文章 APA Rupert, K. L., & Fehl, A. J. (2020).

A patient-centered approach for the treatment of

fungating breast wounds. Journal of Advanced Practitioners in Oncology, 11(5), 503-510.
https://doi.org/10.6004/jadpro.2020.11.5.6
內文 APA (Rupert & Fehl, 2020)
作者/年代 (Rupert & Fehl, 2020)
研究目的
研究方法
研究結果
整合
可以運用 01. Gobally, there are over one million cases of breast cancer diagnosed each year (Global
的地方 Cancer Obsevatory, 2019). Locally advanced breast cancer accounts for 10% to 30%
of new breast cancer diagnoses (Gao, Edlund, & Yuan, 2017). Approximately 2% to
5% of locally advanced breast cancers develop a fungating breast wound (FBW;
Lund-Nielsen, Müller, & Adamsen, 2005). An FBW is due to an infiltration of
malignant cells in the skin that causes breakdown, inflammation, and infection
(Gozzo, Tahan, Andrade, Nascimento, & Prado, 2014). Clinically, FBW can present as
a firm, painful, vascular, ulcerated, exudative, inflamed, malodorous lesion. Due to the
nature of FBW and the limited life expectancy of 6 months to 1 year, it is imperative
that regional control be maximized to help alleviate pain and bleeding, and improve
quality of life (Gozzo et al., 2014). Despite advancements made in the treatment of
locally advanced breast cancer, management of FBW remains challenging. Fungating
breast wounds are a poorly understood and understudied subset of locally advanced
breast cancer. As a result, there are limited resources to highlight the optimal
management of patients with FBW. Comprehensive care of FBW involves a
multidisciplinary approach to treat the malignancy, provide pain control, care for the
wound, and provide social and psychological support.
02. 全球每年診斷出超過一百萬例乳癌病例（全球癌症觀察中心，2019 年）。局部
晚期乳癌佔新乳癌診斷的 10%至 30%。大約 2%至 5%的局部晚期乳癌患者會出
現真菌性乳房傷口。FBW 是由惡性細胞滲入皮膚引起的破壞、發炎和感染所
致。在臨床上，FBW 可能表現為硬塊、疼痛、血管擴張、潰爛、滲出、發炎和
惡臭的病變。由於 FBW 的特性以及有限的 6 個月至 1 年的預期壽命，最大程度
地控制區域病變是至關重要的，以幫助緩解疼痛和出血，改善生活質量。儘管
在局部晚期乳癌治療方面取得了進展，但 FBW 的管理仍然具有挑戰性。真菌性
乳房傷口是局部晚期乳癌中一個鮮為人知且研究不足的亞型。因此，有限的資
源突顯了如何最佳管理患有 FBW 的患者。對 FBW 的全面護理需要多學科的方
法來治療惡性腫瘤、控制疼痛、護理傷口，以及提供社會和心理支持(Rupert &
Fehl, 2020)。
03. Wound care is a crucial element of the management of FBW. Data regarding wound
care is limited, and the literature repeatedly points to a lack of consistency in practice
(da Costa Santos, de Mattos Pimenta, & Nobre, 2010; Gozzo et al., 2014). Much of
the literature available is old, and the studies are on a small scale. Repeatedly noted is
 a lack of consistency in practice and of guidelines and knowledge.
04. 傷口護理是 FBW 管理的關鍵要素。有關傷口照護的資料有限，文獻一再指出
實務上缺乏一致性。許多現有文獻都是舊的，而且研究規模也很小。人們一再
指出實踐、指南和知識缺乏一致性(Rupert & Fehl, 2020)。
05. Dressing selection is made based on the properties of the wound and the dressing.
Various materials and treatments are available, and most of these are manufactured by
readily accessible manufacturers. Popular online retailers provide dressing supplies
that can be easily purchased by patients without prescriptions. The frequency of
dressing changes varies based on the amount of exudate (European Oncology Nursing
Society, 2015).
06. 根據傷口和敷料的特性選擇敷料。有多種材料和處理方法可供選擇，其中大多
數是由容易獲得的製造商製造的。受歡迎的線上零售商提供敷料用品，患者無
需處方即可輕鬆購買。更換敷料的頻率根據滲出液的量而變化(Rupert & Fehl,
2020)。
07. Recommendations in the literature include consultation and collaboration with wound
care nurses (European Oncology Nursing Society, 2015; Tilley, Lipson, & Ramos,
2016; Winnipeg Regional Health Authority, 2006). Lack of access to certified wound
care nurses and lack of knowledge about how to access these resources often lead to
an oncologist or oncology advanced practitioner directing the care of an FBW.
Controlling odor, bleeding, and exudate can be done with appropriate care (see Table
1).
08. 文獻中的建議包括與傷口護理護理師進行諮詢和合作。由於無法獲得經過認證
的傷口護理護理師以及缺乏如何獲得這些資源的知識，通常會導致由腫瘤科醫
生或腫瘤學高級執業醫師來指導 FBW 的護理。透過適當的護理可以控制氣
味、出血和滲出液(Rupert & Fehl, 2020)。
09. Providing wound care can improve the quality of life and decrease symptoms. Lund-
Nielsen and colleagues (2005) report a prospective exploratory study of 12 women
with malignant fungating masses. The women were assessed, treated, and educated.
Overall, the wounds were smaller at the end of the intervention. With intervention,
75% of the wounds had improved when measuring the level of malodor, amount of
bleeding, and amount of seepage. One wound completely healed. Three wounds
progressed, and it should be noted that those women were also off systemic therapy.
Social isolation and anxiety decreased. The frequency with which dressings were
changed decreased (Lund-Nielsen et al., 2005).
10. 提供傷口護理可以改善生活品質並減少症狀。Lund-Nielsen 及其同事 (2005) 報
告了一項針對 12 名患有惡性真菌腫塊的女性的前瞻性探索性研究。這些婦女接
受了評估、治療和教育。整體而言，幹預結束時傷口較小。透過幹預，在測量
惡臭程度、出血量和滲漏量時，75% 的傷口有所改善。一處傷口完全癒合。三
個傷口出現了進展，值得注意的是，這些女性也停止了全身性治療。社會孤立
和焦慮減少。更換敷料的頻率減少了(Rupert & Fehl, 2020)。
11. Wound care can be provided in the clinic as part of the assessment of the wound. It is
 important to note the size, color, amount of exudate, appearance of exudate, and pain.
The Malignant Wound Assessment Tool (MWAT) has been validated, although is not
commonly used (Savage, Murphy-Kane, Lee, Suet-Lam Chung, Howell, 2019).
Particularly useful in this tool is the question “What bothers you most about having
the wound?” This allows the provider to gather important information to guide care.
Photographs can be helpful and used according to institutional policy. Patients with
home care can also receive assistance from their home care services.
12. 作為傷口評估的一部分，可以在診所提供傷口護理。重要的是要注意滲出液的
大小、顏色、量、滲出液的外觀和疼痛。惡性傷口評估工具 (MWAT) 已被驗
證，但並不常用。該工具特別有用的問題是“傷口讓您最煩惱的是什麼？” 這
使得提供者能夠收集重要資訊來指導護理。照片可能會有幫助，並根據機構政
策使用。接受居家照護的患者也可以獲得居家照護服務的協助(Rupert & Fehl,
2020)。
13. Exudate
Malignant wounds cause tissue to become necrotic in a manner that presents as moist,
yellow slough instead of the dry, black eschar of other necrotic tissues. Exudate is
partially from autolysis of necrotic tissue. Irregular cellular perfusion contributes to
exudate. Exudate can also be caused by colonized bacteria activating proteases that
break down necrotic tissue, causing it to liquefy (da Costa Santos et al., 2010).
Additionally, tumor vasculature has increased capillary permeability (Gozzo et al.,
2014). Infection risk is increased in the setting of exudate.
This moist environment requires a dressing that can accommodate moisture and help
debride the wound (Seaman, 2006). Exudate also compromises skin around the
wound, leading to breakdown and maceration of the surrounding skin or enlargement
of the wound itself. Therefore, the surrounding skin must be protected as well.
Alginate and hydrofiber foam dressings are absorbent, and therefore appropriate
choices in malignant wounds with exudate. Both also boast properties of easy
removal, thereby decreasing pain.
Alginate dressings are nonadhesive pads (or ribbons) made of polysaccharide fibers or
xerogel derived from seaweed. They need a moist environment to become activated by
an ion exchange that transforms it to a gel that can absorb up to 20 times its weight in
exudate (Wound management and prevention, 2020; Wound source, 2020). It requires
a second dressing to hold it in place but is a good choice for highly exudative wounds.
Some alginate dressings are also impregnated with silver for antimicrobial properties.
Hydrofiber foam dressings are sheets of foamed polymer solutions (often
polyurethane) with open cells that hold fluid (Wound source, 2020). They can be
impregnated with other materials, such as silver. The dressings vary in absorption
capacity based on the size and material. Hydrofiber foam dressings are available with
an adhesive border, but malignant wounds often do not conform to the size restrictions
of the border, so ones without borders are more appropriate.
Mesalt dressings by Mölnlycke are absorbent material, viscose or polyester,
 impregnated with sodium chloride, which is released when it comes in contact with
moisture. Sodium chloride promotes wound healing and stimulates cleansing. It
should not be used in wounds with low exudate (da Costa Santos et al., 2010).
14. 滲出物
惡性傷口導致組織壞死，表現為潮濕、黃色的腐肉，而不是其他壞死組織的乾
燥、黑色焦痂。滲出物部分來自壞死組織的自溶。不規則的細胞灌注導致滲
出。滲出液也可能是由定植細菌活化蛋白酶引起的，蛋白酶會分解壞死組織，
導致其液化。此外，腫瘤脈管系統毛細血管通透性增加。滲出液的情況下感染
風險會增加(Rupert & Fehl, 2020)。
這種潮濕的環境需要能夠容納水分並幫助清創傷口的敷料。滲出液也會損害傷
口周圍的皮膚，導致周圍皮膚破裂和浸漬或傷口本身擴大。因此，周圍的皮膚
也必須受到保護。海藻酸鹽和水纖維泡棉敷料具有吸水性，因此是有滲出液的
惡性傷口的適當選擇。兩者還具有易於去除的特性，從而減少疼痛(Rupert &
Fehl, 2020)。
海藻酸鹽敷料是由多醣纖維或源自海藻的乾凝膠製成的非粘性墊（或帶）。它
們需要潮濕的環境才能被離子交換激活，離子交換將其轉化為凝膠，可以吸收
高達其重量 20 倍的滲出液(Rupert & Fehl, 2020)。它需要第二層敷料將其固定到
位，但對於高度滲出的傷口來說是一個不錯的選擇。一些藻酸鹽敷料也浸漬銀
以具有抗菌特性。
水纖維泡棉敷料是泡棉聚合物溶液（通常是聚氨酯）片材，具有可容納液體的
開孔(Rupert & Fehl, 2020)。它們可以用其他材料浸漬，例如銀。敷料的吸收能
力因尺寸和材料而異。水纖維泡棉敷料有黏合邊框的，但惡性傷口往往不符合
邊框的尺寸限制，因此無邊框的更為合適。
Mölnlycke 的 Mesalt 敷料是吸收性材料，黏膠或聚酯，浸漬有氯化鈉，與濕氣
接觸時會釋放氯化鈉。氯化鈉促進傷口癒合並促進清潔。它不應該用於滲出量
低的傷口(Rupert & Fehl, 2020)。
15. Moisture-Associated Skin Damage
Prevention and management of moisture-associated skin damage (MASD) is
important in helping to prevent growth of the wound. Macerated skin can appear pale,
wrinkled, grey, or white. It also can present as erythematous skin with swelling, pain,
or pruritis (Tilley et al., 2016). Liquid polymer acrylates are applied to the skin prior
to application of the dressing. They do not interfere with the dressing and can protect
the skin from maceration and injury. Zinc oxide–based ointments and petrolatum-
based ointments are messy, difficult to remove, and interfere with adhesives. They are
less appropriate for a breast wound and more appropriate for malignant wounds that
are frequently exposed to urine or feces. If the surrounding skin is sensitive to
adhesives, an ostomy skin barrier can be applied, which acts as a second skin, and the
dressing can then be taped to that. The ostomy barrier only needs to be changed every
5 to 7 days, while the dressing on top can be changed multiple times without further
damage to the surrounding skin.
16. 與水分相關的皮膚損傷
 預防和管理與水分相關的皮膚損傷 (MASD) 對於幫助防止傷口生長非常重要。
浸漬的皮膚可能會顯得蒼白、皺紋、灰色或白色。它也可能表現為紅斑皮膚，
伴隨腫脹、疼痛或搔癢(Rupert & Fehl, 2020)。在敷用敷料之前將液態聚合物丙
烯酸酯施用於皮膚。它們不會幹擾敷料，並且可以保護皮膚免受浸漬和傷害。
氧化鋅基軟膏和凡士林軟膏很髒，難以去除，並且會幹擾黏合劑。它們不太適
合乳房傷口，更適合經常接觸尿液或糞便的惡性傷口。如果周圍的皮膚對黏合
劑敏感，則可以應用造口皮膚屏障，它充當第二層皮膚，然後可以將敷料粘在
其上。造口屏障只需每 5 至 7 天更換一次，而頂部的敷料可以多次更換，不會
進一步損壞周圍的皮膚(Rupert & Fehl, 2020)。
17. Odor
Care of the patient with malignant wounds includes odor management to improve
quality of life (QOL). Most of the odor is caused by anaerobic microorganisms
breaking down necrotic tissue (da Costa Santos et al., 2010). Approaches include
treating infection and masking odor, often in combination. Patient and caregivers
report that malodor is the worst aspect of a fungating wound and impacts QOL of all
parties (Alexander, 2010).
Topical metronidazole comes in several forms and is inexpensive. It comes as a topical
gel, lotion, or solution. It can be prepared by crushing tablets and mixing in sterile
water, 5 mg/mL or 10 mg/mL (Seaman, 2006). After 2 to 3 days of application, odor
has been shown to be reduced (Gozzo et al., 2014). Topical metronidazole is a grade B
recommendation.
Less studied and less commonly used options may also be helpful. Activated charcoal
dressings filter odor, but can be expensive. If these are used, the wound must be
thoroughly cleaned to ensure that it is all removed from the surface of the wound
during dressing changes (Gozzo et al., 2014). Medical-grade honey can provide
autolytic debridement and antibacterial effects (European Oncology Nursing Society,
2015).
Topical antimicrobial Iodosorb gel is iodine in a starch copolymer in a slow-release
formulation. Applied in a 1/8-inch layer, each gram absorbs 3 mL of fluid and
decreases bacterial counts (Seaman, 2006). Application may be uncomfortable or
produce a burning sensation.
Curcumin and carbon are grade B recommendations for odor reduction. Curcumin
ointment is a compound of turmeric. Activated carbon promotes absorption of
bacterial spores that are responsible for odor. Grade C recommendations include
arsenic trioxide, essential oils, and green tea extract (da Costa Santos et al., 2010).
18. 氣味
惡性傷口患者的照護包括氣味管理以提高生活品質 (QOL)。大多數氣味是由厭
氧微生物分解壞死組織引起的(Rupert & Fehl, 2020)。方法包括治療感染和掩蓋
氣味，通常結合使用。患者和照護者報告說，惡臭是真菌性傷口最嚴重的方
面，會影響各方的生活品質(Rupert & Fehl, 2020)。
外用甲硝唑有多種形式，而且價格便宜。它有外用凝膠、乳液或溶液的形式。
 它可以透過壓碎片劑並在無菌水中混合來製備，濃度為 5 mg/mL 或 10 mg/mL
(Rupert & Fehl, 2020)。使用 2 至 3 天后，氣味明顯減少(Rupert & Fehl, 2020)。
外用甲硝唑是 B 級推薦。
研究較少和不常用的選項也可能有所幫助。活性碳敷料可以過濾異味，但價格
昂貴。如果使用這些，必須徹底清潔傷口，以確保在更換敷料時將其全部從傷
口表面清除(Rupert & Fehl, 2020)。醫用級蜂蜜可以提供自溶清創和抗菌作用
(Rupert & Fehl, 2020)。
局部抗菌 Iodosorb 凝膠是一種澱粉共聚物中的碘緩釋製劑。應用在 1/8 英吋的
層中，每克吸收 3 mL 的液體並減少細菌數量。使用時可能會感到不舒服或產
生灼熱感(Rupert & Fehl, 2020)。
薑黃素和碳是減少氣味的 B 級建議。薑黃素軟膏是薑黃的化合物。活性碳可促
進產生氣味的細菌孢子的吸收。C 級建議包括三氧化二砷、精油和綠茶萃取物
(Rupert & Fehl, 2020)。
19. Bleeding
Bleeding in malignant wounds is a result of hemostasis imbalance (Gozzo et al.,
2014), caused by disruption of the clotting cascade by the tumor. Gozzo and
colleagues (2014) report that it is the most common symptom. Prevention is the
primary treatment: proper dressing selection, wound cleansing, nonadherent dressings,
and gentle dressing changes (Gozzo et al., 2014). Trauma and dressing changes can
worsen bleeding. Treatment is directed by the severity of bleeding.
Minor bleeding, which can be controlled at the bedside, can be topically managed with
direct pressure. Pressure can be applied with gauze saturated with epinephrine (1 mg
epinephrine: 1 mL NS) for 10 minutes (Tilley et al., 2016). Silver nitrate sticks can
control bleeding, but they can also be painful and must be applied with each dressing
change (Tilley et al., 2016). Calcium alginate can control bleeding but runs the risk of
remaining embedded in the wound with dressing changes (Tilley et al., 2016).
Absorbable gelatin and collagen dressings can control bleeding (Seaman, 2006). If the
wound constantly oozes a small amount of blood, sucralfate paste (Carafate) can be
compounded by dissolving a 1-g tablet in 5 mL of a water-soluble gel and applied
(Seaman, 2006).
Major bleeding requires more aggressive interventions. At this point, vascular surgery
or interventional radiology consults are appropriate. If this worsens to hemorrhage, it
may result in death. Comfort measures include towels to absorb the bleeding, as well
as blankets to offset the cold sensation of blood loss. Benzodiazepines and opioids are
also appropriate in this phase (Tilley et al., 2016).
If one searches the internet for methods to control bleeding, they may come across
some dangerous recommendations, particularly that of Mohs’ paste, which is zinc
chloride. It is sold under the title of “black salve,” or Cansema. There are Japanese
case studies that report using Mohs’ paste (Kakimoto, Hiromi, Okamura, & Yoshino,
2010; Yanazume, Douzono, Yanazume, Iio, & Douchi, 2013) to control bleeding from
malignant wounds; however, there are no data from controlled trials, and case reports
 of harm exist in the literature (Eastman, McFarland, & Raugi, 2013). In particular, the
brand Cansema is marketed and prevalent on the internet. Many of these black salves
contain bloodroot, which has been shown to have many toxicities. The U.S. Food &
Drug Administration has taken action against companies selling bloodroot products. It
is important for health-care providers to be aware of the prevalence and accessibility
of these potentially harmful products, so that patients can be educated on avoiding
them.
20. 流血的
惡性傷口出血是止血失衡的結果，這是由腫瘤破壞凝血級聯引起的。Gozzo 及
其同事（2014）報告說，這是最常見的症狀。預防是主要治療方法：正確選擇
敷料、清潔傷口、使用非黏性敷料以及溫和地更換敷料（Gozzo 等，2014）。
創傷和換藥可能會加重出血。根據出血的嚴重程度來指導治療(Rupert & Fehl,
2020)。
輕微出血可以在床邊控制，也可以透過直接按壓進行局部治療。可以用浸有腎
上腺素（1 mg 腎上腺素：1 mL NS）的紗布施加壓力 10 分鐘(Rupert & Fehl,
2020)。硝酸銀棒可以控制出血，但也可能帶來疼痛，並且必須在每次更換敷料
時使用(Rupert & Fehl, 2020)。海藻酸鈣可以控制出血，但在更換敷料時有嵌入
傷口的風險(Rupert & Fehl, 2020)。可吸收的明膠和膠原蛋白敷料可以控制出
血。如果傷口不斷滲出少量血液，可以將 1 克片劑溶解在 5 毫升水溶性凝膠中
配製硫糖鋁糊劑（Carafate）並塗抹(Rupert & Fehl, 2020)。
大出血需要更積極的干預措施。此時，血管外科或介入放射科會診是適當的。
如果情況惡化為出血，可能會導致死亡。舒適措施包括用毛巾吸收出血，以及
用毯子抵抗消失血帶來的寒冷感。苯二氮平類藥物和鴉片類藥物也適合此階段
(Rupert & Fehl, 2020)。
如果人們在網路上搜尋控制出血的方法，他們可能會遇到一些危險的建議，尤
其是莫氏糊劑，它是氯化鋅。它以“黑藥膏”或 Cansema 的名稱出售。日本有
案例研究報告使用莫氏膏(Rupert & Fehl, 2020)來控制惡性傷口出血；然而，沒
有對照試驗的數據，且文獻中存在傷害案例報告尤其是 Cansema 品牌在網路上
進行行銷和流行。許多黑藥膏含有血根草，已被證明具有多種毒性。美國食品
藥物管理局已對銷售血根產品的公司採取行動。對於醫療保健提供者來說，了
解這些潛在有害產品的流行程度和可近性非常重要，以便可以教育患者避免使
用這些產品(Rupert & Fehl, 2020)。
21. Pain
Malignant wounds are a significant source of pain. Pain can be related to the tumor
itself as it presses against other structures. It can be secondary to edema or to
infection. Nerve endings can be exposed leading to pain. Dressing changes themselves
are a source of pain, as are debriding agents. Pain from FBW often causes sleep
disturbances because it becomes difficult to sleep in a comfortable position, thus
resulting in muscular discomfort and routine sleep deprivation.
In addition to opioids for pain management, changing the dressing regimen can
decrease pain. Using moisture-retentive dressings decreases the number of dressing
 changes needed. Soaking the dressing prior to removal with either sterile normal
saline or tap water loosens the dressing and prevents retention in the wound bed or
tearing of the tissue (Seaman, 2006; Tilley et al., 2016). Nonadherent dressings also
prevent tearing of the tissue on removal. Antimicrobial agents can reduce pain
secondary to infection. Securing dressings with nonadhesive alternatives such as burn
netting, elastane (Lycra), or surgical bras can reduce pain to periwound skin. Ostomy
skin barriers can reduce the need for adhesive changes and protect the periwound skin
from repeated trauma from adhesive use (Seaman, 2006; Tilley et al., 2016).
Topical pain control can also be helpful. Topical anesthetics (2% lidocaine jelly) can
be applied 3 to 5 minutes before wound care. Topical opioids such as 10 mg morphine
in 8 g hydrogel can be mixed by compounding pharmacies (Seaman, 2006).
Itching of skin lesions and periwound areas contributes to pain. This can be treated
orally with an antihistamine like hydroxyzine. Topical steroids can be used if they are
found to be helpful, as well as topical antihistamines or calamine preparations
(Winnipeg Regional Health Authority, 2014).
22. 疼痛
惡性傷口是疼痛的重要來源。疼痛可能與腫瘤本身有關，因為它壓迫其他結
構。它可能繼發於水腫或感染。神經末梢可能暴露，導致疼痛。換藥本身就是
疼痛的根源，清創劑也是。FBW 引起的疼痛通常會導致睡眠障礙，因為很難以
舒適的姿勢入睡，導致肌肉不適和日常睡眠不足。
除了使用鴉片類藥物控制疼痛外，改變敷料方案也可以減輕疼痛。使用保濕敷
料可以減少需要更換敷料的次數。在去除敷料之前用無菌生理食鹽水或自來水
浸泡敷料可以使敷料鬆動，並防止保留在創面床上或撕裂組織(Rupert & Fehl,
2020)。非黏性敷料還可以防止移除時組織撕裂。抗菌劑可以減輕感染繼發的疼
痛。使用燒傷網、彈性纖維（萊卡）或手術胸罩等非黏性替代品固定敷料可以
減輕傷口周圍皮膚的疼痛。造口皮膚屏障可以減少更換黏合劑的需要，並保護
創週皮膚免受黏合劑使用造成的反覆創傷(Rupert & Fehl, 2020)。
局部疼痛控制也有幫助。可以在傷口護理前 3 至 5 分鐘使用表面麻醉劑（2%
利多卡因果凍）。局部鴉片類藥物，如 8 克水凝膠中的 10 毫克嗎啡，可以透
過配製藥房進行混合(Rupert & Fehl, 2020)。
皮膚損傷和傷口周圍區域的搔癢會導致疼痛。可以口服羥嗪等抗組織胺藥物來
治療。如果發現有幫助，可以使用外用類固醇，以及外用抗組織胺或爐甘石製
劑(Rupert & Fehl, 2020)。
23. Nutritional Management
Malignant wounds are no different from other wounds in that they have a high
metabolic demand. The patient’s protein intake should be 1.5 to 2.5 g/kg body weight
per day to promote healing (Winnipeg Regional Health Authority, 2006). The
micronutrients zinc, vitamin A, vitamin E, and vitamin C promote wound healing.
24. 營養管理
惡性傷口與其他傷口沒有什麼不同，因為它們具有很高的代謝需求。患者的蛋
白質攝取量應為每天 1.5 至 2.5 克/公斤體重，以促進癒合。微量營養素鋅、維
 生素 A、維生素 E 和維生素 C 促進傷口癒合(Rupert & Fehl, 2020)。
25. Practical Approach to Wound Care
Lund-Nielsen and colleagues (2005) lay out the steps to dressing changes in the home
or office. The first step is to rinse the wound with tap water. If there is exposed bone,
sterile water should be used. Next, the area should be washed with liquid medicinal
soap with a pH between 4 to 6, which is close to that of the skin. Chlorhexidine
gluconate 4% is one option. After cleansing, assessment of the wound can be
performed. If it is a wound with high exudate, the wound edges should be protected
with barrier cream. If using metronidazole topically, it can be applied at this time,
prior to dressing application. Dressings that are treated with an agent are applied
directly to the wound, then the absorbent dressings applied over that. For example, if
using a charcoal dressing, it is applied directly to the wound. If using hydrogel for dry
necrosis, it is applied directly to the wound. The absorbent dressing is applied on top
of that, followed by securing material or adhesive (Lund-Nielsen et al., 2005).
26. 傷口護理的實用方法
27. Lund-Nielsen 及其同事（2005）列出了在家中或辦公室更換衣服的步驟。第一步
是用自來水沖洗傷口。如果有骨頭裸露，應使用無菌水。接下來，用 pH 值在 4
至 6 之間、接近皮膚 pH 值的液體藥皂清洗該區域。4% 葡萄糖酸氯己定是一種
選擇。清潔後，可以對傷口進行評估。如果是滲出液較多的傷口，應使用隔離
膏保護傷口邊緣。如果局部使用甲硝唑，可以在敷料之前此時使用。將經過藥
劑處理的敷料直接敷在傷口上，然後將吸收性敷料敷在傷口上。例如，如果使
用木炭敷料，則將其直接塗在傷口上。如果使用水凝膠治療乾性壞死，則直接
塗在傷口上。將吸收性敷料應用在其頂部，然後使用固定材料或黏合劑（Lund-
Nielsen 等人，2005）。
28. ECONOMIC BURDEN
Appropriate wound care of FBW requires specific topical ointments and dressings,
thus leading to issues with accessibility and cost (Ivetiç & Lyne, 1990). Frequent
dressing changes increase the financial burden of dressing supplies. Frequency of
dressing changes can be decreased by appropriate dressing selection, but these
products can be expensive, particularly if a patient has limited financial resources.
Additionally, patients often require daily help with dressing changes, thus relying
heavily on caregivers for assistance. The financial burden of wound care is only one
aspect of the psychosocial complications that patients with FBW experience.
29. 經濟負擔
FBW 的適當傷口護理需要特定的外用藥膏和敷料，從而導致可及性和成本問
題。頻繁更換敷料會增加敷料供應的經濟負擔。透過選擇適當的敷料可以減少
更換敷料的頻率，但這些產品可能很昂貴，特別是在患者經濟資源有限的情況
下。此外，患者經常需要日常幫助換藥，因此嚴重依賴護理人員的幫助。傷口
照護的經濟負擔只是 FBW 患者所經歷的社會心理併發症的一個面向(Rupert &
Fehl, 2020)。
30. PSYCHOSOCIAL COMPLICATIONS
 Although medical management of FBW is difficult, there are numerous social and
psychological issues that are equally challenging. Fungating wounds lead to patients
experiencing poor self-image. Many patients report embarrassment, shame, anger,
anxiety, and guilt as a result of a fungating wound (Ivetiç & Lyne, 1990). In a study by
Probst and colleagues (2013), FBW patients reported that they felt they were losing
control over their bodies due to the visible manifestation of their cancer. Forty-two
percent of women reported that their wound has a negative influence on their
femininity (Lund-Nielsen et al., 2005). The negative influence on their femininity
included body image disturbances, restriction of clothing options, and lack of a sex
life. During sexual activity, partners of FBW patients reported fear of causing pain or
discomfort, thus resulting in reduced episodes of intimacy (Young, 2017).
Additionally, poor self-image is exacerbated by the anxiety that is associated with
participating in social events, thus ultimately leading to social isolation. Women with
FBW become anxious in social settings due to their malodorous, bulky, bleeding
lesions and thus have limited interactions with other individuals. Similarly, FBW also
limits clothing options for women to participate in social events.
Since clinical depression is common among women with FBW, comprehensive
treatment should include medication and counseling services. Individual counseling
with cognitive behavioral therapy has shown some benefit to patients (Maida,
Alexander, Case, & Fakhraei, 2016). However, dedicated FBW support groups are
rare. Because of the many physical and psychosocial complications of FBW, it is
imperative that medical providers use a comprehensive approach to care for
individuals with FBW.
Similarly, caregivers are affected by FBW. Caregivers of fungating wounds were
found to have higher levels of burnout (Alexander, 2010). A study showed that
caregivers experience significant distress during dressing changes due to the labor-
intensive process, close encounter with a malodorous wound, and emotional trauma
associated with repeat visible exposure to the cancerous lesion (Alexander, 2010).
31. 社會心理併發症
儘管 FBW 的醫療管理很困難，但還有許多同樣具有挑戰性的社會和心理問
題。蕈狀傷口會導致患者自我形像不佳。許多患者表示因蕈狀傷口而感到尷
尬、羞恥、憤怒、焦慮和內疚。在 Probst 及其同事 (2013) 的一項研究
中，FBW 患者報告稱，由於癌症的明顯表現，他們感覺自己正在失去對身體的
控制。42% 的女性表示，她們的傷口對她們的女性氣質產生了負面影響。對她
們女性氣質的負面影響包括身體形象失調、服裝選擇受到限制、缺乏性生活。
在性活動期間，FBW 患者的伴侶報告擔心疼痛或不適，從而導致親密行為減少
(Rupert & Fehl, 2020)。
此外，參與社交活動帶來的焦慮會加劇不良的自我形象，最終導致社會孤
立。FBW 女性由於其惡臭、大塊、出血性病變而在社交場合變得焦慮，因此與
其他人的互動受到限制。同樣，FBW 也限制了女性參與社交活動的服裝選擇。
由於臨床憂鬱症在 FBW 女性中很常見，因此綜合治療應包括藥物和諮詢服
務。認知行為療法的個別諮詢已顯示出對患者的一些益處。然而，專門的 FBW
支援小組很少。由於 FBW 會帶來許多身體和心理社會併發症，醫療服務提供
者必須採用全面的方法來照顧 FBW 患者(Rupert & Fehl, 2020)。
同樣，護理人員也會受到 FBW 的影響。研究發現，蕈狀傷口的護理人員的倦
怠程度較高。一項研究表明，由於勞動密集過程、近距離接觸惡臭傷口以及與
重複可見的癌性病變相關的情緒創傷，護理人員在換藥過程中會經歷顯著的痛
苦(Rupert & Fehl, 2020)。