PATHOPHYSIOLOGY! Starts as discrete, non tender nodules Can be skin tone, pink, red, violet, blue, black or brown! As malignant cells grow and divide, the nodules enlarge – interfere with skin capillaries and lymph vessels
Tumor very disorganized! – poor skin perfusion, edema and necrosis occurs Tumors often extend into deeper structures – sinus and fistula formation
ASSESSMENT Location of Wound Size, Depth and Shape Amount and Nature of Exudate Presence and Level of Malodor Type of Tissue Present Signs and Symptoms of Infection Nature and Type of Pain Condition of Peri-wound Bleeding
ASSOCIATED PROBLEMS WHAT DOES THE PATIENT THINK IS THE MOST IMPORTANT?
ODOR!! Anaerobic Bacteria infecting or colonizing necrotic tissue-Putrescine, Cadaverine Klebsiella, Pseudomonas & Proteus Necrotic Tissue Odor Stale Exudate