Something I've never seen!

  1. I have a new patient that has leiomyosarcoma in her shoulder and it has metastasized as dime shaped fungating tumors all over her back. I covered her whole back with antibiotic ointment and ABD pads. It's very painful for her and very sad
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  2. 16 Comments

  3. by   river1951
    Ow, that sounds awfully painful. If it is odorous, we have had good luck with flagyl solution and wet to dry. We have also used diapers to cover an area completely to prevent leaking. At least this poor gal doesn't have to look at it, like some of these hideous breast masses that take over a body.
    Can she get comfortable?
  4. by   doodlemom
    She's not able to lie on her back but she can lie on her side or stomach. The methadone and Roxanol seem to be working fairly well but we'll probably go up on the methadone today. The wounds are not smelly at this point and the ABD pads seem to be doing the trick with the drainage right now. I've never used a sloution with flagyl - I've just sprinkled the powder on odorous wounds. Is it just flagyl and sterile water?
  5. by   leslie :-D
    flagyl comes in spray, gel, paste, solution and iv.
    the solution is 1%, is effective against aerobic and anaerobic bacteria, and is indicated for fungating wounds.
    i'm sure the pharmacy would be familiar with it.
    but if your pts' wounds aren't malodorous, good chance they aren't infected.
    often in these wounds, the exudate is copious, purulent, with alot of black and yellow necrotic tissue.
    they're very aggressive, painful wounds that seem to eat right through the layers of the skin.
    i wouldn't worry about the flagyl solution if you're not seeing signs of infection.
    you may want to consider an alginate dsg if the abd pads don't contain the drainage.
    the alginate helps with the drainage and odor.
    foam dsgs would just help with the drainage.
    they also have charcoal pads that you lay on top of the wound bed; and also a sm tray of kitty litter under the bed can help if odors get bad.
    these wounds are really distressing for the pt.

    leslie
  6. by   doodlemom
    Thanks for the info. The next time I need to use flagyl on a wound, I'll ask our pharmacy. Do you use a local pharmacy or are you using hospice pharmacaeia? The wounds seem to be contained at this point. I have in the past had pt's with large, smelly fungating tumors but nothing like these little ones all over her back.
  7. by   jessica
    Unfortunately we have seen several fungating wounds recently. Often we find that compounded topical analgesia works very well as an adjunctive. Silvadene/Morphine Cream has been great! I can ask my cohort what strength the morphine is and get back to you if you'd like.


    During the woundcare aspect, my friend used vinegar douches as a lavage daily prior to applying the cream. It aided in removing some of the dead tissue, but was gentle enough (both physically and strength of the acetic acid) to be very effective. Patting dry, and then applied the cream. Once the woundcare was complete she covered the wound with large Mepilex Borders. The great thing about that is the fluid was wicked away from the tumors to the back of the pad (much like feminine products). Whereas ABD pads typically keep the secretions in direct contact with the skin.

    In terms of overall odor, charcoal under the bed was used. I suggested a natural orange spray that has a very fresh scent and can be used PRN when the smell is apparent. It's sold at most grocery stores in the air freshener section.


    HTH and LMK if I can be of more assistance


    Jessica
    Last edit by jessica on Jan 20, '07 : Reason: forgot something
  8. by   doodlemom
    I would like to hear about the compounded silvadene/morphine mix. That's sounds like a good combo. Can you tell me what mediplex is? I thought it was a type of tape - or I'm thinking of medifix.
  9. by   jessica
    Here's a website that provides information and a picture of an individual Mepilex Border Dressing. I ABSOLUTEY love this product! I'll get you the ratio for the Silvadene/Morphine compund and post it tomorrow.

    http://www.molnlycke.net/item.asp?id=3759&si=32
    http://www.directmedicalinc.com/woun...ex_border.html


    Jessica
  10. by   abbieRnChpn
    I have3 recently had to patients with fungating tumors. Metrogel, applied sparingly BID works wonders with the odor and sometimes helps to decease the drainage. For heavy drainage I like alginate pad, covered with 3m' tegagen with the foam center. Can be left inplace longer and is really absorbent I agree these are horrible and unhealable woundws
  11. by   doodlemom
    Thanks Jessica

    Quote from jessica
    Here's a website that provides information and a picture of an individual Mepilex Border Dressing. I ABSOLUTEY love this product! I'll get you the ratio for the Silvadene/Morphine compund and post it tomorrow.

    http://www.molnlycke.net/item.asp?id=3759&si=32
    http://www.directmedicalinc.com/woun...ex_border.html


    Jessica
  12. by   jessica
    I spoke with my coworker and Morphine 1-5% can be compounded with Silvadine. Also, if the pain is more neuropathic then Ketamine or Gabapentin can be included as well.

    HTH
    Jessica
  13. by   doodlemom
    Thanks, I'm going to talk to the pharmacist.
  14. by   introspectiveRN
    Although I have yet to see wounds like the OP is describing, I have been dealing with patients who have terrible, malodorous breakdown wounds that never heal. With the pharm that we used previously, we were able to order flagyl powder; now (HP) we can only get flagyl caplets and crush them ourselves and then apply :icon_roll . Much more awkward to use than being able to "squirt" the powder directly on and around the wound(s). I have not really noticed the flagyl powder really helping that much with the smell of necrotic tissue. The idea of a pan of charcoal under the bed seems interesting. Where can I find this? Is it like the charcoal used for aquarium supplies?

    I find dealing with these wounds discouraging. It seems like nothing I do really makes a big difference in the smell and by the time the pt has declined to the point of having these types of wounds...nothing seems to be able to heal them or stop them from progressing. Here is what I have been doing: crush flagyl caps and apply after cleaning wound with spray wound cleanser (the vinegar solution sounds like a great idea BTW...had not thought of that) than apply algesite, then charcoal pad over that and tegaderm on top (with skin prep around edges). On some wounds I apply flagyl powder into the bed of the wound and then hydrocolloid dsg over. For stage 1 I usually try wound gel and border gauze.

    Any additional suggestions are so appreciated.

    Although I did some wound care in the hospital, the pt population was so different and so were the methods used to treat wounds. We also had a special wound care nurse that floated from pt to pt doing the care (Wound vacs etc.). I really appreciate any and all advice I can get that will help me with wound care for my hospice pts.

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