Skin/wound care and lymphoedema
Pressure wounds are the most common wound management issue in palliative care. Prevention is a vital part of overall care. Good skin care and meticulous attention to pressure areas with regular turning and massage are imperative.
Skin breakdown/discharge
Disease and radiotherapy can lead to skin breakdown. This is aggravated by discharge or incontinence and good skin care is essential to prevent and minimize problems. Discharge is common with advanced gynaecological malignancy and might be offensive and very distressing. Regular, gentle washing with saline or vinegar water can minimize odour. The skin should be dabbed dry to avoid excoriation and maceration. Patients may become fixated on the problem which may cause embarrassment and shame leading to psychological
| Underlying factors | I Specific treatment |
| Breathlessness | |
| Low dose opioids—2-4-hrly Oxygen—may relieve symptoms even if not hypoxic, reassuring | |
| Bronchospasm | Bronchodilators—preferably by nebulization or spacer |
| Pleural effusion | Pleural aspiration ± pleurodesis |
| RadiotherapyZchemotherapy | |
| Lymphangitis carcinomatosis | Corticosteroids—betamethasone 12-18 mg or equivalent |
| Superior vena caval obstruction | Corticosteroids—betamethasone 12-18 mg or equivalent RadiotherapyZchemotherapyZstent |
| Infection/pneumonia | AntibioticsZcorticosteroids (short course) |
| Heart failure | Diuretics, inotropes |
| Pericardial effusion | Refer to specialistZmay need open drainage |
| DyingZbnonchial secretions (terminal breathlessness) | Hyoscine butylbromide intramuscular injection or subcutaneously (20 mg as soon as symptom occurs)Zcan be repeated or given by continuous subcutaneous infusion |
| Anaemia | Consider HansfusionZironZerythropoietin |
| Anxiety | Non-pharmacological treatment + anxiolytics Short-acting lorazepam for panicZlong-acting diazepam for persistent anxiety |
| Cough | |
| Dry | Suppressants—codeine or morphine |
| Wet | Do not suppress Secretions can be loosened with saline nebulization or N-acetylcysteine |
| Haemoptysis | Tranexamic acid (Cyklokapron) or radiotherapy, if fit enough. Prepare the family but be careful not to increase fear |
| Acute chest pain | |
| Pulmonary embolus/ deep vein thrombosis | Consider pros and cons of anticoagulation— warfarin or low-molecular-weight heparin |
| Acute myocardial infarction | Refer if indicated |
Source data from Watson M, Lucas C, Hoy A, Wells J (eds). Respiratory symptoms.
In: Oxford Handbook of Palliative Care, 2nd edn, pp. 363-79. Oxford: Oxford University Press; 2009.
problems. Barrier creams (zinc oxide, Cavilon, Fissan paste, Friars Balsam) are useful to protect the skin and prevent breakdown. Other suggestions for management of fistulae may help with skin care for pressure ulcers and vice versa.
Care of open wounds
As well as causing pain, discharge, odour, and bleeding, wounds are a visual reminder of the disease and add to psychological distress. They may significantly limit mobility and need adjustment of lifestyle. In advanced cancer, wounds may be large, infected, and bleed easily, particularly if there is a cutaneous metastasis present (28, 29).
| To prevent adhesion | Petroleum jelly-based gauze |
| Infection control | Glycerine and ichthammol |
| Wet areas | Corn starch (Maizena) |
| To facilitate adhesion | Friars' Balsam |
| Superficial small wounds | Mercurochrome |
| Good for drying | Gentian violet |
| Minor bleeding | Gauze soaked in adrenaline 1:1000 |
| Odour | Oil of peppermint (1 or 2 drops applied to the top of the wound dressing) |
Wounds should be cleaned gently but thoroughly with normal saline to prevent infection and control odours.
Spray dressings with saline before removing. A spray bottle and a hand shower are useful. Antiseptics should generally be avoided except under special circumstances where their use might advance comfort and reduce pain. Povidone iodine is useful in drying out necrotic tissue and hydrogen peroxide 3% can assist in debridement but both may cause damage to normal cells so long-term use is not viable. Dressing changes can be particularly difficult, so wetting the dressing with saline before removal as well as judicious use of topical analgesics, short-acting analgesics, and relaxation techniques may all aid in making this less painful.Control odour in the room with incense, deodorizing substances (fabric softener, cat litter, charcoal), and air freshener machines.
Dressing changes should be limited. There are a large number of dressings now available. However, simple is usually best and most cost-effective (Table 69.2). Cost, comfort, availability, and appearance need to be taken into account. Simple petroleum jelly-based gauze will prevent adhesion which can add to discomfort and cause bleeding. ‘Selecting the proper dressing will control pain, absorb exudates, and lessen the number of dressing changes' (29). Dressings will also limit exposure to flies in the global context which can lead to maggot infestation.
Antibiotics should be reserved for skin infections which are advancing. Choices are determined by local sensitivities and availability and include flucloxacillin, co-amoxiclav, trimethoprim, and erythromycin and metronidazole for anaerobic infection. Topical metronidazole (powder, creams, gel, intravenous solution) is excellent at reducing odour and can be applied weekly or daily if necessary.
Debridement, surgical or autolytic (e.g. honey), may be necessary to prevent infection (29) and surgical excision or debulking may be helpful in some situations.
Radiotherapy is helpful in shrinking the size of the wound and limiting bleeding.
Oedema
Oedema may be generalized (due to hypoalbuminaemia, or cardiac or renal failure), or localized lymphoedema.
Good skin care is imperative. Localized lymphoedema due to obstruction of lymphatics is common with pelvic disease and may be due to the disease itself or after radiotherapy. Compression, mobilization, and massage may help. Lymphoedema massage is a specialized technique that family members can learn so that it can be done on a daily basis. It can improve comfort even if lymphoedema cannot be relieved. Wrapping the limb with elastic bandages or compression stockings after massage or after reduction with reclining may assist in prevention. Elevation of the feet or the foot of the bed is helpful.Generalized oedema needs pharmacological treatment of the underlying cause of extracellular fluid accumulation and includes diuretics, such as spironolactone, thiazides or loop diuretics.
Oedema may be associated with ascites which may be assisted by paracentesis and diuretics if causing discomfort from either the ascites or the dependent oedema.