Introduction

Pressure ulcers, surgical wounds, malignant cutaneous wounds, radiation therapy-induced skin alterations, and incontinence-induced wounds are commonly experienced by cancer patients.

Assessment

Wound assessment and documentation should include the following findings:

• Degree of tissue layer destruction or color.

• Anatomic location.

• Length, width, depth, and tunneling using consistent units of measure.

• Appearance of the wound bed and surrounding skin.

• Drainage, specifying amount, color, and consistency.

• Pain or tenderness.

• Temperature (Hess 1999).

These parameters were developed to assess pressure ulcers, but they are useful guidelines for assessing other types of wounds.

The skin surrounding the wound must be assessed for color, temperature, and swelling. The wound's epithelial edge is assessed for continuity and integrity. Excessive dryness or moisture or the presence of nonviable tissue or exudate may delay re-epithelialization once granulation occurs. Finally, assess the wound for the presence of foreign objects such as sutures, staples, or environmental debris (Hess 1999).

Urinary or fecal incontinence

Skin-related damage may appear as an irritant contact dermatitis, involving erythema, edema, and vesicle formation. Failure to remove the irritant (urine or stool) will result in progressive inflammation of the skin, resulting in blistering, erosion of epidermis, weeping, and pain. Itching and burning occur with mild inflammation, whereas severe inflammation is associated with epidermal loss and exposure of dermal nerve endings, causing pain. Candida albicans yeast infection commonly causes a rash in these patients.

Prognosis and treatment

Topical wound management is designed to keep the wound moist, clean, warm, and protected from trauma and secondary infection.