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Nursing Diagnosis: Risk for Impaired Skin Integrity
Risk factors may include
- Effects of radiation and chemotherapy
- Immunologic deficit
- Altered nutritional state, anemia
Desired Outcomes
- Identify interventions appropriate for specific condition.
- Participate in techniques to prevent complications/promote healing as appropriate.
13 Cancer Nursing Care Plan (NCP)
- Anticipatory Grieving — Cancer Nursing Care Plan (NCP)
- Situational Low Self-Esteem — Cancer Nursing Care Plan (NCP)
- Acute Pain — Cancer Nursing Care Plan (NCP)
- Altered Nutrition: Less Than Body Requirements — Cancer Nursing Care Plan (NCP)
- Risk for Fluid Volume Deficit — Cancer Nursing Care Plan (NCP)
- Fatigue — Cancer Nursing Care Plan (NCP)
- Risk for Infection — Cancer Nursing Care Plan (NCP)
- Risk for Altered Oral Mucous Membranes — Cancer Nursing Care Plan (NCP)
- Risk for Impaired Skin Integrity — Cancer Nursing Care Plan (NCP)
- Risk for Constipation/Diarrhea — Cancer Nursing Care Plan (NCP)
- Risk for Altered Sexuality Patterns — Cancer Nursing Care Plan (NCP)
- Risk for Altered Family Process — Cancer Nursing Care Plan (NCP)
- Fear/Anxiety — Cancer Nursing Care Plan (NCP)
Risk for Impaired Skin Integrity — Cancer Nursing Care Plan (NCP)
| Nursing Interventions | Rationale |
| 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. |
| Review skin care protocol for patient receiving radiation therapy: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; Recommend wearing soft, loose cotton clothing; have female patient avoid wearing bra if it creates pressure;
Apply cornstarch, Aquaphor, Lubriderm, Eucerin (or other recommended water-soluble moisturizing gel) to area twice daily as needed;
Encourage liberal use of sunscreen/block and breathable, protective clothing. | Designed to minimize trauma to area of radiation therapy.Can potentiate or otherwise interfere with radiation delivery. May actually increase irritation/reaction.
Skin is very sensitive during and after treatment, and all irritation should be avoided to prevent dermal injury.
Helps control dampness or pruritus. Maintenance care is required until skin/tissues have regenerated and are back to normal.
Protects skin from ultraviolet rays and reduces risk of recall reactions. Reduces risk of tissue irritation/extravasation of agent into tissues.
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. |
| Apply ice pack/warm compresses per protocol | Controversial intervention depends on type of agent used. Ice restricts blood flow, keeping drug localized, while heat enhances dispersion of neoplastic drug/antidote, minimizing tissue damage. |
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