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Nursing Diagnosis:Risk for Impaired Skin/Tissue Integrity

Risk factors may include

  • Effects of radiation and chemotherapy
  • Immunologic deficit
  • Altered nutritional state, anemia

Possibly evidenced by
[Not applicable; presence of signs and symptoms establishes an actual diagnosis]

Desired outcomes

  • Identify interventions appropriate for specific condition.
  • Participate inEncourage patient to avoid vigorous rubbing and scratching and to pat skin dry instead of rubbing.techniques to prevent complications/promote healing as appropriate.
Nursing actionsRationale
Assess skin frequently for side effects of cancer therapy; note breakdown/delayed wound healing. Emphasize importance of reporting open areas to caregiver.A reddening and/or tanning effect (radiation reaction) may develop within the field of radiation. Dry desquamation (dryness and pruritus), moist desquamation (blistering), ulceration, hair loss, loss of dermis and sweat glands may also be noted. In addition, skin reactions (e.g., allergic rashes, hyperpigmentation, pruritus, and alopecia) may occur with some chemotherapy agents.
Bathe with lukewarm water and mild soap.Maintains cleanliness without irritating the skin.
Encourage patient to avoid vigorous rubbing and scratching and to pat skin dry instead of rubbing.Helps prevent skin friction/trauma to sensitive tissues.
Turn/reposition frequently.Promotes circulation and prevents undue pressure on skin/tissues.
Avoid rubbing or use of soap, lotions, creams, ointments, powders or deodorants on area; avoid applying heat or attempting to wash off marks/tattoos placed on skin to identify area of irradiation;Can potentiate or otherwise interfere with radiation delivery. May actually increase irritation/reaction.
Recommend wearing soft, loose cotton clothing; have female patient avoid wearing bra if it creates pressure;Skin is very sensitive during and after treatment, and all irritation should be avoided to prevent dermal injury.
Encourage liberal use of sunscreen/block and breathable, protective clothing.Protects skin from ultraviolet rays and reduces risk of recall reactions.
Use appropriate peripheral or central venous catheter, dilute anticancer drug per protocol and ascertain that IV is infusing well;Reduces risk of tissue irritation/extravasation of agent into tissues.
Instruct patient to notify caregiver promptly of discomfort at IV insertion site;Development of irritation indicates need for alteration of rate/dilution of chemotherapy and/or change of IV site to prevent more serious reaction.
Assess skin/IV site and vein for erythema, edema, tenderness; weltlike patches, itching/burning; or swelling, burning, soreness; blisters progressing to ulceration/tissue necrosis.Presence of phlebitis, vein flare (localized reaction) or extravasation requires immediate discontinuation of antineoplastic agent and medical intervention.
Wash skin immediately with soap and water if antineoplastic agents are spilled on unprotected skin (patient or caregiver)Dilutes drug to reduce risk of skin irritation/chemical burn.
Advise patients receiving 5-fluorouracil (5-FU) and methotrexate to avoid sun exposure. Withhold methotrexate if sunburn present.Sun can cause exacerbation of burn spotting (a side effect of 5-fluorouracil) or can cause a red “flash” area with methotrexate, which can exacerbate drug’s effect.
Review expected dermatologic side effects seen with chemotherapy, e.g., rash, hyperpigmentation, and peeling of skin on palms.Anticipatory guidance helps decrease concern if side effects do occur.
Inform patient that if alopecia occurs, hair could grow back after completion of chemotherapy, but may/may not grow back after radiation therapy.Anticipatory guidance may help adjustment to/
preparation for baldness. Men are often as sensitive to hair loss as women. Radiation’s effect on hair follicles may be permanent, depending on rad dosage.
Administer appropriate antidote if extravasation of IV should occur.Reduces local tissue damage.
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