Clinical Practice

Use of Alginates and Foams for Management of Symptoms of Chronic Malignant Wounds and their Impact on Quality of Life: Case Studies

Valerie J. Arklie, Shirley Herlick, Kerron Kidd

CASE STUDY #1

As home care nurses we have many clients with the challenges of malignant wounds. One of those clients is a 67 year old who was working part-time up until a month before she came on service with home care. She is a beautiful lady, always dressed in the latest fashions. Her make-up and nails are always impeccable and her thick hair is always done up "just-so"! She loves to tell jokes, has an easy laugh, and is truly interested in everyone she meets. She adores her children and grandchildren and has many friends.

We started treating her over two years ago when we were going to her home to assist her with colostomy pouch changes. She has cancer of the splenic flexure (bowel). A transverse loop colostomy was done in hopes of removing the cancer at a later date. The tumour was unresectable so the colostomy was reversed, resulting in a permanent mucous fistula. The stoma discharged minor amounts of clear mucous so the client managed to change the stoma every day with a 2 x 2 sponge and tape. We visited her twice a week for support until chemotherapy was to begin.

Chemotherapy took its toll on the client. She lost her thick hair and suffered from nausea, anorexia, stomatitis, and many other indignities. We encouraged her use of caps and wigs, which promoted more social interaction. She was then able to celebrate last Christmas with her family. We visited her three times a week to monitor and assist with the side effects of chemo.

Wound Challenges
This past year the stoma discharge increased to copious amounts of very thick serous-sanguinous mucous on a daily basis. This resulted in four to five gauze dressings changes in a 24-hour period. Gauze or sponges absorb for only 4-8 hours (WRHA, 2003). The literature suggests pouching stomas (Naylor, 2002). We tried, but the pouches did not hold and caused leakage, as well. The discharge often leaked on to the client’s underwear causing her great embarrassment and stress. She felt compelled to stay at home and forgo outings with her friends and family. Staying away was especially painful for her as she is so sociable and she missed the grandchildren’s special events.

Isolation caused the client to feel depressed. This compounded her worries about the possibility that her cancer may become terminal if the chemo stopped being effective. Her chemotherapy symptoms became more severe. We saw her daily for dressing changes and set up pre-cut dressings for the other three of four changes. We tried to offer her emotional support, but she was becoming more depressed with each passing day.

We tried an alginate, a hydrofibre and foam, as they had proven effective in the past. These dressings continued to leak.

Collaboration
Our next step was to consult our Home Care Program Wound Care Best Practice Team. This team of highly trained nurses is certified in advanced wound care under the directions of the Home Care Clinical Nurse Specialist. The Wound Care Best Practice Team practises under the Winnipeg Regional Health Authority (WRHA) Regional Wound Care Recommendations. The recommendations emphasize the importance of prevention in all aspects of wound care. In fact, embedded throughout the recommendations, is the underlying conceptual framework of "Treat the Cause, Treat Patient Concerns, Treat the Wound" (Sibbald et al., 2000). This conceptual framework requires the practitioner to first and foremost identify and hopefully prevent wounds. Home care nurses can consult the team at any time for assistance in the management of complex or non-healing wounds. In this case, the team was as frustrated as we were. We had tried all of the wound-care products that were currently available to us, and none appeared to be working for the client. Finally, a team member suggested discussing the situation with wound product representatives at an upcoming wound-care conference.

At the wound care conference the wound-care consultant suggested their alginate non-adhesive on a trial basis. In the first week with the new products we were able to reduce the dressing changes to every day and then every other day. However, the client wished to shower daily. Fletcher says patients need to "feel clean" and we need to listen to this request (Fletcher, 2002). She was allergic to occlusive waterproof dressings to cover the site, which would have permitted dressings every other day. Therefore, the dressings were done daily. We reduced our visits to three times a week as she felt she could handle the dressing changes as long as the supplies were pre-cut for her. Enabling client participation in their care is an important consideration in wound care (Barton, 2001).

The client started to go out more. Her outlook on life improved and she became more hopeful about the future. Her chemotherapy symptoms became more manageable. She started to laugh again, tell jokes, and be the lovely lady we all had come to appreciate. Her hair is back, just as thick as before. She just celebrated her second Christmas with her family since her original diagnosis.

Cost Analysis
Cost savings were $75.00 per week with the new alginate and foam products, including nursing visits (see Table 1: Cost analysis). This represented a decrease in cost of materials & labor by 38%. There was a significant difference in quality of life. Foams and alginates proved to decrease overall costs in malignant wound treatments for this client and improved the quality of life.

Table 1: Cost Analysis Wound Care – Case Study 1

Old Regime with Dressing Changed QID

The home care nurse would come every day and help change the dressing, then prepare the rest of the dressings for the patient to change the other three times per day.

Total Cost of Dressings/Week: $22.43
*Home Care Visits OD: $175.00
Total Cost of Labor & Supplies: $197.43

New Regime with Dressing Changed Every Day

Total Cost of Dressings/Week $46.76
*Home Care Visits 3 times/week: $75.00
Total Cost Labor & Supplies: $121.76

*Estimate of 1 hour of Registered Nursing Time at $25.00 per hour

Addendum
At the time of this writing the client just received the results of her last CT scan. The tumour is growing and she is very weak. She has discontinued chemo treatments and knows her goal of aiming for another Christmas is futile. We are visiting daily for alginate and foam dressings on her stoma as she can no longer manage her wound care. We will continue to support her with palliative care.

CASE STUDY 2

Our second case study takes place in a long-term care facility. The resident is an elderly female who spends her days in the long-term care facility involved in activities with her family and other residents. She is wheelchair-bound but spends the majority of the day out of bed involved with the activities of daily living.

The resident had multiple medical problems, including cancer of the breast for which she has received a right mastectomy. It is believed that the cancer has metastasized to the bone; her treatment is considered palliative. She started with a lesion on the coccyx, which had a sinus tract along the spine that tunnelled at 4 cm and increased to 7.5 cm within several weeks. After several more weeks, the wound became infected. A raised 9 cm area developed at the 9-oclock position of the coccyx ulcer. This was thought to be a sarcoma or possible abscess. Pain was a major issue from the bone metastasis and the result of the movement required to frequently change the dressings. Because of the palliative nature of the care, issues related to the extent of treatment arose.

Challenges
The wound was initially draining copious amounts of serosanquinous discharge, which later turned into foul-smelling purulent sanguineous discharge. The peri-wound skin was macerated and excoriated. Dressing were changed initially twice a day but increased to 4 – 6 dressing changes per day, using sterile saline to irrigate, silver sulphonamide, hydrogel, alginate packing, non-alcohol barrier film, 4x4 gauze, abdominal pads and a soft cloth adhesive tape. The alginate packing was used to absorb fluids, keep the sinus tract open and assist in reduction of bleeding. Pain was a major issue from the bone metastasis and frequent dressing changes. She had difficulty being moved into her wheelchair because of pain and was frequently confined to her bed.

When the wound became infected a foul odour permeated the room. Because of her decreased social interaction related to confinement to bed and the odour, she became depressed and withdrew from ther social aspects of her life. There were also conflicts as to the extent of treatment with the family and health-care team, especially in the area of using antibiotics.

Collaboration
We consulted the Winnipeg Regional Health Authority Clinical Nurse Specialist for personal care who practises under the Winnipeg Regional Health Authority (WRHA) Regional Wound Care Recommendations, which were discussed in the first case study. With the collaboration of the Clinical Nurse Specialist for personal care and the resident care co-ordinator at the personal care home, physician and the wound-care Cconsultant from the company that supplies our products, we came up with a plan to treat the patient.

Exudate management of the wound was changed from gauze and abdominal pads to a new foam adhesive dressing. We continued to use an alginate dressing to help with absorption, keep the sinus tract open and reduce the bleeding. A non-alcoholic liquid barrier film was used to protect the peri-wound skin. The change of dressing materials reduced the dressing change from 4-6 times per day to once a day. The peri-wound skin was excoriated and macerated from the excessive exudates, and adhesive tape trauma related to the frequency of dressing changes. Initially, we used liquid barrier film and covered the open areas with a transparent film dressing that we changed every two to three days. After we initiated the use of foam dressings, the peri-wound skin healed, and the transparent film dressing was discontinued. The adhesive transparent film, which was also a part of the foam dressings, was removed carefully using the lateral stretch technique, which reduced skin trauma. The reduction of dressing changes and improvement of the peri-wound skin resulted in a reduction of pain related to movement and dressing changes, which could be controlled with a long-acting opiate.

When the wound drainage became infected, there were more challenges with care. There was a lot of discussion with the family and health-care team about treatment options. The family did not want to prolong her life with treatment, while the health-care team felt that the use of antibiotics for the treatment of the infected wound would improve her quality of life. The daughter had been told at the acute care hospital that the wound would not ever heal and that her mother was not expected to live more than a few months. Swabs were taken and systemic antibiotics administered.

We also applied anaerobic antibiotic cream to the area for odour control. The foam dressing had a semi-occlusive transparent film, which helped to seal in the odour. Dressing changes were done daily or when the dressing leaked or lifted. Cat litter was placed in a pan under the bed, which was very effective in absorbing and reducing the odour in the room.

With the decreased dressing changes and control of odour, the client started to get up into her wheelchair to participate in activities of daily living. As the drainage decreased with the antibiotic therapy, the frequency of dressing changes decreased and the odour improved. With the effective management of symptoms in palliative wounds, she once again began to become involved in activities with her family and other residents. Her quality of life has significantly improved from being in bed to being in her wheelchair spending the majority of the day involved with the activities of daily living.

Cost Analysis
With the change in dressing from gauze and abdominal pads, four times per day to foam dressings once per day, there was as a cost reduction of materials by 35% using the new foam dressing. (See Table 2: Cost analysis – Case Study 2). Nursing time to change dressing was reduced by 75%. Pain was reduced related to the dressing change itself, the improvement of the peri-wound skin and the decrease in frequency to move the patient from the wheelchair to the bed for dressing changes. One cannot truly capture the overall impact on the improvement in the quality of life for the resident and her family. Overall, the change in management to the use of advanced wound-care dressings resulted in a total cost effective strategy.

Table 2: Cost Analysis – Case Study 2

Initial Dressing Regime (Dressing changed on an average of 4 times per day)

New Dressing Regime ( Dressing changed once per day)

Reduction in dressing cost of materials per week is $65.39 or a 35% reduction in cost.

Addendum
The resident came to us in December 2002 with this open wound and an expected life expectancy of two months. On October 2003, the wound had stopped draining and was closed. At the time of writing of this case study, in June 2004, Mrs. C continued to live at our home spending quality time with her with family and friends.

Discussion
Proper management of chronic malignant wounds can significantly impact the quality of life for our clients. Appropriate dressing materials are critical to the management of wound exudate and peri-wound skin, bleeding, malodour and infection, and pain.

Dressings that absorb large amounts of fluids such as alginates and foams are highly absorbent and are effective for wound exudate and peri-wound skin health. Both these dressings have variations in effectiveness. As noted in our case studies there are differences in the absorbability in the various brands of products. Control of wound exudates and use of appropriate dressings can prevent skin breakdown related to maceration and adhesive trauma. Use of a barrier film helps to protect the peri-wound skin. Attention to the type of adhesive, frequency of dressing changes and careful techniques in removal of dressings decreases damage to the wound and peri-wound skin.

A further benefit of the use of alginates is their impact on hemostasis, which can reduce bleeding in the friable malignant wound. Dressings should be non-adherent to the wound bed to prevent further trauma.

Both alginates and foams can be used on infected wounds. Infection is often associated with an increase in exudate and odour related to increased bacterial burden and necrotic tissue. Treatment of infection by systemic or topical antimicrobials and/or antibacterials such as silver or slow-release iodine as a topical application or in the form of dressings is beneficial. Effective containment of wound drainage by absorptive, occlusive foam dressings that are changed frequently and removed quickly from the room will reduce odours. Control of odour by charcoal activated dressings may be helpful to absorb gases and filter odour. Odour absorbers such as vinegar, baking soda, or charcoal in the room can help.

Pain and suffering can be reduced with appropriate dressing management. Foams and alginates can reduce frequency of dressing changes. This reduction can help to reduce the trauma related to adhesive products and movement and positioning required for the frequent changes. Choosing non-adherent dressings can further reduce pain.

Appropriate treatment and dressings can help to control symptoms of malignant wounds. Clients can carry on with activities they enjoy. This reduces their isolation and ultimately their depression, and improves their quality of life.

In both case studies cost savings were realized. Cost savings were $75.00 (38%) per week in case study #1 and $65.00 (35%) per week in case study #2. The impact on the quality of life with the effective management of wounds is priceless.

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© CAWC 2003
Last modified: October 5, 2005