,18 The degree of pain experienced by the patient depends on wound location, depth of tissue invasion and damage, nerve involvement, and the patient’s previous experience with pain and analgesia.15

Assessment of malignant wounds

Ongoing comprehensive assessment of the patient and malignant wound facilitates formulation of an appropriate treatment plan, allows for adjustment of the treatment plan as findings change, and promotes recognition of wound complications. Specifically, wound location, size, appearance, exudate, odor, and condition of the surrounding skin guides local therapy. Associated symptoms should be noted so that appropriate measures can be taken to provide comfort. The potential for serious complications such as hemorrhage, vessel compression or obstruction, or airway obstruction should be noted so that the caregiver can be educated regarding their palliative management. Table 17B.1 presents highlights for the assessment of malignant wounds and associated rationale.

Table 17B.1 Assessment of malignant wounds

Assessment

Rationale

Wound location

Is mobility impaired?

Consider occupational therapy referral to facilitate activities of daily living

Located near wrinkled or flat skin?

  • Affects dressing selection

  • Affects dressing fixation

Able to hide from public view?

Affects psychological coping

Wound appearance

Size: length, width, depth, undermining, deep structure exposure

Affects dressing selection, provides information on deterioration or response to palliative treatment

Fungating or ulcerative

Affects dressing selection and fixation

Percentage of viable vs. necrotic tissue

Need for cleansing/debridement

Tissue friability and bleeding

Need for nonadherent dressings and other measures to control bleeding

Presence of odor

Need for odor-reducing strategies

Presence of fistula

Possible need for pouching

Exudate amount

Affects dressing selection

Wound colonized or clinically infected

Need for local vs. systemic care

Surrounding skin

Erythematous

Infection or tumor extension

Fragile or denuded

Impacts dressing type and fixation

Nodular

Tumor extension/metastasis

Macerated

Need for improved exudate management

Radiation-related skin damage

Need for topical care of skin, affects dressing fixation

Symptoms

Deep pain: aching, stabbing, continuous

Need to adjust systemic analgesia

Superficial pain: burning, stinging, may be associated only with dressing changes

Need for topical analgesia and rapid-onset, short-acting analgesics

Pruritus

Related to dressings? If not, may need systemic antipruritic medications

Potential for serious complications

Lesion is near major blood vessels: potential for hemorrhage

Need for education of patient/family about palliative management of severe bleeding

Lesion is near major blood vessels: potential for vessel compression/obstruction

Need for education of patient/family about palliative management of severe swelling and pain, possible tissue necrosis

Lesion is near airway: potential for obstruction

Need for education of patient/family about palliative management of airway obstruction

Malignant wounds may change over time based on the aggressiveness of the cancer and whether the patient is undergoing palliative surgery, chemotherapy, or radiation. Although palliative treatment may result in regression or even disappearance of the cutaneous lesion, it may recur. Ongoing assessment allows the clinician to tailor the local wound management based on the current needs of the patient and wound.

Part of holistic assessment includes evaluation of how the patient and significant others are coping with the malignant wound and the cancer diagnosis.19,20 How the wound affects daily life and relationships, and the availability and use of social support networks in the community should be examined.

Management of malignant wounds

The goals of care for patients with malignant wounds include control of infection and odor, management of exudate, prevention and control of bleeding, and management of pain.11,14,15,21,22,23,24 In determining the appropriate treatment regimen, the abilities of the caregiver must also be considered. There is limited published information on treatment effectiveness, which reflects the absence of evidence-based care in this area and the significant need for further research and dissemination of findings.25 Many articles regarding malignant wounds are based on expert opinion and the personal experience of practitioners knowledgeable in palliative and hospice care. Although research-based treatment is the gold standard of care, anecdotal reports on successful treatment of these challenging wounds are helpful to nurses striving to provide the best care for their patients.

Infection and odor control

Control of infection and odor is achieved by controlling local bacterial colonization with wound cleansing, wound debridement, and use of local antimicrobial agents.26 Because malignant wounds are frequently associated with necrotic tissue and odor, wound cleansing is essential to remove necrotic debris, decrease bacterial counts, and thus reduce odor. If the lesion is not very friable, the patient may be able to shower. This not only provides for local cleansing but also gives the added psychological benefit of helping the patient to feel clean. The patient should be instructed to allow the shower water to hit the skin above the wound and then run over the wound. If there is friable tissue (i.e., tissue that bleeds easily with minimal trauma) or the patient is not able to shower, the nurse or caregiver should gently irrigate the wound with normal saline or a commercial wound cleanser. Skin/incontinence cleansers, which contain mild soaps and antibacterial ingredients used in bathing, can be very effective at controlling local bacterial colonization and odor. As long as they do not cause burning, they may be sprayed directly on the wound. If pain and burning occur with use of skin cleansers in the wound, they should be used only on the surrounding skin. Topical antimicrobial agents such as hydrogen peroxide, sodium hypochorite (Dakin’s solution), and povidone iodine are recommended by some authors,27 however their use should be weighed against the potential negative effects of local pain, skin irritation, wound desiccation with subsequent pain and bleeding on dressing removal, and unpleasant odor associated with Dakin’s and povidone iodine. Newer antimicrobial wound cleansers containing polyhexamethylene biguanide (PHMB) may help decrease bacterial colonization while minimizing toxicity to healthy cells.28,29 Gauze soaked with a PHMB cleanser can be applied to the wound for 15 minutes prior to new dressing application for optimal decolonization.

The necrotic tissue in malignant wounds is typically moist yellow slough. Occasionally, in the absence of exudate, there may be dry black eschar, but this is less common. Debridement is best done with the use of autolytic and/or gentle mechanical methods, as opposed to wet-to-dry dressings, which are traumatic and can cause significant bleeding and pain upon removal. Autolytic debridement, which is the natural breakdown of necrotic tissue by enzymes and white cells present in wound fluid, can be achieved with the use of dressings that support a moist wound environment,30 but odor may be increased under occlusion and/or with the use of hydrogels. Local debridement may be performed by very gently scrubbing the necrotic areas with gauze saturated with skin or wound cleanser. Low-pressure irrigation with normal saline using a 35-mL syringe and a 19-gauge needle can be used to remove loose necrotic tissue and decrease bacterial counts. Care should be taken to avoid causing pain with either procedure. In addition, careful sharp debridement by clinicians trained in this procedure can be performed to remove loose necrotic tissue. Penetration of viable tissue should be avoided, because bleeding may be difficult to control. If necrotic tissue in the wound is extensive, surgical debridement may be indicated to promote infection control, odor reduction, and exudate management, if compatible with the palliative goals of care for the patient.

Local colonization and odor can be reduced with the use of topical antibacterial preparations. Odor is by far the most difficult management aspect of treating malignant wounds and is frequently the most distressing complaint that affected patients have. The literature supports use of topical metronidazole, which has a wide range of activity against anaerobic bacteria, to control wound odor.31,32,33,34,35,36,37,38

Topical therapy is available by crushing metronidazole tablets in sterile water and creating either a 0.5% solution (5 mg/mL) or a 1% solution (10 mg/mL).31,32 This may be used as a wound irrigant, or gauze may be saturated with the solution and packed into wound cavities. Care must be taken not to allow the gauze packing to desiccate, because dressing adherence may lead to bleeding and pain.

An easy, effective alternative to metronidazole solution is metronidazole 0.75% gel, which is applied in a thin layer to the entire wound. Poteete38 evaluated the use of metronidazole 0.75% gel in the treatment of 13 patients with malodorous wounds. Metronidazole gel was applied to the wounds daily and covered with either saline-moistened or hydrogel-saturated gauze. At the end of the 9-day observation period, no odor was detected in any wound after the dressings were removed. Finlay et al.33 prospectively studied subjective odor and pain, appearance, and bacteriological response in 47 patients with malodorous wounds treated with daily application of metronidazole 0.75% gel. Ninety-five percent of the patients reported decreased odor at 14 days. Anaerobic colonization was discovered in 53% of patients and eliminated in 84% of these cases after treatment. Patients reported decreased pain at day 7, and both discharge and cellulitis were significantly decreased by day 14. Bale et al.34 conducted a randomized controlled trial of the daily application of topical metronidazole gel versus placebo gel in the treatment of 41 patients with malodorous wounds, including venous, arterial, and pressure ulcers, and other types of wounds. Based of subjective ratings of odor by the patient at start of therapy and days 1, 3, and 7, metronidazole gel eliminated odor faster than placebo gel. Interestingly, whereas all the patients treated with metronidazole gel noted odor elimination, 76% of placebo gel–treated patients also noted odor elimination by the end of the study. The authors speculated that this good result in the placebo group may have been from daily wound attention and care. Kalinski et al.35 conducted a prospective, uncontrolled trial of metronidazole 0.75% gel in 16 patients with malodorous, malignant fungating wounds. Metronidazole gel was applied to the wounds once or twice daily and covered with a nonadherent contact layer and a secondary gauze dressing. Using a subjective odor rating scale of 0–10, complete odor elimination was noted at day 1 in 10 patients, and significant improvement (> 3 units of improvement on rating scale) was noted in the other six patients. No adverse effects were seen with this regimen. Although metronidazole gel is now available generically, it may still be costly for some patients, depending on insurance coverage, or may not be available in developing countries. In these cases, making a solution from crushed tablets as mentioned previously may be the best option. Choice of dressing over metronidazole gel should be based on the amount of exudate. In low exudate wounds in which dressing adherence is a concern, the gel should be covered with a nonadherent contact layer, and then absorbent dressings such as gauze or ABD pads should be applied. In more heavily draining wounds, a nonadherent contact layer may not be necessary, and the absorbent dressings can be applied directly to the wound. For optimum odor control, dressings should be changed daily, and more often for high levels of exudate that soak through the bandage. In the United States, use of metronidazole gel is considered off-label use, but with significant support for its use in the literature, it can be considered an appropriate choice in the standard care of patients with malodorous malignant wounds.36 Systemic use of metronidazole should only be used in patients with invasive infection, not those with local bacterial colonization.

Another topical antimicrobial agent is Iodosorb gel (Smith & Nephew), 0.9% cadexomer iodine, which is iodine complexed in a starch copolymer. This product contains slow-release iodine and has been shown to decrease bacterial counts in wounds without cytotoxicity.39,40 Cadexomer iodine is available in a 40-g tube and is applied to the wound in a 1/8-inch layer. An advantage of this product is exudate absorption: each gram absorbs 6 mL of fluid. Disadvantages include cost (comparable to metronidazole 0.75% gel) and possible burning on application.

A PHMB-based gel is available for odor reduction. Prontosan gel (B. Braun) contains PHMB, to provide bacterial control, and betaine, a surfactant that softens and facilitates debridement of necrotic debris. It is applied in a 3- to 5-mm layer over the wound and covered with secondary dressings similar to what are used over metronidazole gel. It can also be applied to gauze packing for wounds with depth.

There are dressings that may also help decrease bacterial colonization and odor in malignant wounds.41 Charcoal dressings, which absorb and trap odor, are available as either primary or secondary bandages. Some products trap odor under the bandage, requiring application of a perfect seal around the dressing for effectiveness. This can be a disadvantage in that adhesive will have to be applied to fragile surrounding skin. Some charcoal products are complexed with absorptive ingredients such as alginates or hydrocolloids, which help to trap the odor in the dressings. Because these dressings vary in their application and performance, package inserts should be reviewed before use.

Any dressing that decreases bacterial counts in a wound has the potential to decrease odor. Silver has broad-spectrum activity against microorganisms found in wounds.42 Silver-based dressings are available in multiple different types including alginates, hydrocolloids, hydrogels, hydrofibers, foams, contact layers, and mesh gauze. Dressing type is chosen based on exudate level; for example, a silver-based alginate or hydrofiber might be used on a high exudating wound, whereas a silver-based contact layer and/or a silver-based hydrogel may be used on a low draining wound. Medical grade honey-based dressings and gels may also decrease wound odor as honey is naturally antibacterial.41,43,44 Lund-Nielsen et al.45 compared the use of honey-coated bandages with silver coated bandages in the treatment of 69 subjects with malignant wounds. Subjects were randomized to receive either treatment, and dressing effects on wound size, cleanliness, malodor, exudate, and pain were assessed. After 4 weeks of treatment, no differences were noted between the groups regarding outcomes, but when the data was pooled for all 69 subjects, there were significant decreases in subject-rated visual analog scale scores for malodor (P = 0.007) and exudate level (P < 0.0001) from study start to study end. Although a meta-analysis by Lo et al.46 concluded that silver dressings improve healing and reduce odor, pain, and exudate in nonmalignant chronic wounds, Cochrane reviews of the use of topical silver for both prevention and treatment of wound infections have concluded insufficient evidence to provide recommendations for practice.47,48 A Cochrane review of honey used as a topical treatment for acute and chronic wounds resulted in the same conclusion.49 Further research is needed on these treatments for firm conclusions to be made regarding their efficacy.

Less conventional methods of odor management are also available. Environmental deodorizers such as cat litter or charcoal briquettes can be placed under the bed to help reduce room odor for patients at home.11 Use of peppermint oil or other aromatherapy products, applied below the nostril or near the bed may help mask the odor. Odor-eliminating room sprays are more effective than room deodorant sprays and can be used before and after wound care to reduce the odor associated with wound exposure.

Although local colonization is treated with topical cleansing, debridement, and antibacterial agents, clinical infection, as evidenced by erythema, induration, increased pain and exudate, leukocytosis, and fever, should be treated with systemic antibiotics. Cultures should be used to identify infecting organisms once the wound is diagnosed with an infection based on clinical signs; cultures should not be taken routinely to diagnose infection. Because of the local inflammatory effects of the tumor, wounds may have many of the same signs as infection, so the clinician must be discriminating in differentiating between the two. A complete blood count, assessing the white cell count and differential, may be helpful in guiding assessment and therapy. It is crucial to avoid treating patients with oral antibiotics if they are only colonized and not infected, to prevent side effects and emergence of resistant organisms.

Management of exudate

Because of the inflammation and edema commonly associated with malignant wounds, there tends to be significant exudate. Dressings should be chosen to conceal and collect exudate and odor. This is essential because a patient who experiences unexpected drainage on clothing or bedding may suffer significant feelings of distress and loss of control. Specialty dressings, such as foams, alginates, or starch copolymers, are notably more expensive than gauze pads or cotton-based absorbent pads. However, if such dressings reduce the overall cost by reducing the need for frequent dressing changes, they may be cost-effective. Table 17B.2 summarizes dressing considerations with malignant wounds. Nonadherent dressings are best utilized as the primary contact layer, because they minimize the trauma to the wound associated with dressing changes. Seaman23 suggests using nonadherent contact layers, such as Vaseline gauze, for the primary dressing on the wound bed, and covering these with soft, absorbent dressings, such as gauze and ABD pads, for secondary dressings to contain drainage. The entire dressing should be changed once a day; the secondary dressing should be changed twice a day if drainage strikes through to the outside of the bandage. When applied over metronidazole gel, this dressing regimen is both clinically and cost effective. Many active patients may prefer to use menstrual pads as the secondary dressing, not only because of their excellent absorption, but also because the plastic backing blocks exudate and protects clothing. For patients with highly exudating wounds in which frequent bandage changes are required, an ostomy pouch may be used to contain the drainage. An appliance with a spout, such as urostomy pouch or wound management pouch, is applied to completely enclose the wound, and is changed twice a week. These devices are odor-proof as long as the seal is maintained; however, pouch deodorants may be used to decrease odor that will be noticed when the device is emptied. Partnering with a Certified Wound, Ostomy, and Continence Nurse (CWOCN) when deciding whether to pouch a malignant wound is recommended.

Table 17B.2 Dressing choices for malignant wounds

Type of wound and goals of care

Dressing choice

Low exudate

  • Maintain moist environment

  • Prevent dressing adherence and bleeding

  • Nonadherent contact layers

    • Adaptic (Systagenix)

    • Adaptic Touch (Systagenix)

    • Conformant 2 (Smith & Nephew)

    • Dermanet (DeRoyal)

    • Mepitel One (Mölnlycke)

    • Mepilex Transfer (Mölnlycke)

    • Petrolatum gauze (numerous manufacturers)

    • Restore Contact Layer (Hollister)

    • Tegaderm Contact (3M Health Care)

  • Amorphous hydrogels

  • Sheet hydrogels

  • Hydrocolloids: contraindicated with fragile surrounding skin, may increase odor

  • Semipermeable films: contraindicated with fragile surrounding skin

High exudate

  • Absorb and contain exudate

  • Prevent dressing adherence in areas of lesion with decreased exudate

  • Alginates

  • Foams

  • Starch copolymers

  • Gauze

  • Soft cotton pads

  • Menstrual pads (excessive exudate)

Malodorous wounds

  • Wound cleansing (see text)

  • Reduce or eliminate odor

  • Charcoal dressings

  • Topical metronidazole (see text)

  • Iodosorb Gel (Healthpoint): iodine-based, may cause burning

  • Prontosan Gel (B. Braun)

  • Honey-based dressings

  • Silver-based dressings

Protection of the surrounding skin is another goal of exudate management. The skin around the malignant wound may be fragile secondary to previous radiation therapy, inflammation due to tumor extension, repeated use of adhesive dressings, and/or maceration. Although adhesive dressings may assist with drainage and odor control, their potential to strip the epidermis upon removal may outweigh their benefit. Using flat ostomy skin barriers on the skin surrounding the wound and then taping the dressings to the skin barriers is one method of protecting against excess drainage and skin stripping due to tape removal. The ostomy barriers are changed every 5 to 7 days. Another method of protecting the surrounding skin is to use a barrier ointment or skin sealant on the skin surrounding the ulcer. These barriers protect the fragile tissue from maceration and the irritating effects of the drainage on the skin. Avoid excessive use of skin barrier ointments though; they can actually cause or increase maceration if too much is used. Dressings can then be held in place with tape affixed to the skin barrier placed on healthy skin, flexible netting, tube dressings, sports bras, panties, briefs, snug tank tops, or tube tops. New silicone-based adhesive tapes may also be effective at keeping dressings in place while allowing for atraumatic removal.

Controlling bleeding

The viable tissue in a malignant wound may be very friable, bleeding with even minimal manipulation. Prevention is the best therapy for controlling bleeding. Prevention involves use of a gentle hand in dressing removal and thoughtful attention to the use of nonadherent dressings or moist wound dressings. On wounds with a low amount of exudate, the use of hydrogel sheets, or amorphous hydrogels under a nonadherent contact layer, may keep the wound moist and prevent dressing adherence. Even highly exudating wounds may require a nonadherent contact layer to allow for atraumatic dressing removal. If dressings adhere to the wound on attempted removal, they should be soaked away with normal saline to lessen the trauma to the wound bed. If bleeding does occur, the first intervention should be direct pressure applied for 10 to 15 minutes. Local ice packs may also assist in controlling bleeding. If pressure alone is ineffective, several other options exist.50,51,52 Application of an alginate dressing or sucralfate paste (1 g sucralfate tablet crushed in 5 mL water-soluble gel) may stop mild bleeding. Gauze soaked with 1:1000 epinephrine applied to the wound may control bleeding, but can lead to local tissue necrosis. Other local vasoconstrictive agents may be used, including topical cocaine or oxymetazoline spray.51 Small bleeding points can be controlled with silver nitrate sticks. As an alternative, use of topical, absorbable hemostatic agents made from gelatin, collagen, and/or oxidized regenerated cellulose (e.g., Gelfoam, Surgicel, Promogran) may be appropriate, but are costly. Moh’s Paste, a chemical fixative applied topically to the wound, has been shown to be successful at controlling bleeding in gynecological and breast cancer tumors.53,54 Caution must be used to avoid excessive tissue damage, periwound dermatitis, and pain associated with this treatment. More aggressive therapy may be necessary in cases of significant bleeding,50 including transcatheter embolization of the arteries feeding the tumor55,56 intra-arterial infusion chemotherapy, and/or radiotherapy57,58 or surgery if compatible with palliative care goals of the patient. Oral fibrinolytic inhibitors, such as tranexamic acid or a minocaproic acid, have been used in the palliative management of cancer-associated bleeding59 and have been used topically in patients with hemophilia.60 If terminal hemorrhage is expected to occur, crisis medications such as midazolam should be kept ready at the bedside for immediate use if needed.52 Clinicians should not hesitate to consider any of these options if they will improve the quality of life in patients with malignant wounds.

Pain management

Several types of pain are associated with tumor malignant wounds: deep pain, neuropathic pain, and superficial pain related to procedures.15 Deep pain should be managed by premedication before dressing changes. Opioids for preprocedural medication may be needed, and rapid-onset, short-acting analgesics may be especially useful for those already receiving other long-acting opioid medication. For management of superficial pain related to procedures, topical lidocaine or benzocaine may be helpful.61 These local analgesics may be applied to the wound immediately after dressing removal, with wound care delayed until adequate local anesthesia is obtained. Ice packs used before or after wound care may also be helpful to reduce pain.

Another option for topical analgesia is the use of topical opioids, which bind to peripheral opioid receptors.61,62,63,64 Back and Finlay65 reported on the use of diamorphine 10 mg added to an amorphous hydrogel and applied to the wounds of three patients on a daily basis. Two of the patients had painful pressure ulcers, and the third had a painful malignant ulcer. All three were receiving systemic opioid therapy. The patients noted improved pain control on the first day of treatment. Zeppetella et al.66 demonstrated efficacy of topically applied morphine sulfate 10 mg/mL in 8 g amorphous hydrogel in the treatment of five hospice patients with painful pressure ulcers. The results of this pilot study were later validated in a larger randomized controlled study.67 Sixteen hospice inpatients with painful pressure or malignant wounds were randomized to receive topical morphine as described above or placebo (water for injection 1 mL in 8 g amorphous hydrogel) to their wounds. After 2 days of treatment, patients entered a 2-day washout period and then were crossed over to the opposite group for two more days. Patients assigned a numerical rating score to the analgesia that they obtained in each 2-day period, the lower score indicating better pain relief. Topically applied morphine provided significantly lower scores compared to pretreatment and placebo (P < 0.001) and was well tolerated. Topical opioids may be a viable adjunct to systemic analgesia in the care of patients with malignant wounds.

Adjunctive therapies

Palliative care of the patient with a malignant wound may include surgical debulking of fungating masses and/or resection of new nodules, or chemotherapy, radiotherapy, hyperthermia, and/or radiofrequency ablation for tumor shrinkage and pain control.50,68,69,70 Electrochemotherapy, a treatment in which the application of electric pulses to tumors facilitates penetration of topical chemotherapy, has been shown to have high efficacy at reducing or eliminating cutaneous tumors, while having minimal side effects.71,72,73 Topical chemotherapy regimens can also help to shrink the tumor and thus ease local care.74 Although these interventions will not cure patients of their advanced cancers, they may extend life, ease pain and bleeding, and improve quality of life. Patients with malignant wounds should be referred for these treatments if compatible with the palliative goals of care.

Promotion of patient and caregiver welfare through education

Dealing with a cancer diagnosis is traumatic enough without the added physical and psychological burden of a malignant wound.75 Lo et al.76 interviewed 10 patients with malignant fungating wounds to examine how this condition affected their lives. Central issues that negatively affected quality of life were pain, social isolation secondary to exudate and odor, and ignorance of both patients and healthcare providers regarding appropriate wound care. Piggin and Jones77 interviewed five women with malignant fungating wounds to gain an understanding of their lived experiences. Four central themes were found: the wound was the “worst part” of having cancer, there was “an overwhelming sense of vulnerability of living within a body that cannot be trusted,” they experienced “a changing relationship with family and friends” that was mainly related to unrelenting malodor and an unsightly wound, and had “a loss of identity while striving to be normal, yet feeling different.” Probst et al.78 conducted a similar study of nine women with malignant fungating wounds secondary to breast cancer. Key findings included the difficulty in dealing with the unpredictability of the wound, including odor, exudate, bleeding, and pain, and the embarrassment of having the wound, especially around family and when out in public. Similar findings have been published by other authors.79,80 Lo et al.81 measured quality of life in 70 subjects with malignant fungating wounds using the McGill Quality of Life (QOL) Questionnaire. Subjects had low QOL scores with their age, frequency of dressing change, pain, comfort of wound dressing, wound pain, bleeding and malodor negatively correlating with QOL at a statistically significant level. Probst et al.78 examined the caregiver experience of tending to loved ones with these wounds. Caregivers described “shock, disgust and nausea” when providing local care and highlighted their isolation and lack of knowledge in how to care for their loved ones. The main conclusions of these studies are that the key to improving quality of life for these patients is access to a wound care team or specialist who educates patients and caregivers on how to care for the wound with appropriate dressings and how to control exudate and odor. Education must also focus on the psychosocial aspects of having a malignant wound. As noted, patients may experience grief, anxiety, embarrassment, and stigma and may withdraw from loved ones.19 Caregivers may experience feelings of helplessness and fear about caring for the patient. The nurse can facilitate a trusting relationship with the patient and caregivers by reviewing the goals of care and by openly discussing issues that the patient may not have talked about with other providers. For example, it is helpful to acknowledge odor openly and then discuss how the odor will be managed. Attention to the cosmetic appearance of the wound with the dressing in place can assist the patient in dealing with body image disturbances. Use of soft flexible dressings that can fill a defect and protect clothing may help to restore symmetry and provide security for the patient.

Assisting the patient and the caregiver to cope with the distressing symptoms of the malignant wound such that odor and bleeding is managed, exudate is contained, and pain is alleviated will improve the quality of life for these patients and contribute to the goal of satisfactory psychological well-being. Education must include realistic goals for the wound. In these patients, the goal of complete wound healing is seldom achievable; however, quality of life can be maintained even as the wound degenerates. Continual education and reevaluation of the effectiveness of the treatment plan are essential to maintaining quality of life for those suffering from a malignant wound.

Fistulas

Definition

A fistula is an abnormal passage or opening between two or more body organs or spaces. The most frequently involved organs are the skin and either the bladder or the digestive tract, although fistulas can occur between many other body organs and/or spaces. Often, the organs involved and the location of the fistula in difficult anatomical areas or open abdominal wounds influence management methods and complicate care. For example, fistulas involving the small bowel and the vaginal vault and those involving the esophagus and skin create extreme challenges in care related to both the location and the organs involved in the fistula. Although spontaneous closure occurs in at least 50% of all enteric or small-bowel fistulas, the time required to achieve closure is 4 to 7 weeks, so long-term treatment plans are required for all patients with fistulas. Ninety percent of those fistulas that close spontaneously do so within the 4- to 7-week time frame.82 Therefore, if the fistula has not spontaneously closed with adequate medical treatment within 7 weeks, the goal of care may change to palliation, particularly if chances of closure are limited by other factors. Factors that inhibit fistula closure include complete disruption of bowel continuity, distal obstruction, presence of a foreign body in the fistula tract, an epithelium-lined tract contiguous with the skin, presence of cancer, previous radiation, and Crohn’s disease. The presence of any of these factors can be deleterious for spontaneous closure of a fistula. The goals of management for fistula care involve containment of effluent, management of odor, comfort, and protection of the surrounding skin and tissues.

Pathophysiology of fistula development

In cancer care, those with gastrointestinal cancers and those who have received irradiation to pelvic organs are at highest risk for fistula development. Fistula development occurs in 1% of patients with advanced malignancy.82 In most cases of advanced malignancy, the fistula develops in relation to either obstruction from the malignancy or irradiation side effects. Radiation therapy damages the vasculature and underlying structures. In cancer-related fistula development, management is almost always palliative. However, fistula development is not limited to patients with cancer.

In addition to cancer and radiation therapy, postsurgical adhesions, inflammatory bowel disease (Crohn’s disease), and small-bowel obstruction place an individual at high risk for fistula development. The number one cause of fistula development is postsurgical adhesions. Adhesions are scar tissues that cause fistula development by providing an obstructive process within the normal passageway. Enterocutaneous fistulas also arise as complications in 0.8%–2% of abdominal operations.83 The incidence of fistula development as a result of abdominal surgery has declined due to techniques of modern wound management using plastic barriers to protect exposed viscera and topical negative pressure on the soft tissues in open abdominal wounds.83,84,85,86 Further, the use of biological dressings like human acellular dermal matrix and fibrin glue to help seal the orifice of acute fistula has helped support early fistula closure.87,88,89 Unfortunately, once an enterocutaneous fistula develops, mortality remains 10%–30%.83 Those with inflammatory bowel disease—Crohn’s disease in particular—are prone to fistula development by virtue of the effects of the disease process on the bowel itself. Crohn’s disease often involves the perianal area, with fissures and fistulas being common findings. Because Crohn’s disease is a transmural disease, involving all layers of the bowel wall, patients are prone to fistula development. Crohn’s disease can occur anywhere along the entire gastrointestinal tract, and there is no known cure. Initially, the disease is managed medically with steroids, immunotherapy, and metronidazole for perianal disease. If medical management fails, the patient may be treated with surgical creation of a colostomy, to remove the portion of bowel affected by the disease. In later stages of disease, if medical and surgical management have failed, multiple fistulas may present clinically, and the goal for care becomes living with the fistulas and palliation of symptoms.

Other factors contributing to fistula development include the presence of a foreign body next to a suture line, tension on a suture line, improper suturing technique, distal obstruction, hematoma/abscess formation, tumor or additional disease in anastomotic sites, and inadequate blood supply. Each of these can contribute to fistula formation by promoting an abnormal passage between two body organs. Typically, the contributing factor provides a tract for easier evacuation of stool or urine along the tract rather than through the normal route. Such is the case with a foreign body next to the suture line and with hematoma or abscess formation. In some cases, the normal passageway is blocked, as with tumor growth or obstructive processes. Finally, in many cases, the pathology relates to inadequate tissue perfusion, as with tension on the suture line, improper suturing, and inadequate blood supply.

Fistula assessment

Assessment of the fistula involves assessment of the source, surrounding skin, output, and fluid and electrolyte status. Evaluation of the fistula source may involve diagnostic tests such as radiographs to determine the exact structures involved in the fistula tract. Assessment of the fistula source involves evaluation of fistula output, or effluent, for odor, color, consistency, pH, and amount. These characteristics provide clues to the origin of the output. Fistulas with highly odorous output are likely to originate in the colon or may be related to cancerous lesions. Fistula output with less odor may have a small-bowel origin. The color of fistula output also provides clues to the source: clear or white output is typical of esophageal fistulas, green output is usual of fistulas originating from the gastric area, and light brown or tan output may indicate small-bowel sources. Small-bowel output is typically thin and watery to thick and pasty in consistency, whereas colonic fistulas have output with a pasty to a soft consistency. The volume of output is often an indication of the source. For small-bowel fistulas, output is typically high, with volumes ranging from 500 to 3000 mL over 24 hours, for low-output and high-output fistulas, respectively. Esophageal fistula output may be as high as 1000 mL over 24 hours. Fistulas can be classified according to output, with those producing less than 500 mL over 24 hours classified as low output and those producing greater volumes classified as high output.82

The anatomical orifice location, proximity of the orifice to bony prominences, the regularity and stability of the surrounding skin, the number of fistula openings, and the level at which the fistula orifice exits onto the skin influence treatment options. Fistulas may be classified according to the organs involved and the location of the opening of the fistula orifice. Fistulas with openings from one internal body organ to another (e.g., from small bowel to bladder, from bladder to vagina) are internal fistulas; those with cutaneous involvement (e.g., small bowel to skin) are external fistulas.82

The location of the fistula often impedes containment of output. Skin integrity should be assessed for erythema, ulceration, maceration, or denudation from fistula output. Typically, the more caustic the fistula output, the more impaired the surrounding skin integrity. Multiple fistula tracts may also impede containment efforts.

Assessment of fluid and electrolyte balance is essential because of the risk of imbalance in both. In particular, the patient with a small-bowel fistula is at high risk for fluid volume deficit or dehydration and metabolic acidosis due to the loss of large volumes of alkaline small-bowel contents. Significant losses of sodium and potassium are common with small-bowel fistulas. Laboratory values should be monitored frequently. Evaluation for signs of fluid volume deficit is also recommended.

Fistula management

Wherever anatomically possible, the fistula should be managed with an ostomy pouching technique. The surrounding skin should be cleansed with warm water without soap or antiseptics; skin barrier paste should then be used to fill uneven skin surfaces, so that a flat surface is created to apply the pouch. Pediatric pouches are often smaller and more flexible and may be useful for hard-to-pouch areas where flexibility is needed, such as the neck for esophageal fistulas. The type of pouch should be chosen based on the output of the fistula. For example, if the fistula output is watery and thin, a pouch with a narrow spigot or tube for closure is chosen; in contrast, a fistula with a thick, pasty output would be better managed with a pouch with an open end and a closure clamp. Pouches must be emptied frequently, at least when one-third to one-half full. There are several wound drainage pouching systems on the market that allow for visualization and direct access to the fistula through a valve or door that can be opened and closed. These wound management pouches are available in large sizes and often work well for abdominal fistulas. Pouching of the fistula allows for odor control (many fistulas are quite malodorous), containment of output, and protection of the surrounding skin from damage. Gauze dressings with or without charcoal filters may be used if the output from the fistula is less than 250 mL over 24 hours and is not severely offensive in odor. Colostomy caps (small, closed-end pouches) can be useful for low-output fistulas that continue to be odorous.

There are specific pouching techniques that are useful in complex fistula management, including troughing, saddlebagging, and bridging. These techniques are particularly helpful when dealing with fistulas that occur in wounds, most commonly the small-bowel fistula that develops in the open abdominal wound. Troughing is useful for fistulas that occur in the posterior aspect of large abdominal wounds.90 The skin surrounding the wound and fistula should be lined with a skin barrier wafer and the edge nearest the wound sealed with skin barrier paste. Then, thin film dressings are applied over the top or anterior aspect of the wound, down to the fistula orifice and the posterior aspect of the wound. Finally, a cut-to-fit ostomy pouch is used to pouch the opening in the thin film dressing at the fistula orifice. Wound exudate drains from the anterior portion of the wound (under the thin film dressing) to the posterior portion of the wound and out into the ostomy pouch, along with fistula output. The trough technique does not prevent fistula output from contaminating the wound site.

The bridging technique prevents fistula output from contaminating the wound site and allows for a unique wound dressing to be applied to the wound site. Bridging is appropriate for fistulas that occur in the posterior aspect of large abdominal wounds, where it is important to contain fistula output away from the wound site. Using small pieces of skin barrier wafers, the clinician builds a “bridge” by consecutively layering the skin barriers together until the skin barrier has the appearance of a wedge or bridge and is the same height as the depth of the wound.82 With the use of a skin barrier paste, the skin barrier wedge is adhered to the wound bed (it does not harm the healthy tissues of the wound bed), next to the fistula opening. An ostomy pouch is then cut to fit the fistula opening, using the wedge or bridge as a portion of intact surrounding skin to adhere the pouch.82 The anterior aspect of the wound may then be dressed with the dressing of choice.

Saddlebagging is used for multiple fistulas, if it is important to keep the output from each fistula separated and the fistula orifices are close together. Two cut-to-fit ostomy pouches (or more for more fistulas) are used. The fistula openings are cut on the back of the pouch, off-center, or as far to the side as possible, and the second pouch is cut to fit the next fistula, off-center, or as far to the other side as possible. The skin is cleansed with warm water, and skin barrier paste is applied around the orifices. Ostomy pouches are applied and, where they contact each other (down the middle), they are affixed or adhered to each other in a “saddlebag” fashion. Multiple fistulas can also be managed with one ostomy pouching system that accommodates the multiple openings. Consultation with an enterostomal therapy (ET) nurse or ostomy nurse is extremely advantageous in these cases.

Another method of managing fistulas is by a closed suction wound drainage system. Jeter and colleagues91 described the use of a Jackson-Pratt drain and continuous low suction in fistula management. After the wound is cleansed with normal saline, the fenestrated Jackson-Pratt drain is placed in the wound, on top of a moistened gauze that has been opened up to line the wound bed (primary contact layer); a second fluffed wet gauze is placed over the drain, and the surrounding skin is prepared with a skin sealant. Next, the entire site is covered with a thin film dressing, which is crimped around the tube of the drain where it exits the wound. The tube exit site is filled with skin barrier paste, and the drain is connected to low continuous wall suction; the connection site may need to be adjusted and may require use of a small “Christmas tree” connector or device and tape to secure it. Jeter and colleagues91 advised changing the system every 3 to 5 days. Others have used a similar setup for pharyngocutaneous fistulas.92

Negative pressure wound therapy (NPWT) devices present an easier method of closed suction and have also been used for fistula management.83,84,85 In certain circumstances, NPWT may help to promote healing in wounds with an enteric fistula. Candidates must have a fistula that has been examined/explored, and the fistula opening must be readily visualized and accessible. The patient must be receiving nothing by mouth, on total parenteral nutrition with fistula effluent that is thin to viscous. In most cases, fistulas managed by NPWT occur in open abdominal wounds and use of NPWT assists with both fistula closure and wound healing.83,84,85 Use of NPWT in open abdominal wounds with fistula formation should be used with caution, as there have been reports of new fistula formation after wound closure and an associated high mortality rate in these cases.

Pouches to contain the fistula output usually assist in containing odor as well. If odor continues to be problematic with an intact pouching system, internal body deodorants such as bismuth subgallate, charcoal compositions, or peppermint oil may be helpful.93 Taking care to change the pouch in a well-ventilated room also helps with odor. If odor is caused by anaerobic bacteria, use of 400 mg metronidazole orally three times a day may be helpful. Management of high-output fistulas may be improved with administration of octreotide 300 mcg subcutaneously over 24 hours.82

Nutrition management and fluid and electrolyte maintenance are essential for adequate fistula care. Fluid and nutritional requirements may be greatly increased with fistulas, and there are difficulties with fistulas that involve the gastrointestinal system. As a general guideline, the intestinal system should be used whenever possible for nutritional support. If nutrition can bypass the fistula site, absorption and tolerance are better with use of the intestinal tract. For small-bowel fistulas, bypass of the fistula orifice is not always feasible. If the small-bowel fistula is located distally, enough of the intestinal tract may be available to adequately absorb nutrients before the fistula orifice is reached. If the fistula is located more proximally, there may not be enough intestinal tract available for nutrient absorption ahead of the fistula orifice. Many of these patients must be given intravenous hyperalimentation during the early stages of fistula management. The specific goals of fluid and electrolyte and nutritional support for fistula management must be discussed with the patient and family in view of the palliative nature of the overall care plan.

Patient and caregiver education

Patient and caregiver teaching first involves adequate assessment of the self-care ability of the patient and of the caregiver’s abilities. The patient and caregiver must be taught the management method for the fistula, including pouching techniques, how to empty the pouch, odor control methods, and strategies for increasing fluid and nutritional intake. Many of the pouching techniques used to manage fistulas are complicated and may require continual surveillance by an expert such as an ET nurse or ostomy nurse.

Palliative Stoma Care

The significance of palliative care for an individual with a stoma is to improve well-being during this critical time and to attain the best quality of life possible. In regard to the stoma, palliative care and is achieved by restoring the most efficient management plan and providing optimal functional capacity. It is essential to involve the family in the plan of care and to provide care to the extent of the patient’s wishes.

Management of the ostomy includes physical care as well as psychological and social care. To meet the needs of the patient and family, access to the multidisciplinary care team is crucial. This team may include the ET nurse, physicians such as the surgeon and oncologist, a nutritionist, and social service personnel. The urinary or fecal stoma can be managed (by the ET nurse) to incorporate the needs and goals of both the patient and the caregiver and to provide the highest quality of life possible.

Pathophysiology

A stoma is an artificial opening in the abdominal wall that is surgically created to allow urine or stool to be eliminated by an alternative route. The most common indications for the creation of a stoma are as follows:

  1. 1. Cancers that interfere with the normal function of the urinary or gastrointestinal system

  2. 2. Inflammatory bowel diseases such as Crohn’s or ulcerative colitis

  3. 3. Congenital diseases such as Hirschsprung’s disease or familial adenomatous polyposis

  4. 4. Trauma

In planning the care of an individual with a stoma, it is necessary to understand the type of ostomy that was created, including the contents that will be eliminated.

Types of diversion

The three types of diversion created with a stoma as the outlet for urine or stool are the ileoconduit (urinary output), the ileostomy (fecal output), and the colostomy (fecal output). Construction of any of these diversions requires the person to wear an external appliance to collect the output.

Ileoconduit

Since the early 1950s, the Bricker ileoconduit has been the primary method for diverting urinary flow in the absence of bladder function. This procedure involves isolation of a section of the terminal ileum. The proximal end is closed, and the distal end is brought out through an opening in the abdominal wall at a site selected before surgery. The ileal segment is sutured to the skin, creating a stoma. The ureters are implanted into the ileal segment, urine flows into the conduit, and peristalsis propels the urine out through the stoma. An external appliance is worn to collect the urine; it is emptied when the pouch is one-third to one-half full, or approximately every 4 hours.

Ileostomy

The ileostomy is created to divert stool away from the large intestine, typically using the terminal ileum. The stoma is created by bringing the distal end of the ileum through an opening surgically created in the abdominal wall and suturing it to the skin. The output is usually a soft, unformed to semiformed stool. Approximately 600 to 800 mL/day is eliminated. An external appliance is worn to collect the fecal material; it is emptied when the bag is one-third to one-half full, usually four to six times per day.

An ileostomy may be temporary or permanent. A temporary ileostomy usually is created when the colon needs time to heal or rest, such as after colon surgery or a colon obstruction. A permanent ileostomy is necessary if the entire colon, rectum, and anus has been surgically removed, such as in colorectal cancer or Crohn’s disease.93

Colostomy

The colostomy is created proximal to the affected segment of the colon or rectum. A colostomy may be temporary or permanent. There are three sections of the colon: the ascending, transverse, and descending colon. The section of colon used to create the stoma determines in part the location and the consistency of output, which may affect the nutritional and hydration status of the individual at critical times. The ascending colon stoma usually is created on the right midquadrant of the abdomen, and the output is a semiformed stool. The transverse stoma is created in the upper quadrants and is the largest stoma created; the output is usually a semiformed to formed stool. The descending colon stoma most closely mirrors the activity of normal bowel function; it usually is located in the lower left quadrant.

The stoma is created by bringing the distal end of the colon through an opening surgically created in the abdominal wall and suturing it to the skin. An external appliance is worn to collect the fecal material; it is emptied when the bag is one-third to one-half full, usually one or two times per day. A second option for management is irrigation, to regulate the bowel. The patient is taught to instill 600 to 1000 mL of lukewarm tap water through the stoma, using a cone-shaped irrigation apparatus. This creates bowel distention, stimulating peristaltic activity and therefore elimination within 30 to 45 minutes. Repetition of this process over time induces bowel dependence on the stimulus, reducing the spillage of stool between irrigations. The elimination process after initial evacuation is suppressed for 24 to 48 hours.94,95

Assessment

Stoma characteristics

Viability of the stoma is assessed by its color. This should be checked regularly, especially in the early postoperative period. Normal color of the stoma is deep pink to deep red. The intestinal stomal tissue can be compared with the mucosal lining of the mouth. The stoma may bleed when rubbed because of the capillaries at the surface. Bleeding that occurs spontaneously or excessively from stoma trauma can usually be managed by the application of pressure. Bleeding that persists or that originates from the bowel requires prompt investigation, with the management plan based on the cause of the bleeding and the overall status of the individual.94,95

A stoma with a dusky appearance ranging from purple to black, or a necrotic appearance, indicates impairment of circulation and should be reported to the surgeon. A necrotic stoma may develop from abdominal distention that causes tension on the mesentery, from twisting of the intestine at the time of surgery, or from arterial or venous insufficiency. Necrotic tissue below the level of the fascia indicates infarction and potential intra-abdominal urine or stool leakage. Prompt recognition and surgical reexploration are necessary.

Stoma edema is normal in the early postoperative period as a result of surgical manipulation. This should not interfere with stoma functioning, but a larger opening will need to be cut in the appliance to prevent pressure or constriction of the stoma. Most stomas decrease by 4 to 6 weeks after surgery, with minor changes over 1 year. Teaching the individual to continue to measure the stoma with each change of appliance should alleviate the problem of wearing an appliance with an aperture too large for the stoma. The stoma needs only a space one-eighth of an inch in diameter to allow for expansion during peristalsis.

Stoma herniation occurs when the bowel moves through the muscle defect created at the time of stoma formation and into the subcutaneous tissue. The hernia usually reduces spontaneously when the patient lies in a supine position, as a result of decreased intra-abdominal pressure. Problems associated with the formation of a peristomal hernia are increased difficulty with ostomy pouch adherence and possible bowel strangulation and obstruction. The peristomal hernia may be managed conservatively with the use of a peristomal hernia belt to maintain a reduction of the hernia. The belt is an abdominal binder with an opening to allow for the stoma and pouch. The belt is applied with the patient in a supine position, while the hernia is reduced, creating an external pressure that maintains the bowel in a reduced position. Aggressive treatment includes surgical intervention for correction of the peristomal hernia. However, this is usually reserved for emergency situations, such as obstruction or strangulation of the bowel. Colostomy patients who irrigate should be taught to irrigate with the hernia in a reduced position, to prevent perforation of the bowel.

Stoma prolapse occurs as a result of a weakened abdominal wall caused by abdominal distention, formation of a loop stoma, or a large aperture in the abdominal wall. The prolapse is a telescoping of the intestine through the stoma. Stoma prolapse may be managed by conservative or surgical intervention. Surgical intervention is required if there is bowel ischemia, bowel obstruction, or prolapse of excessive length and unreducible segment of bowel. Conservative management includes reducing the stoma while in a supine position to decrease the intra-abdominal pressure, then applying continuous gentle pressure at the distal portion of the prolapse until the stoma returns to skin level. If the stoma is edematous, cold soaks or a hypertonic solution such as salt or sugar is applied to reduce the edema before stoma reduction is attempted. Once the stoma is reduced, a support binder is applied to prevent recurrence. In most cases, it is necessary to alter the pouching system by including a two-piece appliance and cutting the barrier size opening larger to accommodate changes in stoma size.

Retraction of the stoma below skin level can occur in the early postoperative period due to tension on the bowel or mesentery or related to breakdown at the mucocutaneous junction. Late retraction usually occurs as a result of tension on the bowel from abdominal distention, most likely as a result of intraperitoneal tumor growth or ascites. Stomal retraction is managed by modification of the pouching system—for example, by using a convex appliance to accommodate changes in skin contour. Stomas that retract below the fascia level require prompt surgical intervention.

Stenosis of the stoma can occur at the skin level or at the level of the fascia. Stenosis that interferes with normal bowel elimination requires intervention. Signs and symptoms of stenosis include change in bowel habits (e.g., decreased output, thin-caliber stools), abdominal cramping, abdominal distention, flank pain from urinary stomas, and nausea or vomiting. The stenotic area may be managed conservatively by dilatation or may require surgical intervention by local excision or laparotomy.94,95 Many of the stoma problems discussed can occur from simple stretching and displacement of normal organs due to bulky tumors, as might occur in the end stages of some disease states.

Peristomal skin problems

Peristomal skin complications commonly include mechanical breakdown, chemical breakdown, rash, and allergic reaction. Mechanical breakdown is caused by trauma to the epidermal skin layer. This is most often related to frequent appliance changes that cause shearing or tearing to the epidermal skin. The result is denuded skin or erythematous, raw, moist, and painful skin. The use of pectin-based powder with or without a light coating of skin sealant aids in healing and protecting the skin from further damage, while allowing appliance adherence.

Chemical breakdown is caused by prolonged contact of urine or fecal effluent with the peristomal skin. Inappropriate use of adhesive skin solvents may also result in skin breakdown. The result of chemical breakdown is denudation of the peristomal skin that has been exposed to the caustic effects of the stool, urine, or adhesive solvents. Prompt recognition and management are essential. Modification of the pouching system, such as using a convex wafer instead of a flat wafer or adding protective skin products such as a paste (or both), can be used to correct the underlying problem. Instructing patients and caregivers to thoroughly cleanse the skin with plain water after using the skin solvent can eliminate the problem of denuded skin. Treatment of denuded skin is the same as described previously.

A peristomal fungal rash can occur as a result of excessive moisture or antibiotic administration that results in overgrowth of yeast in the bowel or, at the skin level, due to perspiration under a pouch or leakage of urine or stool under the barrier. The rash is characterized as having a macular, red border with a moist, red to yellow center; it is usually pruritic. Application of antifungal powder, such as nystatin powder, to the affected areas usually produces a prompt response. Blotting the powder with skin preparation or sealant may allow the pouching system to adhere more effectively.

Allergic reactions are most often caused by the barrier and tape used for the pouching system. Erythematous vesicles and pruritus characterize the area involved. Management includes removal of the offending agent. The distribution of the reaction can usually aid in defining the allergen. It may be necessary to perform skin testing if the causative agent is not clear. Patients with sensitive skin and those who use multiple products may respond to simple pouching techniques such as using water to clean the skin, patting the skin dry, and applying the wafer and pouch without the use of skin preparations. Changing to products from a different manufacturer may also eliminate the allergen. A nonadhesive pouching system may be used temporarily for patients with severe blistering and hypersensitivity, to allow healing and prevent further peristomal skin damage. Patients with severe blistering and pruritus may also require temporary use of systemic or topical antihistamines or corticosteriods.94,95

Principles and products for pouching a stoma

The continuous outflow of urine or stool from the stoma requires the individual to wear an external appliance at all times. Ideally, the stoma protrudes one-half to three-fourths of an inch above the skin surface, to allow the urine or stool to drain efficiently into a pouch.95 The objective of stoma management is to protect the peristomal skin, contain output, and control odor.

The skin around the stoma should be cleaned and thoroughly dried before the appliance is positioned over the stoma. An effective pouch should adhere for at least 3 days, although this is not always possible. If no leakage occurs, the same pouch may remain adhered to the skin for up to 10 days. It should then be changed for hygienic reasons and to observe the peristomal area. Today, there is an ever-changing supply of new appliances. Materials and design are being updated rapidly to provide the consumer with the best protection and easiest care.96 Factors to consider when choosing a pouch include the consistency and type of effluent, the contour of the abdomen, the size and shape of the stoma, and the extent of protrusion, as a well as patient preferences.

Pouching systems are available as one-piece or two-piece systems. The one-piece system is constructed with the odor-proof pouch joined to a barrier ring that adheres to the skin. The barrier can be precut to the size of the stoma, or it can be customized with a cut-to-fit barrier. A two-piece system usually consists of an individual barrier with a flange ring and an odor-proof pouch, which attach (snap) together by matching the ring size of the barrier and pouch. The pouch barrier may be flat or convex and is chosen based on the contour of the abdomen and the extent of stoma protrusion. The colostomy pouch maybe closed-ended or open-ended with a clip for closure. Some individuals choose to clean the pouch daily. The pouch of the one-piece system can be cleaned by instilling water into the pouch (with a syringe or turkey baster) and rinsing while preventing the water from reaching the stoma area. The pouch of the two-piece system can be cleaned daily by detaching and washing it in the sink with soap and water and drying it before reattaching it to the barrier.

The urinary pouch has a spout opening to allow for controlled emptying of the pouch. This end may also be attached to a bedside bag or bottle to collect urine. It typically holds up to 2000 mL of urine. The urinary system can be easily disassembled and cleaned with soap and water. After cleaning, a vinegar-and-water solution should be rinsed through the tubing and bag/bottle to prevent urine crystallization.

Skin barriers, skin sealants, powders such as Stomahesive powder or karaya powder, and pastes such as Stomahesive paste or karaya paste are available to protect the peristomal skin from the caustic affects of urine or stool. These products may also be used to aid in the healing of peristomal skin problems.

Belts and binders are available to assist in maintaining pouch adherence and for management of certain stoma problems.95 Table 17B.3 presents an overview of pouching options for patients with fecal or urinary diversions.

Table 17B.3 Pouch options

Type

Barrier

Odor-proof pouch

1-piece

Flat

Open end with clip (ileostomy with colostomy)

2-piece

Convex

Closed end (colostomy)

Cut-to-fit precut

Spout opening (urostomy)

Interventions

Prevention of complications

Stoma surgery performed as a palliative measure is not intended to provide a cure but, rather, to alleviate difficulties such as obstruction, pain, or severe incontinence. Unfortunately, at a difficult time in patients’ and families’ lives, the created stoma disrupts normal physical appearance, normal elimination of urine or stool, and control of elimination with, in some cases, loss of body parts and/or sexual function. The patient then has to learn to care for the stoma or allow someone else to care for them. Physically and psychologically, the patient has to come to terms with the presence of the stoma, its function, and care. This takes time and energy to cope emotionally, physically, and socially.94,97

Educating the patient and family regarding management issues related to ostomy care and palliation could assist in the physical and psychological adaptation to the ostomy. Additional therapies that may be required for treatment of the underlying disease or a new disease process, such as progressed or recurrent cancer, may affect the activity of the stoma or the peristomal skin. Additional therapies may include chemotherapy, radiation therapy, or analgesics for pain management.

Chemotherapy and radiation therapy may affect a fecal stoma by causing diarrhea. Associated symptoms include abdominal discomfort, larger quantities of loose or liquid stool produced per day, and potential dehydration and loss of appetite with prolonged diarrhea. The ostomy bag requires more frequent emptying, and the ostomy pouch seal needs to be monitored more closely for leakage. In addition, radiation therapy that includes the stoma in the radiation field can cause peristomal skin irritation, particularly redness and maceration. The effects on the peristomal skin may be exacerbated by leakage of urine or stool, as described earlier.94

Analgesic use may result in constipation and ultimately bowel obstruction. It is necessary to coadminister stool softeners or laxatives for the prevention of constipation. Irrigation of the colostomy may also assist in treating constipation. The patient and family need to be instructed regarding these measures so that they can be used to treat and prevent constipation. The patient and family need to be aware that adequate pain relief and prevention of constipation can be achieved.94,97

Patients may become very tired or may experience anxiety, nausea, or pain as a result of their condition and palliative management. Patients often want to remain as independent as possible but may allow assistance from family and staff. For example, the patient may want to perform the actual pouch change but allow someone else to gather and prepare the supplies. This allows for conservation of energy during part of the task to be accomplished. The patient may also choose the time of day to perform such tasks—when he or she has the most energy and maximal pain and nausea control.96

Nutrition and hydration

Anorexia and dehydration can be major problems for the patient with advancing disease or disease-related treatments such as chemotherapy and radiation therapy. Compromised ingestion, digestion, and absorption can have major influences on nutritional and hydration status.

Anorexia is the loss of appetite resulting from changes in gastrointestinal function, including changes in taste, changes in metabolism, psychological behaviors, and the effects of disease and treatment. Decreased oral intake and changes in metabolism, including decreased protein and fat metabolism, increased energy expenditure, and increased carbohydrate consumption, result in loss of muscle mass, loss of fat stores, and fatigue, leading to weight loss and malnutrition.98

Managing the underlying cause of poor nutritional and hydration status, such as controlling the cancer or disease, treating an infection, or slowing down the high-volume ileostomy output, can improve the nutritional state. However, despite effective treatment, other assistance may be necessary, such as small and more frequent meals, nutritional liquid supplements, appetite stimulants (e.g., megestrol acetate), corticosteroids, and parenteral or enteral support.99 Foods and drinks need to be appealing to the patient. Strong odors and large-portion meals may result in appetite suppression. Promoting comfort before meals may also increase appetite; this may include administering antiemetics or analgesics, oral care, or resting for 30 minutes before mealtime.99

Management issues

Controlling odor, reducing gas, and preventing or managing diarrhea or constipation are management issues related to patients with a colostomy. Odor can be controlled by ensuring that the pouch seal is tight, that odor-proof pouches are used, and that a clean pouch opening is maintained. In addition, deodorants such as bismuth subgallate or chlorophyllin copper complex may be taken orally. Gas can be reduced by decreasing intake of gas-producing foods such as broccoli, cabbage, beans, and beer. Peppermint or chamomile tea may be effective in gas reduction.94,97

Diarrhea can be managed as in a patient with an intact rectum and anus. Diarrhea may be a result of viral illness or use of a chemotherapeutic agent. Management includes increased fluid intake, a low-fiber and low-fat diet, and administration of antidiarrhea medications such as loperamide (Imodium), bismuth subsalicylate (Pepto-Bismol), or diphenoxylate plus atropine (Lomotil) by prescription.95,100 If the patient irrigates, it is necessary to hold irrigation until formed stools return. Constipation more commonly occurs in patients with advanced malignancies due to the affects of analgesic use, reduced activity level, and reduced dietary fiber intake. Management of constipation includes administration of laxatives such as milk of magnesia, mineral oil, or lactulose and initiation of a plan for prevention of constipation with use of stool softeners and laxatives as needed. Cleansing irrigation may be necessary for patients who normally do not irrigate. Cleansing irrigation is performed as described previously for individuals with a colostomy who irrigate for control of bowel movements.95

Skin protection, fluid and electrolyte maintenance, prevention of blockage, and modification of medications are management issues related to an ileostomy. Because of the high-volume liquid or loose stools, protecting the skin from this effluent is critical. Leakage of effluent can cause chemical skin breakdown and pain from the irritated skin. The ET nurse can work with the patient and family to determine the cause of the effluent leak. It may be necessary to modify the pouching system, to ensure a proper fit. The peristomal skin may need to be treated with a powder or skin sealant, or both, to aid in healing. The transit time of food and wastes through the gastrointestinal system and out through the ileostomy is rapid and potentially contributes to dehydration and fluid and electrolyte imbalance. Ensuring adequate fluid and electrolyte intake is essential and may be accomplished by ingestion of sports drinks or nutrition shakes. Patients with an ileostomy are instructed to include fiber in their diet, to bulk stools and promote absorption of nutrition and medications.

Food blockage occurs when undigested food particles or medications partially or completely obstruct the stoma outlet at the fascia level. It is necessary to instruct the patient and family about the signs of a blockage, including malodorous, high-volume liquid output or no output accompanied by abdominal cramping, distention, and/or nausea and vomiting. These symptoms should be reported as soon as they occur. Blockage is resolved by lavage or mini-irrigation performed by the physician or ET nurse. A catheter is gently inserted into the stoma until the blockage is reached, 30 to 60 mL of normal saline is instilled, and the catheter is removed to allow for the return. This process is repeated until the blockage has resolved. Patient teaching should be reinforced regarding the need to chew food well before swallowing, to prevent food blockage. Timed-release tablets and enteric-coated medications should be avoided because of inadequate or unpredictable absorption. Medications often come in various forms, including liquid, noncoated, patch, rectal suppository, and subcutaneous or intravenous administration. Choosing the most appropriate route that provides the greatest efficacy for the individual is essential. For example, a transdermal patch may be used for analgesia instead of a timed-release pain tablet. For patients who have an intact rectum that is no longer in continuity with the proximal bowel, rectal administration of medications is effective.95

Management issues for an individual with an ileoconduit include prevention of a urinary tract infection, stone formation, peristomal skin protection, and odor control. Each of these issues is preventable by the maintenance of dilute and acidic urine through adequate fluid intake (1800 to 2400 mL/day). Vitamin C (500 to 1000 mg/day) and citrus fruits and drinks may assist in accomplishing acidic urine. Alkaline urine can cause encrustations on the stoma and peristomal skin damage with prolonged exposure. Acetic acid soaks may be applied three or four times per day to treat the encrustations until they dissolve. Adjustments in the pouching system may be necessary to prevent leakage of urine onto the skin, and the temporary addition of powder, paste, skin sealant, or some combination of these products may be needed to aid healing of the affected skin.95

Case study

Wound care in a woman with breast cancer and a fungating ulcerative lesion of her chest

A 64-year-old woman was referred to the wound clinic for assessment and management of wounds on the left anterior chest wall, shoulder, upper arm, and upper abdomen. She had a history of a left modified radical mastectomy for breast cancer, followed by local radiation therapy and chemotherapy 6 years prior. About 2 years prior to being referred to the wound clinic, she developed painless nodules on the left anterior chest. Biopsy revealed a local recurrence of breast cancer. She was started on a course of chemotherapy, but despite this, the lesions spread to her upper abdomen and left shoulder and upper arm. The left anterior chest wall eventually ulcerated and drained. Her main complaints to the nurse practitioner (NP) were exudate that leaked through her clothing during the day and her nightgown at night, and odor. She said that she had stopped meeting her girlfriends for their weekly lunch because of her embarrassment over this. She shared that she was quite disgusted by the lesions and was very afraid to touch them, so she would just lightly dab them with water to clean them and would cover the chest wounds with gauze in her bra, and tape gauze over the lesions on her abdomen. The nodules on the shoulder and upper arm were not draining, and she questioned whether or not she could have these surgically removed.

Assessment revealed a 12 × 8 cm irregularly shaped ulcerative lesion on the left chest wall with fungating tissue along the wound edges that was mildly friable. There was a moderate amount of serous exudate from this wound and mild to moderate odor. Surrounding skin was thin, mildly erythematous, and fragile. There were multiple nodules, some of which were coalesced, on her upper abdomen. Some had dry crust on their surface, but no apparent exudate. There were a few isolated, nondraining nodules on her left shoulder and upper arm.

She had continuous aching, vise-like pain in the left chest wall, which she rated a 5–8 on a scale of 0–10. She only used acetaminophen for this, strongly refusing to take narcotics, stating that she did not want to get “hooked on drugs.” Her husband, who accompanied her, was very concerned about his wife’s uncontrolled pain, and he stated that he was available to help in any way that he could.

Goals of care included exudate and odor control, and pain management. A long discussion about palliative goals of care was undertaken. The nurse practitioner concentrated on what could be done (exudate, odor, pain control) versus what could not be offered (permanent cure). The hope for quality of life with return to her social activities (which the patient stated she desired) was promoted. The patient’s fears about touching the wound were also explored. With the NP’s confidence that the patient could learn how to take care of the wound, she agreed to try. The patient was instructed regarding daily care:

  1. 1. Spray wound/incontinence cleanser on ulcerative wound and on surrounding skin.

  2. 2. Stand in shower and allow water to hit the skin above the wound and rinse over it.

  3. 3. Pat area dry with clean towel or paper towels or gauze.

  4. 4. Apply thin coat (the thinness of a dime) of metronidazole gel to the ulcerative wound on the chest.

  5. 5. Cover wound edges with petrolatum-impregnated contact layer (Adaptic)

  6. 6. Cover wound area with two large ABD pads and secure with boy’s-size tank top (this ended up being more comfortable than the bra). Small squares of paper tape were applied to a few areas of the ABD pad that contacted healthy skin.

  7. 7. Cover crusted abdominal lesions with ABD pad to protect from friction from clothing, and secure with paper tape.

  8. 8. No dressings were needed on the shoulder nodules, and the patient preferred not to cover them with dressings. If she had preferred coverage, soft gauze or an ABD pad could have been used.

The NP, patient, and husband had a long philosophical discussion about use of narcotics for pain management. The benefits of adequate pain management were discussed including the ability to enjoy activities, sleep better, and generally feel better. Misconceptions about opiate addiction versus dependence were cleared up and the patient agreed to try some hydrocodone with acetaminophen, 5/500, 1–2 tabs every 4 hours as needed for pain.

The NP believed that it was entirely reasonable for the patient to have the discreet nodules on the left shoulder and upper arm removed. The patient was instructed that they might or might not return. She was referred back to her surgeon, who removed them, sutured the skin together, and she healed uneventfully.

The patient returned to the wound clinic 2 weeks later for a recheck. She was in better spirits and reported a complete cessation in the odor, good control of exudate, and much better pain control. She actually had plans to meet her friends for lunch, and because she was still concerned about exudate leakage, it was suggested that she use unscented menstrual pads over the chest wound instead of the ABD pads. She was grateful that the NP had “nagged” her about the pain management and acknowledged that she was sleeping better and feeling more rested. She appeared to have more hope that she could have some good quality of life.

She was seen every month thereafter. At one point, her odor was so well controlled that she stopped the metronidazole gel and just used the skin cleanser with daily showers. This resulted in satisfactory odor control. She eventually started long-acting morphine for pain, and this led to a significant improvement in overall comfort.

The ulcer on the chest eventually eroded so that a rib was exposed. Six months after treatment started in the wound clinic, she had an episode of significant bleeding from the wound, which could not be stopped. She was sent to interventional radiology and underwent successful intra-arterial embolization of the artery feeding the tumor in her chest wall. At her next wound clinic visit, she was very afraid of further bleeding, and did complain of mild oozing from the wound edges. She and her husband were reassured and given written and verbal instructions regarding a stepwise approach for local control of bleeding:

  1. 1. Rest in a reclined position with the chest elevated.

  2. 2. Apply local pressure with water-moistened gauze for 10–15 minutes.

  3. 3. If still bleeding, apply collagen/oxidized regenerated cellulose dressing (Promogran) to the area and hold pressure for 15 minutes.

  4. 4. If still bleeding, apply ice packs for 15–20 minutes.

  5. 5. May spot-treat bleeding areas with silver nitrate (the husband was competent to do this).

  6. 6. Contact wound clinic if these measures fail.

  7. 7. For severe bleeding, go to ER (this was compatible with the patient’s wishes as she still wanted aggressive care).

Thereafter, the patient had mild episodes of bleeding but reported that she and her husband felt confident in their ability to control this with the instructions provided.

Although she did slow down in her remaining months, she remained fairly active until a week before her death, which occurred 11 months after first being seen at the wound clinic. She finally accepted hospice, and was able to die at home with her loved ones at her side. Her husband later called the NP and thanked her for helping them to cope with the wounds, stating that just knowing how to take care of them and what to expect had decreased their stress significantly and helped his wife have some quality and happiness in her last year of life.

Summary

Skin disorders are both emotionally and physically challenging for patients and caregivers. Cutaneous symptoms may be the result of disease progression (e.g., malignant wounds, fistula development), complications associated with end-stage disease or the end of life (e.g., pressure ulcers), or simple changes in function of urinary or fecal diversions. All cutaneous symptoms require attention to basic care issues, creativity in management strategies, and thoughtful attention to the psychosocial implications of cutaneous manifestations. Palliative care intervention strategies for skin disorders reflect an approach similar to those for nonpalliative care. Although the goals of care do not include curing the condition, they always include alleviating the distressing symptomology and improving quality of life. The most distressing symptoms associated with skin disorders are odor, exudate, and pain. The importance of attention to skin disorders for palliative care is related to the major effect of these conditions on the quality of life and general psychological well-being of the patient.

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