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The Memorial Sloan Kettering Cancer Center GERIATRIC PLAN©: Integumentary

An Ambulatory Nurses' Guide to Assist Older Adults Through Cancer Treatment

I=Integumentary

Related Issues:

Circulation, wound healing, nutritional status, thermoregulation, absorption, nails, alopecia

Why the Integumentary System is Important:

  • The Integumentary system contains the largest organ of the human body, the skin; it also includes hair and nails
  • The skin is the first line of defense against infection
  • The skin protects and cushions the body's delicate organs
  • Acts as barrier to keep out foreign material
  • Regulates body temperature
  • Contains sensory receptors to detect pain, sensation, pressure, and temperature
  • Provides for vitamin D synthesis
  • Almost 1 out of every 3 people in the United States will develop shingles, also known as zoster or herpes zoster; there are an estimated 1 million cases each year in this country (CDC, 2011); herpes zoster most commonly occurs in older people, with the risk increasing sharply after 50 years of age; 50% of all Americans will have had Shingles by age 80, and it is most common in people of ages 60-80 (NIH, 2011)

Normal Age-Related Changes:

  • Stem cell production declines with aging, causing epidermal cells to decrease in production leading to larger and more irregular cells; this causes skin changes:
  • Thinning
  • More translucent
  • Increase in injury and tears
  • Increased risk of infection
  • Ability to lose body heat is altered due to a decrease in sweat gland activity and circulation
  • The loss of fat and collagen in the underlying tissues causes the integument to weaken producing skin sagging and wrinkling
  • The number of macrophages and other immune cells leading to skin damage and increased risk of infection
  • Melanocyte activity declines leading to decreased protection from ultraviolet and a great susceptibility to sunburn and skin cancers
  • Sebaceous gland and sebum activity declines causing perspiration to decrease leaving skin dry, scaly, and pruritic
  • Vascular supply to the nail bed decreases resulting in dull, brittle, hard, and thick nails
  • Vascularity and circulation decreases in the subcutaneous tissues causing drug absorption to be altered when administered in this manner

Older adults are at increased risk if they have any of the following:

Conditions

  • Malnutrition
  • Dehydration
  • Cardiovascular disease
  • Hyperglycemia
  • Pressure ulcer
  • Low body weight
  • Wound infections
  • History of falls
  • Prolonged hospital stay
  • Cognitive impairment
  • Depression
  • Neuropathy
  • Edema
  • Incontinence
  • Ostomies, catheters, and drains

Special note regarding Shingles: Varicella Zoster

  • Shingles is a painful skin disease caused by reactivation of the chickenpox virus; it is distinctive as it affects one side of the body; shingles is caused by a Herpes Virus; once someone is infected  with this virus (having chickenpox), it remains in your body for life; it stays inactive until a period when immunity is down; having a diagnosis of cancer, or receiving drugs such as steroids or chemotherapy may weaken the immune system

Behavioral Risk Factors

  • Immobility
  • Unprotected sun exposure
  • Functional impairment

Medication-Related Risk Factors

  • Steroids (special attention to topical)
  • Polypharmacy
  • Possible altered absorption with injections and transdermal medications
  • Anticoagulants
  • Photosensitivity
  • Radiation recall: Azithromycin, Levaquin

Chemotherapy-Related Risk Factors

  • Rashes: cetuximab, gefitinib erlotinib, lapatinib, pemetrexed, docetaxel, paclitaxel
  • Palmar-Plantar Erythrodysesthesia (PPE)/Hand foot skin Reaction (HFSR): liposomal doxorubicin, capecitabine, fluorouracil (5FU), sunitinib, sorafenib, lapatinib
  • Nail changes: bleomycin, cyclophosphamide, daunorubicin, doxorubicin, fluorouracil, hydroxyurea, aminoglutethimide, busulfan, cisplatin, dacarbazine, docetaxel, idarubicin, ifosfamide, melphalan, methotrexate, mitomycin, and mitoxantrone
  • Radiation recall: docetaxel, doxorubicin, gemcitabine
  • Vesicant chemotherapy agents include: dactinomycin, daunorubicin, doxorubicin, epirubicin, idarubicin, mechlorethamine, mitomycin, mitoxantrone, paclitaxel, streptozocin, teniposide, vinblastine, vincristine, vinorelbine.
  • Possible altered absorption with injections
  • Alopecia

Surgery-Related Risk Factors

  • Alterations in wound healing

Radiation Risk Factors

  • Radiation skin reactions
  • Alteration in wound healing
  • Hair loss
  • Radiation recall

Cancer Diagnoses

  • Melanoma
  • T Cell Lymphoma
  • Mycosis fungoides
  • Malignancies associated with Bone Marrow Involvement
  • Squamous Cell Carcinoma
  • Basal Cell Carcinoma
  • Head and neck cancers

Assessment:

1. Screening Questions

  • Do you now or have you ever had trouble wound healing?
  • Do you bruise easily?
  • Have you fallen recently?
  • Are you able to change position in bed and chair without assistance?
  • Are you having trouble with urine or fecal incontinence?

2. Observations

  • Bruising
  • Wounds
  • Rashes (zoster usually develop in three stages: severe pain or tingling, possible itchy rash, and blisters looking like chickenpox)
  • Dry and scaly skin
  • Edema
  • Erythema

3. Screening Tests and Measurements

4. Physical Assessment: standard examination with special focus on integumentary system

I=Integumentary

Nursing Intervention:

  • Determine underlying etiology of skin conditions and correct if possible
  • Initiate and coordinate appropriate referrals
  • Dietary assessment
  • Social work referral or VNS/HHA depending on assessment of social and environmental support
  • Provide education to patient and caregivers
  • Assess and educate on cleanliness and use of moisturizers
  • Nail and hair care: moisturizers,conditioners
  • Health maintenance and disease prevention
  • Importance of early ambulation and position changes post operative
  • Use of off loading devices, egg crates, gel pads, etc.
  • Range of motion exercises
  • Special attention to skin care with use of immobility devices
  • Discuss with LIP use of Shingles Vaccine (Zostavax)
  • Available for people 50 years of age and older
  • Designed to reduce risk of developing shingles and the risk of post herpetic neuralgia
  • Not recommended for persons with a weakened immune system due to HIV/AIDS, treatment with drugs affecting immune system (i.e. steroids, cancer treatment such as radiation or chemotherapy, or history of cancer affecting the bone marrow or lymphatic system, such as leukemia or lymphoma)
  • For procedures: review patient positioning and pad surfaces for skin protection
  • Utilize smallest diameter needles for blood draw and injections
  • Ongoing monitoring for alterations in health status
  • Collaborate with all other healthcare providers
  • Evaluate effectiveness of interventions and modify as needed

References

Barclay, L. & Nghiem, H. T. (2012). Guidelines Issued for Care of Elderly Surgical Patients. Medscape Educational Clinical Briefs. Retrieved from http://www.medscape.org/viewarticle/772848.
Chang, A.L.S., Wong, J.W., Endo, J.O., & Norman, R.A. (2013). Geriatric dermatology review: Major changes in skin function in older patients and their contribution to common clinical challenges. Journal of the American Medical Directors Association 14(10), 724-730.
Kim, E.K., Kim, E.O., Park, Y.M., Park, C.J., Yu, D.S., Lee, J.Y. (2013). Prevalence and Risk Factors of Depression in Geriatric Patients with Dermatological Diseases. Annals of Dermatology 25(3), 278-284.
Norman, R.A. (2008). Common Skin Conditions in Geriatric Dermatology. Annals of Long-Term Care 16(6), 40-45.