Textbook of Medical-Surgical Nursing 3e

266

Unit 3   Applying concepts from the nursing process

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,

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.