education

Malignant fungating wounds: managing pain, bleeding and psychosocial issues

Management of these non-healing wounds typically involves practices that diverge from those used in other settings. The nal article of this four-part series explores the holistic approach required in dealing with the complex symptoms
pain; bleeding; psychosocial issues; non-healing wound; management; malodour
S. Alexander, Bachelor of Health (Nursing) (Hons), RN, MRCNA, Researcher, CQ University, Bundaberg, Australia. Email: s.alexander@cqu. edu.au

his is the fourth and nal part of a series of articles summarising the available literature on malignant wounds. The epidemiology, aetiology, presentation and assessment of these wounds were explored in the rst article,1 and the proceeding article looked at key symptoms and their psychosocial effects.2 This article discusses how these psychosocial effects can be managed, and also explores the management of pain and bleeding. The management of malodour and exudate were covered in the third article.3 As in the previous articles, this fourth part takes a holistic approach to the literature, which practitioners can use to inform their decisions when caring for people with these devastating wounds.

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

Pain
Pain is a signicant aspect of many malignant wounds and practitioners must have a sound understanding of its causes and impact to ensure that management strategies are appropriate. In particular, the concept of total pain is important when assessing and managing pain; this recognises that the total pain experience is affected by all dimensions of a patients existence, rather than the physical sensation related to tissue pathology alone.14-16 An example of the impact of contributory factors was described in part two of this series,2 in which a case study found a decrease in pain scores recorded by participants once the malodour associated with their wounds had been resolved.17 Consequently, the management team will need to assess what other factors might also be contributing to the pain experience.

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

Managing pain
In keeping with all aspects of the management of malignant wounds, developing an individualised pain management protocol is crucial and must be based on a comprehensive assessment.14,15,18 The World Health Organisation (WHO) guidelines for the control of cancer pain provide a sound starting point for developing a protocol for physical pain management.19 The possibility that the doses of analgesia sufcient to manage pain can adversely affect mental and cognitive functions should also be explained to the patient. This conversation will provide the patient with the opportunity to express her/his preferences and assist the clinician to achieve the appropriate balance in accordance with the patients wishes.20
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Management
Part three of the series discussed the general principles of management of malignant wounds.3 It was noted that an individualised and multi-faceted approach provided through a multidisciplinary team is considered best practice, given the unique and complex nature of these wounds.7-8 The typical non-healing status of malignant wounds generally requires a focus on management of the wound and
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Attention should also be paid to the dressing regimen which may be contributing to the patients pain experience. Pain during dressing changes can be reduced through pre-medication with short-acting opioids,9 but care should be taken to ensure they are administered in sufcient time before the procedure to enable maximum effectiveness. Pain may also be reduced through the use of appropriate dressings, including non-adherent dressings and those that facilitate a moisture balanced wound healing environment and may be left in situ for longer periods.9

Topical analgesia
A small number of articles that discussed the use of topical analgesia in chronic wound management have included malignant wounds21,22 but the evidence is still minimal. Accordingly, ndings of other studies investigating the use of topical analgesia in chronic wound management have been included in this review. With careful extrapolation, these supplementary ndings may bolster the evidence currently available on the use of topical analgesia in malignant wounds. Some authors have reported empirical success in the use of topical opioids (diamorphine, morphine, meperidine or oxycodone in a carrier gel), to alleviate pain in chronic wounds both during dressing changes and in the intervening periods.23-27 Recommendations included a composition of 0.1% w/w (weight for weight) which would equal 1mg morphine to 1g hydrogel;28 or 20mg of diamorphine in 30g of hydrogel.29 Other authors discussed the use of a 2.75% topical lidocaine cream prepared by blending one 454g jar of zinc oxide cream with 35.44g of lidocaine 5% ointment.18 There have also been reports on the successful blending of diamorphine with metronidazole gel to alleviate infection, pain and malodour.26,30 Three patients with malignant wounds were included in one small (n=16) crossover, randomised controlled trial (RCT) of topical analgesia on chronic wounds.22 It is not possible to comment on the adequacy of methodological processes because the reporting of this trial was brief and the trial was halted early for administrative reasons. However, the researchers reported their preliminary ndings in the hope that they would be informative for practitioners. Patients in the study arm (morphine in Intrasite gel, Smith & Nephew) reported signicantly lower pain scores compared with pre-treatment and the control arm. The authors reported that the topical morphine appeared to be safe and well tolerated by participants. They acknowledged the limitations of their study, particularly the small sample size, and recommended that further research be conducted. One potential advantage of topical analgesia is the possible reduction or elimination of systemic
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References
1 Alexander, S. Malignant fungating wounds: epidemiology, aetiology, presentation and assessment. J Wound Care 2009; 18: 7, 273-280. 2 Alexander, S. Malignant fungating wounds: key symptoms and psychosocial issues. J Wound Care 2009; 18: 8, 325-329. 3 Alexander, S. Malignant fungating wounds: managing malodour and exudate. J Wound Care 2009; 18: 9, 374-382. 4 Wilkes, L., White, K., Smeal, T., Beale, B. Malignant wound management: what dressings do nurses use? Journal of Wound Care 2001; 10; 3, 65-69. 5 Noblet, M. Assessment of a fungating breast wound. Practice Nursing 2008; 19; 6, 282, 284-286. 6 Lazelle-Ali, C. Psychological and physical care of malodorous fungating wounds. Br J Nurs 2007; 16; 15, S16, S18, S20, S22, S24. 7 Wilkes, L., Boxer, E., White, K. The hidden side of nursing: why caring for patients with malignant malodorous wounds is so difcult. J Wound Care 2003; 12; 2, 76-80. 8 Grocott, P. Care of patients with fungating malignant wounds. Nurs Standard 2007; 21; 24, 57-66. 9 Naylor, W. A guide to wound management in palliative care. Int J Palliat Nurs 2005; 11; 11, 572-579. 10 Wollina, U., Liebold, K., Konrad, H. Topical treatment for malignant wounds. Eur J Geriatr, 2001; 3; 3, 118-121. 11 Grocott, P. A Review of Advances in Fungating Wound Management since EWMA 1991. EWMA J 2002; 2; 1, 21-24. 12 Adderley, U., Smith, R. Topical agents and dressings for fungating wounds. Cochrane Database Syst Rev 2007; 2: CD003948. 13 Grocott, P., Browne, N., Cowley, S. Quality of life: assessing the impact and benets of care to patients with fungating wounds. Wounds 2005; 17; 1, 8-15. 14 Naylor, W. Assessment and management of pain in fungating wounds. Br J Nurs 2001; 10: 22, S33-S56.

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

Non-pharmacological pain relief

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

Histamine receptor blockers (doxepin) Hydroxyzine Ondanestron.8,30,33-37 The majority of these articles provided only generic information on the aetiologies and treatment of pruritus; however, two articles also provided anecdotal information on the successful treatment of pruritus in malignant wounds. Grocott provided an anecdotal report on the use of TENS to relieve pruritus in a malignant wound30 and Holme et al. reported the success of a number of interventions in a case study of a patient with cutaneous metastases from breast carcinoma.35 Of the interventions trialled by Holmes et al, TENS was successful but was impractical due to the limited amount of unaffected skin. Greater relief was achieved through twice-weekly doses of narrowband ultraviolet B phototherapy concurrent with topical Crotamiton 10% cream (Eurax, Novartis) in a hydrogel carrier.35

Bleeding
Protection of the fragile tissue surrounding the blood vessels is vitally important in malignant wound management and includes gentle techniques during dressing changes to prevent trauma. If a dressing has adhered to the wound, it must be soaked to facilitate easy removal, and consideration must then be given to reviewing the dressing regimen. Where cleansing of the wound is considered necessary, it should be done gently with warmed normal saline to avoid further trauma to the fragile peri-wound tissue.38 Some authors recommended the use of an 1820 gauge angiocath on a 3060ml syringe to create a pressure of 815 pounds per square inch (psi) which will effectively clean the wound without causing further trauma.32,39 Although rarely mentioned in the malignant wound literature, careful use of sodium chlorine ampoules or aerosols may also be helpful in irrigating the wound40 as it is possible to vary the delivery pressure to suit wound conditions. In addition, this method is less expensive and requires less equipment than the syringe method.41,42 Much of the literature on bleeding events in malignant wounds is prescriptive in nature, and suggests what interventions might be appropriate. However, very little is based on empirical evidence of interventions. Some of these suggestions which might be helpful, depending on individual circumstances, are discussed below.

Treatment of pruritis
Although not strictly categorised as painful, pruritus is capable of causing discomfort to such an extent that some authors have recommended that it deserves the same degree of attention as pain.33 The unpleasant itch associated with pruritus may be widespread or restricted to certain areas and can be caused by a variety of pathogenicities, ranging from dehydrated skin to the complex array of factors present in uraemia. In the absence of broad spectrum anti-pruritic drugs,33 non-pharmaceutical methods of alleviating the discomfort associated with pruritus were noted. These methods included: Cooled hydrogel sheets Menthol in aqueous cream (for unbroken skin only) Transcutaneous electrical nerve stimulation (TENS) Paroxetine Calamine Capsaicin Local anaesthetics Systemic corticosteroids H-receptor antagonists Anti-convulsants Antidepressants Ultraviolet B therapy

Minor bleeding
Suggestions of measures to control minor bleeding included:9,23,43,44 Local pressure Ice packs Haemostatic alginates
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Sucralfate paste (1g dispersed in 5ml of water soluble gel) Ostomy adhesive or other hydrocolloid powders containing carmellose, sodium, gelatin and/or pectin which promote haemostasis.

Moderate bleeding
For moderate bleeds, some practitioners recommended alginates because of their haemostatic properties.45,46 However, Grocott recommended that only non-brous alginates should be used because of the possibility of alginate bres irritating the friable tissue.47 A number of authors have suggested the use of haemostatic surgical sponges as an emergency measure, but only one author has reported its use.47 According to the prescriptive advice, surgical sponges can be left on the wound and covered with a secondary dressing once the bleeding is under control.28,32,47 An additional advantage of this approach is that sponges can be applied by patients or carers in the home setting, which may reduce the need for emergency referral and the associated anxiety. According to Grocott, surgical sponge is a natural gelatine which absorbs some of the blood. The sponge is then either naturally absorbed, or remains as a soft gelatinous structure which slides off with the next dressing change.47

Heavy bleeding
Heavier bleeding events require more urgent measures. In instances where it is possible for interventions to be arranged before the blood loss becomes too severe, options outlined in the literature included: Antibrinolytics (tranexamic acid) Vasoconstrictors Radiotherapy, Ligation Cauterisation.39,44 Oxidised cellulose or collagen to promote clotting has also been suggested.18 The use of gauze saturated with adrenaline 1:1000 (1mg/1ml) has been recommended but caution is required as ischaemia and consequent necrosis could result from injudicious use.32,48 Less commonly used haemostatic agents included: somatostatin analogues; acetone; thrombin/thromboplastin; topical cocaine; prostaglandins; formalin and brin sealants; aminocaproic acid; ethamsylate; ornipressin (Por 8, Sandoz); 1% alum solution; and vitamin K treatment to resolve disrupted clotting mechanisms.43,44,49-51 Despite the wide range of interventions discussed in the literature, few were supported by empirical evidence. However, Carville reported on the successful use of Por 8 to control bleeding43 and Jones reported on the use of tranexamic acid syrup and adrenalinesoaked (1:1000) pads to control bleeding.52
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15 Ngugi,V. Managing neuropathic pain in endstage carcinoma. End of Life Care 2007; 1: 1, 38-46. 16 Strasser, F., Walker, P., Bruera, E. Palliative pain management: when both pain and suffering hurt. J Palliative Care 2005; 21: 2, 69-79. 17 Bale, S., Tebble, N., Price, P. A topical metronidazole gel used to treat malodorous wounds. Br J Nurs 2004; 13: 11, S4-S11. 18 Alvarez, O., Kalinski, C., Nusbaum, J. et al. Incorporating wound healing strategies to improve palliation (symptom management) in patients with chronic wounds. J Palliat Med 2007; 10: 5, 1161-1189. 19 World Health Organisation. WHOs pain ladder. WHO 2009. http:// www.who.int/cancer/ palliative/painladder/en/ index.html 20 Hughes, R.G., Bakos, A.D., OMara, A., Kovner, C.T. Palliative wound care at the end of life. Home Health Care Management & Practice 2005; 17: 3, 196-202. 21 Back, I.N., Finlay, I. Analgesic effect of topical opioids on painful skin ulcers. J Pain Symptom Manag 1995; 10: 7, 493. 22 Zeppetella, G., Ribeiro, M.D.C. Morphine in Intrasite Gel applied topically to painful ulcers. J Pain Symptom Manag 2005; 29: 2, 118-119. 23 Seaman, S. Management of malignant fungating wounds in advanced cancer. Semin Oncol Nurs 2006; 22: 3, 185-193. 24 Wilson,V. Assessment and management of fungating wounds: a review. Br J Community Nurs 2005; 10: 3, S28-34. 25 Flock, P. Pilot study to determine the effectiveness of diamorphine gel to control pressure ulcer pain. J Pain and Symptom Management 2003; 25: 6, 547-554.

Catastrophic bleeding
A catastrophic bleed is clearly very distressing for the patient and family, not only because of the copious outow of blood but because it signies imminent death. However, even in cases where the risk of a catastrophic bleed has been identied, there is often little warning of the actual event and carers are frequently ill-equipped to deal with the emergency. Accordingly, a strategic plan should be developed in conjunction with the patient and family when such an event is considered to be a possibility. Following careful assessment of the patients circumstances and depending on whether the plan was developed for the hospital or home setting, such a plan might include:9,29,50 Caregivers and family members being informed about the possibility of a catastrophic bleeding event, what is likely to happen in this event and what they should do Dark towels and a basin being kept close to the patients bedside The preparation of an emergency pack, including a sedating drug such as midazolam in a prelled syringe to be administered subcutaneously Access to emergency services and transport Open lines of communication with appropriate specialist centres where emergency control of bleeding could be easily and rapidly facilitated.

spective and that of a society that harboured revulsion for uncontrolled body uids and only granted full personhood to those in possession of a sanitised, deodorised, hygienic, somatically bounded body. Some of these unbounded individuals were observed to withdraw from social interaction and undergo a form of social death even though physical death was still some weeks away.54 The huge impact of psychosocial issues on patients with malignant wounds has been illustrated in the literature. People have been found to be reluctant to seek medical assistance because they are embarrassed by the appearance or location of the wound.6,38,52,55,56 Often these people only seek medical advice when the wound is advanced, by which time palliative care is the only realistic treatment option.57,58 For these people, coping with the physical problems unassisted is less burdensome than coping with the psychosocial anxieties. However, it is not only patients who struggle to manage psychosocial issues; authors have discussed tendencies among health-care professionals to avoid these issues because they do not know how to handle them.59-61

Psychosocial interventions
In view of the inter-relatedness of physical and psychosocial domains, it is likely that alleviating the physical symptoms of malignant wounds will also help alleviate the psychosocial burden. However, there are some interventions recommended specically for psychosocial issues. A simple and cost-effective way of helping people to manage their condition is to listen to their story.57,62,63 Knowing that their story has been heard and their difculties acknowledged can be both therapeutic and cathartic for the patient, and so lead to improvements in treatment.59-61,64 Once the practitioner understands the challenges being faced by patients, he/she will be better placed to help them overcome their difculties. For example, a Danish study reported the concerns of women with malignant breast wounds.62 The participants expressed their anxieties about leakage and malodour, not being able to wear feminine attire and having to refrain from physical or sexual intimacy or any form of social interaction. As a result of their discussions with a clinical nurse advisor, dressing regimens were developed for each participant that enabled them to dress in feminine clothes once again and resume social interaction without fear of seepage or malodour. Because the women had been able to discuss the wider implications of their wounds with nurses, they were able to enjoy a new sense of freedom.62 Neal provided a useful maxim for practitioners to remember in such instances: Dont just do something, sit there.63
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Psychosocial issues
The dearth of information on the lived experience and associated psychosocial issues of living with or caring for a malignant wound was discussed in part one.1 This lack of knowledge affects the practitioners ability to care for patients holistically, particularly when it is often the psychological issues associated with an illness that cause more distress than physical issues. Given the limited evidence base in this area, this section will review some of the general psychosocial issues associated with chronic wounds, and suggest how they might be addressed. Research into the lived experience of chronic wounds, predominantly leg ulcers, suggested that practitioners do not often understand the profundity of the life-changing nature of the experience and the day-to-day challenges involved. Participants in one study felt that they had become the wound, as it became the focal point of their existence and took over their lives.53 Because of the wound, the participants considered they had a different way of being in the world than those who were healthy and wound-free.53 Lawton introduced the concept of unboundedness to describe those people whose bodily contents spilled uncontrollably into the external world.54 She described how unbounded people suffered from diminished personhood, both from their own per-

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The benets of a strong social support network for people living with chronic illness have been reported extensively in the literature.65,66 Such relationships are of vital importance in reducing stress levels and inuencing wellbeing and coping processes. However, as the discharge and malodour associated with a malignant wound continue to breach social boundaries, individuals tend to withdraw from social contact, while at the same time friends and family not knowing how to handle the situation decrease the duration and frequency of visits.57,67,68 In these instances, cognitive behaviour therapy can be helpful in reminding patients that, although they cannot inuence the reactions of others, they can control their own responses to them.69 It is clearly never easy to discount the unthinking responses of others but Clarke has shown that those who were able to maintain self-esteem despite disgurement rmly believed that the unkind reactions of others reected more harshly on the perceiver than the perceived.69 Finally, and most importantly, practitioners must never lose sight of the personhood of the people in their care. It takes very little to recognise somebody as a person but that small act can reap huge rewards for both the practitioner and patient.

Emerging treatments
The third and fourth articles in this series have discussed mainstream approaches to the management of malignant wounds. It is hoped that ongoing research will discover more interventions. Two emerging treatments that have demonstrated an ability to palliate the symptoms of cutaneous metastases are miltefosine and electrochemotherapy. Miltefosine is a topical cytostatic treatment that was found to be superior against placebo in extending the time to treatment failure in a sample of breast cancer patients (n=52) with cutaneous metastases.70 However, the lesions in the study sample were all supercial, being <1cm in depth, which is signicantly less than many of the malignant wounds encountered in clinical practice. Electrochemotherapy combines the administration of a cytotoxic chemotherapeutic drug (commonly bleomycin) with electrical pulses applied to the tumour to enhance the permeability of the tumour cells, thus increasing the cellular uptake of the drug.71 However, as the majority of reports of its clinical applications included patients with nodular involvement only, its usefulness in the larger malignant wounds appears to be limited. It remains to be seen whether the ability of these or other new interventions to successfully treat malignant cutaneous lesions will result in a reduction in the incidence of ulcerating malignant wounds.
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Implications for research
Box 1. Areas for further research
Research questions What causes malodour in malignant wounds? Metronidazole appears to be effective in reducing malodour in malignant wounds, but why? Is the effectiveness of metronidazole reduced (diluted) in heavily exuding wounds? Is the effectiveness of systemic metronidazole reduced if the circulation proximating the tumour is compromised? How do we assess the appropriate amount of metronidazole gel to apply? Which dressings are the most suitable for malignant wounds? Are charcoal dressings (with silver and without silver) effective in controlling the malodour associated with malignant wounds? Do some (brous) alginates exacerbate bleeding incidents in friable malignant wounds? Exploration of patients measurement of malodour; are there issues such as shame and embarrassment associated with them accurately measuring the odour? Do patients, lay caregivers and/or practitioners become accustomed (desensitised) to the malodour of malignant wounds over time? Is there a role for analgesia-impregnated dressings in malignant wound management? How effective is topical analgesia in alleviating pain in malignant wounds and are there any adverse effects? Development areas Development of an objective tool for measuring malodour Development of an objective tool for measuring exudate

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

Conclusion
Given the complexity and overwhelming nature of malignant wounds for patients, it is recommended that these wounds be managed by a multidisciplinary approach within a palliative care framework. This will facilitate the provision of comprehensive and individualised care, which is of vital importance if quality of life is to be maximised. There is a clear need for research into the management of malignant wounds as most of the existing literature is based on prescriptive advice, sometimes generalised from the management of other chronic wounds, anecdotal reporting and case studies. One area where the lack of research is particularly evident is psychosocial issues. Although lack of information on psychosocial issues has hampered discussion of management options, some simple interventions that will be of use have been highlighted here. These include acknowledging that the patient has been heard and never losing sight of their personhood. It is hoped that further research will contribute to the existing knowledge base, thereby enhancing the practitioners ability to provide holistic care for patients with this challenging condition.
31 Ribeiro, M.D.C., Joel, S.P., Zeppetella, G. The bioavailability of morphine applied topically to cutaneous ulcers. J Pain Symptom Management 2004; 27: 5, 434-439. 32 McDonald, A., Lesage, P. Palliative management of pressure ulcers and malignant wounds in patients with advanced illness. J Palliative Med 2006; 9: 2, 285-295. 33 Twycross, R., Greaves, M.W., Handwerker, H. et al. Itch: scratching more than the surface. Quality J Med 2003; 96: 1, 7-26. 34 Rhiner, M., Slatkin, N.E. Pruritus, fever, and wweats. In: Ferrell, B.R., Coyle, N. (eds.). Textbook of Palliative Nursing. Oxford University Press, 2006. 35 Holme, S.A., Pease, N.J., Mills, C.M. Crotamiton and narrowband UVB phototherapy: novel approaches to alleviate pruritus of breast carcinoma skin inltration. J Pain Symptom Manag 2001; 22: 4, 803-805. 36 Lovell, P.,Vender, R.B. Management and treatment of pruritus. Skin Therapy Letter 2007; 12; 1. http://www.medscape.

26 Flock, P., Gibbs, L., Sykes, N. Diamorphine-metronidazole gel effective for treatment of painful infected leg ulcers. J Pain Symptom Manag 2000; 20: 6, 396-397. 27 Zeppetella, G., Paul, J., Ribeiro, M.D.C. Analgesic efcacy of morphine applied topically to painful ulcers. J Pain Symptom Manag 2003; 25: 6, 555-558. 28 Naylor, W. Malignant wounds: aetiology and principles of management. Nurs Standard 2002; 16: 52, 45-56.
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29 Grocott, P. The Palliative Management of Fungating Malignant Wounds. Paper presented at the Evening Hosted by South Australian Wound Management Association and Association of Stomal Therapy Nurses, Queen Elizabeth Hospital 2003. 30 Grocott, P. Palliative management of fungating malignant wounds. JCN Online 2000; 14; 3. http://www.jcn.co.uk/ journal.asp?MonthNum=03&Year Num=2000&Type=backissue&Art icleID=221

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com/viewarticle/554692_print 37 Fleck, C. Ethical wound management for the palliative patient. Extended Care Product News 2005; 100: 4, 38-46. 38 McMurray,V. Managing patients with fungating malignant wounds. Nurs Times 2003; 99; 13, 55. 39 Haiseld-Wolfe, M.E., Rund, C. Malignant cutaneous wounds: a management protocol. Ostomy/ Wound Management 1997; 43: 1, 56-66. 40 Davis,V. Goal-setting aids care. Nurs Times 1995; 91: 39, 72-76. 41 Williams, C. Irriclens: a sterile wound cleanser in an aerosol can. Br J Nurs 1996; 5: 16, 1008-1010. 42 Young, T. Common problems in wound care: wound cleansing. Br J Nurs 1995; 4: 5, 286, 288-289. 43 Carville, K. Wound Care Manual (Vol. 5). Silver Chain Foundation 2005. 44 Pereira, J., Phan, T. Management of bleeding in patients with advanced cancer. Oncologist 2004; 9: 561-570. 45 Nazarko, L. Malignant fungating wounds. Nursing Residential Care 2006; 8: 9, 402-406. 46 Thomas, S.,Vowden, K.R. Controlling bleeding in fragile fungating wounds. J Wound Care 1998; 7: 3, 154. 47 Grocott, P. Controlling bleeding in fragile fungating tumours. J Wound Care 1998; 7: 7, 342. 48 Grocott, P. An Evaluation of the palliative management of fungating malignant wounds, within a multiple-case study design. Kings College, 1999. 49 Saunders, J., Regnard, C. Management of malignant ulcers a ow diagram. Palliat Med 1989; 3: 153-155. 50 Gagnon, B., Mancini, I., Pereira, J., Bruera, E. Palliative management of bleeding events in advanced cancer patients. J Palliat Care 1998; 14: 4, 50-54. 51 Walton, A., Broadbent, A. Radiation-induced second malignancies. J Palliat Med 2008; 11: 10, 1345-1352. 52 Jones, S. Easing the symptoms. Nurs Times 1998; 94: 24, 74, 77. 53 Neil, J.A., Munjas, B.A. Living with a chronic wound: the voices of sufferers.Ostomy Wound Manage 2000; 46: 5, 28-38. 54 Lawton, J. The Dying Process: Patients experiences of palliative care. Routledge, 2000. 55 Mekrut-Barrows, C. Softening the pain of cancer-related wounds. Ostomy Wound Manage 2005; 52: 9. 56 Haller, S.M. A large ulcerated fungating breast lesion. Clin J Oncol Nurs 2004; 8: 1, 76-78. 57 Queen, D., Woo, K., Schulz,V. N., Sibbald, R.G. Chronic wound pain and palliative cancer care. Ostomy Wound Management 2002; 49; 10. http://www.o-wm. com/article/2117 58 Davies, A. Nursing a patient with a malodorous fungating nonhealing wound. Nurs Times 2003; 99; 13, 58-60. 59 Bredin, M. Mastectomy, body image and therapeutic massage: a qualitative study of womens experience. J Adv Nurs 1999; 29; 5, 1113-1120. 60 Price, B. Altered body image: managing social encounters. Int J Palliat Nurs 2000; 6: 4, 179-185. 61 Piff, C. A patients perspective: living with facial cancer. J Tissue Viability 2000; 11: 2, 64-66. 62 Lund-Nielsen, B., Muller, K., Adamsen, L. Malignant wounds in women with breast cancer: feminine and sexual perspectives. J Clin Nurs 2005; 14: 56-64. 63 Neal, K. Treating fungating lesions. Nurs Times 1991; 87: 23, 84, 86. 64 Hack, A. Malodorous wounds: taking the patients perspective into account. J Wound Care 2003; 12: 8, 319-321. 65 Karnell, L.H., Christensen, A.J., Rosenthal, E.L. et al. Inuence of social support on health-related quality of life outcomes in head and neck cancer. Head Neck, 2007; 29; 2, 143-146. 66 Detillion, C.E., Craft, T.K.S., Glasper, E.R. et al. Social facilitation of wound healing. Psychoneuroendocrinology 2004; 29: 1004-1011. 67 Maund, M. Use of an ionic sheet hydrogel dressing on fungating wounds: two case studies. J Wound Care 2008; 17: 2, 65-68. 68 Mercier, D., Knevitt, A. Using topical aromatherapy for the management of fungating wounds in a palliative care unit. J Wound Care 2005; 14: 10, 497-501. 69 Clarke, A. What happened to your face? Managing facial disgurement. Br J Community Nurs 1998; 3: 1, 13-16. 70 Leonard, R., Hardy, J., van Tienhoven, G. et al. Randomized, double-blind, placebo-controlled multicenter trial of 6% miltefosine solution, a topical chemotherapy in cutaneous metastases from breast cancer. J Clin Oncol 2001; 19; 21: 4150-4159. 71 Marty, M., Sersa, G., Garbay, J.R. et al. Electrochemotherapy: an easy, highly effective and safe treatment of cutaneous and subcutaneous metastases: results of ESOPE (European Standard Operating Procedures of Electrochemotherapy). Eur J Cancer Supplements 2006; 4, 11, 3-13.

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Stockings gain Sigel certication

brand of compression stockings has achieved independent certication in their use against deep vein thrombosis (DVT). Mlnlycke Health Cares Brevet tx antiembolism stockings gained independent accreditation for their compliance with international compression standards. The stockings follow

the international Sigel standards at the measuring points of ankle, mid calf and upper thigh, as set by the National Institute for Health and Clinical Excellence (NICE). That this product adheres to an internationally recognised standard ensures that patients receive the best possible care, said Nick Howard, International Product Manager at Mlnlycke Health Care.
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