Skin Management
What are some considerations for managing patients receiving radiation therapy?
Physical assessment and documentation - those on biotherapy and chemotherapy are a higher risk
Patient education
Prophylaxis treatments to reduce severity of dermatitis: emoliants and topical steroids
More frequent assessment
What are some side effects of minimal sedation?
Behavioral changes
Short-term impairment in cognitive function
If a patient has mild urticaria, after stopping the infusion, what would you do next?
Give 500 mL of oral hydration
Name 2 examples of immediate extravasation.
Infusion flow that slows or stops
Resistance when performing IVP
No blood return
Leakage of infusion around injection/infusion site
Pain, redness, or swelling on or around the injection/infusion site
When is a patient screened for distress?
Patient screened for distress at specified time points (new patient visit, every 30 days during outpatient visit, ACCC visit, and within 2 hours of admission)
What are some risk factors for radiation dermatitis?
Patient Related
● Age
● Race
● Area of treatment (more reactions with skin folds and moist areas)
● Nutritional status
● Smoking and alcohol use
● Comorbidities
● Chronic UV exposure
● Obesity
Therapy Related
● Type of energy/beam (e.g., higher skin dose with electron beams and certain beam angles of proton)
● Fractionation
● Total dose
● Dose per fraction
● Treated volume and surface area
● Use of bolus materials
● Concurrent chemotherapy/biotherapy
● Surgery or surgical history
What are some examples of patient safety measures during anxiolytic administration?
Appropriate activity limitations with adult supervision
No unsupervised ambulation for 2 hours
No driving or operating heavy equipment for 24 hours
What should be monitored if a patient is having hypotension?
Vital signs
Name 2 examples of delayed extravasation.
Persistent or worsening pain or redness on or around the injection/infusion site
Blistering, sloughing off, ulceration
What PNS score will automatically generate a consult/referral to the appropriate provider?
6 or more
What skin changes should be monitored at each visit?
● Location
● Skin color
● Size of the area
● Drainage
● Signs of infection
● Changes affecting activity or performance level
What needs to be reviewed prior to giving anxiolytics?
A review of the patient’s allergy and medication history, level of consciousness, orientation level, and baseline vital signs
What classification of medications needs to be reported to the provider prior to giving glucagon?
Beta blockers
Name 2-3 interventions for a suspected extravasation
Stop and disconnect infusion immediately. Do not flush the line.
Leave IV access in place. (Note: Remove constricting bands that may act astourniquets.)
Assess site and aspirate agent using 1-3 mL syringe.
Pull IV/Implanted Port needle.
Assess injection/infusion site and surrounding skin/tissue for capillary refill, sensation, and motor function.
Loosen garment and elevate extremity, if appropriate. (Note: Do not put pressure on the injection/infusion site.)
Mark the site, as appropriate.
Notify Provider or their designee and administer antidote as ordered/apply topical compress.
How do you contact the on-call appropriate provider or ancillary services if a patient has a PNS score of 6 or more?
Via phone during regular business hours
Page during after hours or on the weekends
Name some examples of basic skin care
Patients receiving treatment for vulvar cancer should have their skin examined weekly and/or when there is a change in their symptoms
● Nurses can assess skin reaction with the provider at patient’s weekly appointment
● Aluminum acetate (Domeboro® ) sitz bath twice a day is the initial recommendation for skin erythema or dry desquamation. Nurses can provide education on its use.
○ Baking soda sitz bath may be a less expensive and best alternative treatment to aluminum acetate (Domeboro® )
● Nystatin powder can be used as prevention when dry desquamation is noted, or with large skin folds that remain moist
● Lidocaine gel can be used for pain during urination. Do NOT use on open skin.
● NDX (nystatin, zinc oxide, lidocaine) compound for painful dermatitis
What should be included in the comprehensive pain assessment?
Intensity score
Type
Location
Orientation
Characteristic/Descriptors
Onset
Frequency
Duration
Aggravating Factors
Alleviating Factors
If a patient is having seizures or convulsions, what is your priority nursing action?
Keeping the airway open & suction close by
Avoiding aspiration
What are some examples of additional required documentation for suspected extravasation?
Date and time event occurred
Estimated amount of Vesicant infused
Description and volume aspirated
Signs/Symptoms observed or reported by patient
Site assessment (e.g., range of motion, if applicable); include images or photographs, if available
Physician/designee notification
Nursing interventions implemented (e.g., warm/cold compress)
Antidote administration, if ordered
Discharge instructions (include consults, follow-up care, and wound management, if applicable)
What are 3 examples of good protective skin barriers for prevention?
Aquaphor, Eucerin, and Vaseline
What are some examples of safety measures for monitoring a patient on opioids?
Independent double check on high risk medications
Texas Prescription Monitoring Program
Safety reporting system: events related to over treatment, delay in treatment, and/or need for naloxone as a rescue medication.
If a patient is having an anxiety attack, what should also be completed by the nurse in addition to monitoring vital signs?
Thorough nursing assessment to monitor developing s/s that may indicate another disease process
What should be documented when infusing vascular vesicants and vascular irritants?
A. Date and time of administration. Refer to the Medication Administration and Medication Administration Record (MAR) Policy (MD Anderson Institutional Policy #CLN0617).
B. Injection site location, type of device used, and needle size (if applicable).
Note: For PIV, include location and number of insertion attempts.
C. Drug name, dosage, and duration of infusion.
D. Line assessment including verification of blood return and line patency prior to
administration and subsequent blood return/line patency checks.
E. Monitoring of infusion flow and assessment for signs and symptoms of suspected
Extravasation.
F. Amount and type of flush/lock solution used at the end of the infusion.
G. Plan of care. Refer to the Interdisciplinary Inpatient Care Plan and Education Record Policy (MD Anderson Institutional Policy #CLN0473).
H. Patient/caregiver education. Refer to the Patient/Family Education Policy (MD Anderson Institutional Policy #CLN0581).
I. Patient's tolerance/response to the infusion.
J. Independent double check. Refer to the Independent Double-Check: Order, Product
What is the purpose of the PNS tool and how often should they be completed?
To identify a patient's need for multidisciplinary services
The PNS must be completed at the following designated times:
A. At the time of a new patient visit
B. During an in-person ambulatory care visit with a Physician or APP, if more than 30 days have elapsed since the last Screen
C. During each Acute Cancer Care Center visit (ACCC), Pediatric Acute Cancer Care Center visit (PACCC), or upon arrival to the Clinical Decision Unit (CDU)
D. For patients with an admitted or extended recovery status in the Transitional Post Anesthesia Care Unit (TPACU)
E. Within two hours of inpatient admission unless completed in the ACCC, PACCC, CDU, or TPACU
F. Anytime per the judgment of a health care team member or as patient needs are identified