266
Unit 3
Applying concepts from the nursing process
drying and damage, which are discussed in the Plan of nursing
care (see Chart 11-4), under ‘Impaired skin integrity: erythem-
atous and wet desquamation reactions to radiation therapy’.
Alopecia
The temporary or permanent thinning or complete loss of
hair is a potential adverse effect of various radiation therapies
and chemotherapeutic agents. The extent of alopecia (hair
loss) depends on the dose and duration of therapy. These
treatments cause alopecia by damaging stem cells and hair fol-
licles. As a result, the hair is brittle and may fall out or break
off at the surface of the scalp. Loss of other body hair is less
frequent. Hair loss usually begins within 2 to 3 weeks after the
initiation of treatment; regrowth begins within 8 weeks after
the last treatment. Some patients who undergo radiation to
the head may sustain permanent hair loss. Many healthcare
providers view hair loss as a minor problem when compared
with the potentially life-threatening consequences of cancer.
For many patients, however, hair loss is a major assault on
body image, resulting in depression, anxiety, anger, rejection
and isolation (Nolte et al., 2006). To patients and families,
hair loss can serve as a constant reminder of the challenges
cancer places on their coping abilities, interpersonal relation-
ships and sexuality.
The nurse’s role is to provide information about alopecia
and to support the patient and family in coping with disturb-
ing effects of therapy, such as hair loss and changes in body
image. Patients may be encouraged to acquire a wig or hair-
piece before hair loss occurs so that the replacement matches
their own hair. Use of attractive scarves and hats may make
the patient feel less conspicuous. Nurses can refer patients to
supportive programs, such as ‘Look Good, Feel Better’, offered
by the Australian Cancer Council and New Zealand Cancer
Society. Knowledge that hair usually begins to regrow after
completing therapy may comfort some patients, although the
colour and texture of the new hair may be different.
Malignant skin lesions
Skin lesions may occur with local extension of the tumour
or embolisation of the tumour into the epithelium and its
surrounding lymph and blood vessels. Secondary growth of
cancer cells into the skin may result in redness (erythematous
areas) or can progress to wounds involving tissue necrosis and
infection. The most extensive lesions may ulcerate with an
overgrowth of microorganisms that result in a very distressing
malodour. In addition, these lesions are a source of consider-
able pain and discomfort. Although this type of lesion is most
often associated with breast cancer and head and neck cancers,
it can also occur with lymphoma, leukaemia, melanoma, and
cancers of the lung, uterus, kidney, colon and bladder.
Ulcerating skin lesions usually indicate widely dissem-
inated disease unlikely to be eradicated. Managing these
lesions becomes a nursing priority. Nurses carefully assess
malignant skin lesions for the size, appearance, condition of
the surrounding tissue, odour, bleeding, drainage, and associ-
ated pain or other symptoms including evidence of infection.
The potential for serious complications such as haemorrhage,
vessel compression/obstruction, or airway obstruction should
be noted so that the caregiver can be instructed in palliative
measures to maintain patient comfort (Seaman, 2006). Since
this type of lesion is associated with advanced disease, the
nurse assesses the wound for progression over time.
Myelosuppression (bone marrow depression) resulting from
underlying disease or its treatment predisposes the patient
to oral bleeding and infection. Pain associated with ulcerated
oral tissues can significantly interfere with nutritional intake,
speech and a willingness to maintain oral hygiene. As a result
of the ability to give higher doses of chemotherapy due to
improvements in managing neutropenia with growth factors,
stomatitis is a common reason for treatment delays and dose
reductions (Cawley & Benson, 2005). Advanced stomatitis
may cause or prolong hospitalisations, significantly reduce the
patient’s quality of life, and ultimately lead to poor patient
outcomes (Eilers & Million, 2007).
Although multiple studies on stomatitis have been pub-
lished, the optimal prevention and treatment approaches
have not been identified. However, most clinicians agree that
good oral hygiene that includes brushing, flossing and rinsing
is necessary to minimise the risk for oral complications asso-
ciated with cancer therapies. Soft-bristled toothbrushes and
non-abrasive toothpaste prevent or reduce trauma to the oral
mucosa. Oral swabs with spongelike applicators may be used
in place of a toothbrush for painful oral tissues. Flossing may
be performed unless it causes pain or unless platelet levels are
below 40 × 10
9
/L. Oral rinses with saline solution or tap water
may be necessary for patients who cannot tolerate a tooth-
brush. Products that irritate oral tissues or impair healing, such
as alcohol-based mouth rinses, are avoided. Foods that are diffi-
cult to chew or are hot or spicy are avoided to minimise further
trauma. The patient’s lips are lubricated to keep them from
becoming dry and cracked. Topical anti-inflammatory and
anaesthetic agents may be prescribed to promote healing and
minimise discomfort. Products that coat or protect oral mucosa
are used to promote comfort and prevent further trauma. The
patient who experiences severe pain and discomfort with sto-
matitis requires systemic analgesics.
Adequate fluid and food intake is encouraged. In some
instances, parenteral hydration and nutrition are needed.
Topical or systemic antifungal and antibiotic medications are
prescribed to treat local or systemic infections.
Palifermin (Kepivance), a synthetic form of human keratino-
cyte growth factor, is an IV medication used for the treatment
of oral mucositis in patients with hematologic cancer who are
undergoing chemotherapy and radiation prior to haematopoi-
etic stem cell support. Palifermin promotes epithelial cell repair
and more rapid replacement of cells in the mouth and gastro
intestinal tract (Oncology Nursing Society, 2006). It is not yet
been approved for use in patients with other types of cancer.
Careful timing of administration and monitoring are essential
for maximum effectiveness and to detect adverse effects.
Radiation-associated skin impairment
Although advances in radiation therapy have resulted in
decreased incidence and severity of skin impairments, patients
may still develop skin reactions that lead to pain, irritation,
pruritis, burning and diminished quality of life. Nursing care
for patients with skin reactions includes maintaining skin
integrity, cleansing the skin, promoting comfort, reducing pain,
preventing additional trauma, and preventing and managing
infection. Although a variety of methods and products are
used in clinical practice for patients with radiation-induced
skin reactions, there is limited evidence to support their value.
Patients with skin and tissue reactions to radiation therapy
require careful skin care to prevent further skin irritation,
