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Course: Oncology Nursing

Topic: Nursing Management of Tissue Integrity in Cancer Patient

The Nurses International Community

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Module Goals

Learners will be able to:

Identify cancer treatment procedures that affect skin integrity of the patient.
Describe how skin integrity is assessed and cared for in cancer patients.
Explain the concept of maintenance of tissue integrity for cancer patient in nursing care management and planning.
Identify information for patient education/counselling on self-care related to skin integrity.

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Cancer Treatment and Skin Integrity

Skin: largest body organ with vital functions

First defense barrier of the body from infection and damage.
Regulate temperature.
Eliminate some body waste through sweat.
Sensory organ for heat, cold, pain and other feelings.
Produce vitamin D.

Cancer and its treatment can cause undesirable skin changes.
Surgery and changes in activity level make skin prone to problems.

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Skin Related Side-effects of Cancer Treatment

Major skin related side-effects:

Dryness
Pruritus (Itching)
Rash
Swelling
Alopecia and Hair changes
Changes to Fingernails and Toenails
Pressure Sores
Mouth and Throat Problems
Skin color changes

National Cancer Institute (2019).

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Dryness of Skin

American Cancer Society, 2020, Dry skin.

Dry skin is rough, flaky, and sometimes red and painful.
Dry skin is caused by dehydration, heat, cold or poor nutrition.
Can be caused by: Chemotherapy, Radiation Therapy, Targeted Therapy, or Stem Cell Transplant.
Assessment of dry skin:

Red, rough, flaky
Can look normal
Cracks in the skin (Fissures)
Slight bleeding between the lines of skin

covering joints like knuckles or elbows

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Dryness of Skin: Nursing Management

Assist patient in applying emollient to hard-to-reach places.
Ensure patient is adequately hydrated.

Especially with patient on fluid restriction.

Provide patient/carer education:

Apply alcohol-free emollient twice daily.
Mineral or baby oil in warm bath water or apply to damp skin after shower.
Wash with cool or warm water, not hot water.
Avoid alcohol based products: colognes, after shaves, etc.
Use electric razor, or don’t shave.

American Cancer Society, 2020, Dry skin

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Pruritus

National Cancer Institute (2020).

Usually an unpleasant sensation that elicits desire to scratch.
Subjectively quantified by intensity, severity, location, and intractability.
Can be side-effect of Chemotherapy, Radiation Therapy, Targeted Therapy, Immunotherapy, Hormonal Therapy or Cancer itself.
Other causes of pruritus may include dry skin, infection, or condition that are not cancer.
Continuous itching can cause skin to break, bleed, or get infected from scratching.

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Pruritus

Cancer treatments that cause long-term itching include:

Healthline (2020)

Hormonal therapy like-

anastrozole (Arimidex)
exemestane (Aromasin)
fulvestrant (Faslodex)
letrozole (Femara)
raloxifene (Evista)
toremifene (Fareston)
tamoxifen (Soltamox)

Chemotherapy
Radiation therapy
Bortezomib (Velcade)
Brentuximab vedotin (Adcetris)
Ibrutinib (Imbruvica)
Interferons
Interleukin-2
Rituximab (Rituxan, MabThera)

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Pruritus

American Cancer Society, 2020, Itching
National Cancer Institute (2020)

Assessment¹:

Dry, red, rough, flaky skin
A yellowing of the skin or of the whites of eyes
Rash or bumps
Scratch marks
Skin sores
Scratching

Management interventions can be categorized into²:

Prevention and elimination of provocative factors
Topical therapies
Systemic therapies
Physical modalities

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Pruritus: Prevention and Elimination of Provocative Factors

Patient should avoid aggravating factors:

Bathing /washing with hot water
Extensive bathing of longer than 30 minutes
Using alcohol based products
Using products with scents, fragrances, perfumes, underarm deodorants or antiperspirants
Tight fitting clothing
Dry environment
Laundering sheets/clothings with detergents containing scents/dyes/preservatives
Emotional stress

National Cancer Institute (2020)

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Pruritus Management: Alleviating Factors

National Cancer Institute (2020)

Balanced diet of proteins, carbohydrates, fats, vitamins, minerals, and fluids.
Adequate hydration: 3000 mL daily recommended.
Bathing technique:

Tepid water is suitable for bathing.
Use mild cleansers/soap and only for dirty areas.
Bathing less than 30 minutes every day or every other day.
Gentle washing, patting dry instead of rubbing.

Clothing: cotton-made, without dyes/preservatives/scents, loose fitting.
Distraction, relaxation, positive energy.

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Pruritus Management: Topical Therapies

National Cancer Institute (2020)
Dreno et al. (2013)

Talcum and aluminium should be avoided throughout the course of radiotherapy¹.

metal ions enhance skin reactions during external-beam radiation.

Cornstarch should be avoided on moist surfaces to prevent fungal growth¹.

in moist skin
areas with hair/sebaceous glands/skin folds
areas close to mucosal surfaces like vagina/rectum

Dermatologist recommended emollient to be used daily².
Menthol, camphor, pramoxine or capsaicin cool, soothe, or inhibit itch sensations¹.

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Pruritus Management: Topical Therapies

Dilute bleach bath for significant skin breakdown from scratching or secondary infection

A half-cup sodium hypochlorite in half a tub of water for soaking
5 mL bleach to 1 gallon of water for sponge bath

Topical steroid :

Used for pruritic skin with associated primary dermatitis or inflammatory etiologies
Avoid on skin surfaces inside radiation field during the course of treatment

Source: National Cancer Institute (2020).

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Pruritus Management: Systemic Therapies

National Cancer Institute (2020).

Treatment directed towards underlying disease or control of symptoms.
Antibiotics for reducing symptoms associated to infection.
Antihistamines for histamines-related itching

Second generation antihistamines have

advantages over first generation:

Fewer adverse effects
Allow once-daily dosing
Less sedation

If one antihistamine is ineffective, one from other class may provide relief.
May not be useful for pruritus of neuropathic origin.

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Pruritus Management: Systemic Therapies

Pruritus Management: Physical Modalities

Antidepressants

Selective serotonin reuptake inhibitors and selective nor-epinephrine reuptake inhibitors are first line agents for psychogenic pruritus.

Aspirin has shown mixed results in alleviating pruritus.
Aprepitant has been used successfully in treatment of pruritus.

National Cancer Institute (2020)

Application of cool washcloth or ice over the site.
Firm pressure at the site, contralateral to it, and acupressure points.
Rubbing and vibration.
Cotton gloves at night to reduce scratch damage at sleep.

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What would the nurse do?

During a patient education session about skin care what should the nurse advise the patient to do in order to prevent dryness of the skin?

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Rash

American Cancer Society, 2020, Skin Rash

An area of irritated or swollen skin that may appear on just one part of the body or all over it.
Cancer treatments that can cause rash:

Chemotherapy
Radiation Therapy
Skin Cell Transplants
Immunotherapy
Targeted therapy

Rashes can itch, burn, sting or be painful.
Usually develop within a few weeks of receiving cancer treatment.
Skin rash that develops suddenly administering a drug could be a sign of allergic reaction to that drug.

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Rash Types Experienced by Patient on Treatment

American Cancer Society, 2020, Skin Rash

Papulopustular Eruption:

may itchy, painful
commonly occurs on chest, upper back, or face
common with certain treatment drugs

Radiation Dermatitis develops due to radiation therapy

occur in the same area the skin is getting radiation.

Radiation Recall: Rash that develops in the previously irradiated area after chemo/ targeted therapy.
Hand-foot Syndrome: Rash with redness/swelling/pain/tingling in palms of hands and soles of the feet only.

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Rash

American Cancer Society, 2020, Skin Rash.
Salzmann et al (2019)
Dreno et al. (2013)

Symptoms¹:

Itchy
Red
Blisters

Management:

UV protection with sunscreen avoids aggravation of rash^1,2,3
Prophylactic use of oral tetracyclines shown to reduce severity²

i.e doxycycline 100 mg bid, or Minocycline 50 mg bid

Application of non-occlusive emollients³, can be combined with steroid for inflamed moderate rash².
Topical antibiotics can be applied on acneiform rashes².

Dry skin
Painful

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Rash: Hand Foot Syndrome

Government of New South Wales (2019)

Also known as palmar-plantar erythrodysaesthesia.
Characterized by gradual onset of bilaterally symmetrical reactions over palms and soles including.
May result in sub-optimal dosing.
Assessment:

Assess baseline skin of patients hands and feet
Monitor changes in skin colour and texture of palms of hands and soles of feet throughout treatment.
Monitor for associated symptoms such as numbness, tingling and pain throughout treatment.

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Hand Foot Syndrome: Management

Search for and treat already existing disease of hands and feet before start of cancer therapy¹.
Apply topical agents like emollient containing 5-10% urea^1,2.
Reduce physical stress to skin like heat, pressure, rubbing, occlusion and contact with chemicals^1,2.
Cooling of hands and feet to reduce blood flow ^1,2

e.g cooling glove during chemotherapy¹

Dose reduction or stopping causative chemotherapy drug².
Referral to dermatologist for persistent symptoms.

Salzmann et al (2019)
Government of New South Wales (2019)

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Hand Foot Syndrome: Patient Education

Apply emollient, use sunscreen SPF 30+ or greater
Bathe/shower in lukewarm water
Avoid friction,rubbing of the skin surfaces
Use barrier cotton gloves when handling chemicals
Wear thick cotton socks, avoid tight-fitting shoes
Avoid topical anaesthetic containing creams
Keep track of what might have caused rash and report any skin changes as soon as possible
Avoid exposure of hands and feet to heat

Government of New South Wales (2019)

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What would the nurse do?

What should the nurse do before administering an anti-cancer medication known to cause itching and rash?

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Pruritus or Rash may be sign of allergic reaction!

Inform patient to seek medical care as soon as possible.

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Swelling/Edema

National Cancer Institute, 2020, Edema (Swelling) and Cancer Treatment
Canadian Cancer Society, n.d.,

Skin problems

A condition in which fluids builds up in body’s tissues¹.
May be caused by some types of Chemotherapy¹, Radiotherapy², certain cancers.
Assessment¹:

Skin is puffy, shiny
Pressure leaves a dent on the skin
Shortness of breath, cough or irregular heartbeat

Management¹- Patient must be advised to-

Wear loose clothing and shoe.
Raise feet with a stool or pillows while sitting or lying down.

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Swelling/Edema: Management

Continued…..

Avoid crossing legs when sitting
Wear special stockings, sleeves, or gloves that help circulation in severe edema
Exercise: walking or moving body parts with edema to improve circulation as per health professionals advice
Limit salt in diet, checking label for sodium content
Take physician prescribed medication like diuretics as instructed
Seek medical help immediately for shortness of breath and cough!

National Cancer Institute, 2020, Edema (Swelling)and Cancer Treatment.

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Alopecia and Other Hair Changes

National Cancer Institute, 2020, Hair Loss (Alopecia) and Cancer Treatment
Cancer Research UK, 2019, Hair loss, thinning and cancer treatment

Alopecia is lack or loss of hair from body areas where hair is usually found¹.
Radiation therapy causes hair loss on part of body being treated
Chemotherapy, hormone therapy, immunotherapy and targeted cancer drugs, likely to cause hair thinning².

Might have hair loss in some people.

Patient must be counseled on-

Possible hair loss or hair changes as side-effects.
Hair management strategies and options.

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Alopecia and Other Hair Changes: Management

National Cancer Institute, 2020, Hair Loss (Alopecia) and Cancer Treatment.

Managing hair loss:

Use soft bristles or wide-tooth comb, and mild hair shampoo.
Wash less often gently, pat dry with soft towel.
Avoid hair dryers, irons, products that may hurt scalp.
Can choose to

Cut hair short or shave with electric shaver.
Buy wig that matches hair color prior hair loss.
Wear comfortable scarf or turban.

Protect scalp using sunscreen/hat.
Use lotions/contiditioner to soothe itches or tenderness.

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Alopecia and Other Hair Changes: Management

Post-treatment hair care:

Hair often grows back

2 to 3 months after chemotherapy
3-6 months after radiotherapy

May grow back thinner or not at all with high-doses.
New hair may grow curlier/straighter/different color.

Avoid too much brushing, curling, blow-drying, frequent washing.

Patient psychological support:

Validate patient’s feelings
May feel angry, depressed, or embarrassed about hair loss
Sharing feelings with close family/people with similar experience can help.

National Cancer Institute, 2020, Hair Loss (Alopecia) and Cancer Treatment.

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Changes to Fingernails and Toenails

Canadian Cancer Society, n.d., Skin problems
Salzmann et al. (2019)

Changes to fingernails and toenails are common during chemotherapy and targeted therapy^1,2
Changes include:¹

yellowing
brittleness, cracking
lines across the nail
partial separation of nail from nail bed
darkening
paronychia

Paronychia is painful inflammatory reaction of nail folds

Difficult to treat, nail folds become sensitive to infection

Regrowth of nail expected after discontinuation of treatment²

however, deformities or dysesthesia may persist

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Changes to Fingernails and Toenails: Management

Keep nail short^1,2
Avoid mechanical stress to fingers/feet such as²-

pressure, humidity, tight shoes, contact with chemical
nail manipulation

Cool of hands/feet during docetaxel infusion recommended²
Apply urea-containing nail polish on thin, brittle nails²
Gloves for household chores¹
Avoid alcohol-based nail polish remover¹
Apply moisturizer around cuticles¹
Treat paronychia daily with antiseptic baths and creams²
Systemic antibiotics or surgery indicated in sever cases²

Canadian Cancer Society, n.d., Skin problems.
Salzmann et al. (2019).

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What Would the Nurse Do?

Which of the following therapies for breast cancer may cause hair loss?

Chemotherapy
Radiation Therapy
Hormone therapy
Surgery

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Pressure Sores

Also called decubitus ulcers or bedsores
Damage to skin area under constant pressure for a long time
Cancer patient are at risk for pressure sores

Compromised skin tissue due to nutritional status
Skin vulnerable due to treatment
Bed ridden due to pain and fatigue

Common places for pressure sores:

Hips/buttocks
Heels/elbows/shoulders
Ears/back of head

American Cancer Society, 2020, Pressure Sores.

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Pressure Sores

American Cancer Society, 2020, Pressure Sores

Assessment:

Cracked, blistered, scaly, or broken skin
Open sore on the skin’s surface or in the tissue under the skin
Yellowish stains on clothing, sheets, or chairs (may be tinged with blood)
Painful or tender pressure points such as elbows, hips etc
Red pressure points on skin that do not go away after pressure is removed

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Pressure Sores: Management

Change position frequently

every 2 hours while lying in bed
clothing should be wrinkle free
pressure points protected and supported with pillows, foam wedge

In wheelchair

shifting weight every 15 minutes
applying foam or gel seat cushions

Consuming adequate nutrition:

Protein rich food such as fish, eggs, meat, milk, nuts
Drinking enough fluids for adequate hydration

American Cancer Society, 2020, Pressure Sores

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Pressure Sores: Management

Exercise as much as possible
Proper wound care for open sores

Moist and non-adherent dressing to

maintain moist, healing environment

Changing the dressing with new one when soaked/soiled
Keeping dressing clean

Skin care:

Applying moisturizer in the skin
Massaging skin with moisturizer in bedridden patient
Washing skin with lukewarm water, instead of hot

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Skin Color Changes

Chemotherapy can cause hyper- or hypo-pigmentation of the skin^1,2
Skin may appear bruised resulting in yellow, green, purple, or dark brown color².
Hyperpigmentation may occur asspots/patches/follow the line of distribution of veins².
Skin discoloration cannot be prevented or treated¹.

Gradually fades over time after completion of treatment.
Patient should consult dermatologist about concerns with skin discoloration².

Canadian Cancer Society, n.d., Skin problems
Breastcancer.org, as cited

in Casteillo L., 2021

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Nursing Role in Management of Tissue integrity

Provide patient education :

How to care for skin, hair, nails
Importance of balanced diet and hydration
Skin problems that are associated with cancer treatment
Prevention or management options for skin problems

Provide psychological support to the patient:

Skin changes/problems might impact patient’s mental health affecting their activities of daily living
Listen to the patient’s concern
Encourage patient to share feelings with close relative or friend
Counselling with dermatologists might help alleviate their concern

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Nursing Role in Management of Tissue integrity

Provide direct skin care to the patient

Assess and identify skin changes/problems accurately
Assist in applying emollients and antiseptic ointments in hard to reach areas
Apply non-adherent dressings on open wounds

Keep it clean
Apply prescribed antiseptic ointments

Ensure adequate hydration

Especially in patient on fluid restrictions

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Nursing Role in Management of Tissue integrity

Assist immobile/partially mobile patient in-

Frequent position changing in bed/wheelchair
Supporting pressure points using pillows/soft mattresses
Back massages, walking, range of motion exercises

Cross-check patient history for allergies with medications prescribed before administering
Report and manage anaphylactic reactions immediately!

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What Would the Nurse Do?

Which nutrition is important for the nurse to emphasize with patients with wounds/decubitus?

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Reference:

American Cancer Society (February, 2020). Dry Skin. Accessed from: https://www.cancer.org/treatment/treatments-and-side-effects/physical-side-effects/skin-problems/skin-dryness.html

American Cancer Society (February, 2020). Itching. Accessed from: https://www.cancer.org/treatment/treatments-and-side-effects/physical-side-effects/skin-problems/itching.html

American Cancer Society (December, 2020). Skin Rash. Retrieved from: https://www.cancer.org/treatment/treatments-and-side-effects/physical-side-effects/skin-problems/skin-rash.html

Contact info: info@nursesinternational.org

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Reference:

Cancer Research UK (July, 2019). Hair loss, thinning and cancer treatment. Accessed from: https://www.cancerresearchuk.org/about-cancer/coping/physically/changes-appearance/hair-loss/treatment

Castiello L., March 2021, How does chemotherapy affect the skin?. MedicalNewsToday Website. Accessed from:https://www.medicalnewstoday.com/articles/skin-changes-after-chemotherapy

Dreno, B., Bensadoun, R. J., Humbert, P., Krutmann, J., Luger, T., Triller, R., Rougier, A., & Seité, S. (2013). Algorithm for dermocosmetic use in the management of cutaneous side-effects associated with targeted therapy in oncology. Journal of the European Academy of Dermatology and Venereology : JEADV, 27(9), 1071–1080. https://doi.org/10.1111/jdv.12082

Contact info: info@nursesinternational.org

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Reference:

Government of New South Wales, August 2019, Hand-foot syndrome (HFS) - palmar-plantar erythrodysaesthesia (PPE) associated with chemotherapeutic agents. Accessed from: https://www.eviq.org.au/clinical-resources/side-effect-and-toxicity-management/hair-skin-and-nails/1416-hand-foot-syndrome-associated-with-chemothera

Healthline (March 2021). Does Itchy Skin Indicate Cancer?. Accessed from: https://www.healthline.com/health/itchy-skin-cancer#cancer-and-itch

National Cancer Institute (February, 2020). Pruritus. Retrieved from: https://www.cancer.gov/about-cancer/treatment/side-effects/skin-nail-changes/pruritus-hp-pdq

Contact info: info@nursesinternational.org

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Reference:

National Cancer Institute (January, 2020). Edema (Swelling) and Cancer Treatment. Accessed from: https://www.cancer.gov/about-cancer/treatment/side-effects/edema

National Cancer Institute (January, 2020). Hair Loss (Alopecia) and Cancer Treatment. Accessed from: https://www.cancer.gov/about-cancer/treatment/side-effects/hair-loss

National Cancer Institute (June, 2019). Skin and Nail Changes during Cancer Treatment. Retrieved from: https://www.cancer.gov/about-cancer/treatment/side-effects/skin-nail-changes

Salzmann, M, Marmé, F, & Hassel, J. C. (2019). Prophylaxis and Management of Skin Toxicities. Breast Care,14(2):72-77. Accessed from: https://doi.org/10.1159/000497232

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