1. The EPEC-O Curriculum is produced by the EPEC TM Project with major funding provided by NCI, with supplemental funding provided by the Lance Armstrong Foundation. Education in Palliative and End-of-life Care - Oncology The Project EPEC-O TM

2. EPECEPECOOEPECEPECOOO EPECEPECOOEPECEPECOOO Module 3q Symptoms – Skin Module 3q Symptoms – Skin EPEC – Oncology Education in Palliative and End-of-life Care – Oncology

3. Skin wounds... l Acute vs. chronic; likely to heal or not l Chemotherapy agent extravasation l Radiation damage l Decubitus ulcers l Malignant wounds l Acute vs. chronic; likely to heal or not l Chemotherapy agent extravasation l Radiation damage l Decubitus ulcers l Malignant wounds

4. ... Skin wounds Associated with l Pain l Depression l Anxiety l Poorer interpersonal interactions Associated with l Pain l Depression l Anxiety l Poorer interpersonal interactions

5. Key points 1.Pathophysiology 2.Assessment 3.Management 1.Pathophysiology 2.Assessment 3.Management

6. Skin symptoms l Organ system l Highly innervated l Visible l Psychological, social, and spiritual l Interdisciplinary care l Symptom control l Organ system l Highly innervated l Visible l Psychological, social, and spiritual l Interdisciplinary care l Symptom control

7. Chemotherapy extravasation: pathophysiology l Acute wound l Products of inflammation RednessSwellingPain l Cell death Necrosis, open wound l Acute wound l Products of inflammation RednessSwellingPain l Cell death Necrosis, open wound

8. Radiation: pathophysiology l Radiation damage l Acute wound l Products of inflammation l Cell death l Radiation damage l Acute wound l Products of inflammation l Cell death

9. Decubitus ulcers: pathophysiology l Pathophysiology Ischemia l Fat is protective l Pathophysiology Ischemia l Fat is protective

10. Malignant wounds: pathophysiology l Disrupted physiology l Products of inflammation l Neovascularization Bleeding l Necrosis Anaerobic and fungal infections l Disrupted physiology l Products of inflammation l Neovascularization Bleeding l Necrosis Anaerobic and fungal infections

11. Assessment... l Acute versus chronic l By wound type l Acute versus chronic l By wound type

12. Chemotherapy extravasation: assessment l Type of chemotherapy Vesicant, eg, doxorubicin Irritant, eg, carmustine Non-irritants, eg, fluorouracil l Extent Volume of extravasation and time Seconds, minutes, hours l Involved anatomy l Type of chemotherapy Vesicant, eg, doxorubicin Irritant, eg, carmustine Non-irritants, eg, fluorouracil l Extent Volume of extravasation and time Seconds, minutes, hours l Involved anatomy

13. Radiation: assessment l Radiation sensitizers Topical agents Drugs, including chemotherapy l Dose and fractionation schedule Expected course l Radiation sensitizers Topical agents Drugs, including chemotherapy l Dose and fractionation schedule Expected course

14. Decubitus ulcers l Assessment Risk factors l Prevention Skin protection – shear / tear / moisture Pressure reduction and pressure relief l Assessment Risk factors l Prevention Skin protection – shear / tear / moisture Pressure reduction and pressure relief

15. Decubitus ulcers: staging 1.Non-blanchable erythema 2.Partial-thickness skin loss 3.Full-thickness skin loss 4.Extensive necrosis exposing muscle or bone 1.Non-blanchable erythema 2.Partial-thickness skin loss 3.Full-thickness skin loss 4.Extensive necrosis exposing muscle or bone

16. Management l Acute versus chronic l By wound type l Acute versus chronic l By wound type

17. Necrotic wound: management l Debridement Surgical Enzymes and gels Mechanical Pain control l Cleansing l Debridement Surgical Enzymes and gels Mechanical Pain control l Cleansing

18. Chemotherapy extravasation: management l Contain damage Stop infusion Neutralize l Assess for surgical consultation l Watch and wait l Contain damage Stop infusion Neutralize l Assess for surgical consultation l Watch and wait

19. Radiation: management l Promote healing Avoid cytotoxic agents Moist environment Treat infection Pain control l Promote healing Avoid cytotoxic agents Moist environment Treat infection Pain control

20. Decubitus ulcers: management l Goals: healing vs non-healing l Healing Debridement Dressings that promote healing l Non-healing Pain control, comfort Prevent worsening l Goals: healing vs non-healing l Healing Debridement Dressings that promote healing l Non-healing Pain control, comfort Prevent worsening

21. l Moist, interactive environment l Control infection l 6 types of dressing FoamsAlginatesHydrogelsHydrocolloids Thin films Cotton gauze l Moist, interactive environment l Control infection l 6 types of dressing FoamsAlginatesHydrogelsHydrocolloids Thin films Cotton gauze Decubitus ulcers: dressing

22. Malignant wounds: management l Healing vs non-healing l Infections l Odors l Pain l Exudate l Bleeding l Healing vs non-healing l Infections l Odors l Pain l Exudate l Bleeding

23. Odors l Topical and / or systemic antibiotics Metronidazole Silver sulfadiazine l Kitty litter l Activated charcoal l Vinegar l Burning candles l Topical and / or systemic antibiotics Metronidazole Silver sulfadiazine l Kitty litter l Activated charcoal l Vinegar l Burning candles

24. EPECEPECOOEPECEPECOOO EPECEPECOOEPECEPECOOO Summary Use comprehensive assessment and pathophysiology-based therapy to treat the cause and improve the cancer experience