Melissa A. Grier, MSN, APRN, ACNS-BC
When you think of factors that place oncology patients at high risk for infection, some of the first that come to mind are probably invasive devices like Foley catheters and central venous access devices. Contact with sick visitors or staff members is also high on the list, but what about that surgical incision or radiation burn?
Wounds are very common among oncology patients and can lead to whole host of problems. As oncology nurses, we need to perform frequent wound assessment, monitor the progress of wound healing, and most importantly, ensure that we help our patients learn to care for them on their own.
What do I need to consider?
Surgical incisions are more than just a source of physical discomfort for patients; they also place the patient at high risk for infection if they’re not cared for appropriately. Patients may find it difficult to manage dressings or look at surgical incisions, either because they’re squeamish or because they’re self-conscious about how the incision has altered their physical appearance. This may ultimately influence their ability to care for the wound independently. It’s important for us as nurses to provide adequate pain relief prior to wound care and to ensure that we’re demonstrating aseptic technique in order to prevent infection. We also need to monitor patients for any signs and symptoms of infection following surgery, educating them on what to watch for and report once they go home.
How do I care for surgical incisions?
Immediately following surgery
Make sure to follow the postoperative orders for care of the incision outlined by the surgeon. Frequently, dressings need to remain in place for at least 24 hours following surgery. If excessive bleeding is noted on initial assessment of a surgical incision/dressing, immediately notify the provider and find out if you should change the entire dressing yourself or reinforce it until a surgeon can assess the incision in person. Monitoring for signs and symptoms of localized infection (warmth, erythema, purulent drainage, etc) and systemic infection (elevated WBC/ANC, fever, tachycardia, tachypnea, hypotension, etc) is also vital during the immediate postoperative period. Be aware that some of these symptoms may not manifest in immune-compromised patients—septic shock can occur with little to no warning in this patient population.
The simplest intervention is often the most effective in preventing infection: hand hygiene. Cleanse your hands with soap and water prior to performing a dressing change. When selecting a dressing and tape/adhesive, be sure to assess your patient for allergies or past history of medical adhesive-related skin injury (MARSI). Immunosuppression, advanced age, malnutrition, dehydration, and several other factors common to the oncology patient population place these patients at high risk for skin tears.
What do I need to consider?
Topical burns (radiation dermatitis) will likely be present over areas of the skin where the patient is receiving radiation therapy, depending on the duration and total dosage of therapy. These burns can range from mild erythema and flaking of the skin (dry desquamation) to severe blisters and broken skin (moist desquamation). Internal burns may also be present. Patients receiving therapy for head and neck cancers may have burns in the oral mucosa or esophagus. Those with anal or rectal cancer may have burns to the perineum that make elimination very painful, and keeping those burns clean is of the utmost importance.
How do I care for radiation burns?
: When managing radiation dermatitis, use mild soap and lukewarm water to cleanse the skin. A soft washcloth is best for applying soap, and the skin should be gently patted dry or allowed to air dry after bathing. Patients should also be advised to avoid using products that may make burns worse, such as deodorants that contain aluminum. Encourage your patients to use mild unscented lotion to moisturize dry, flaky skin.
: A provider may prescribe steroid cream to be applied prior to treatment in order to prevent and/or manage erythema, inflammation, and pruritis. However, if moist desquamation develops, use of steroid cream should be discontinued. Silver sulfadiazine cream, an antimicrobial agent, may then be used to help prevent infection. Keep in mind that the cream will have to be removed prior to subsequent radiation treatments; apply a thin layer over the burn to aid in easier removal.
: Mild dermatitis can be managed by applying moisturizer and leaving the burned area open to air. When dressing areas affected by moist desquamation, hydrocolloid or hydrogel dressings will promote healing and prevent further trauma to the skin during removal. Loose-fitting cotton clothing and undergarments should be worn to prevent excess moisture from being trapped against burned skin.
Melissa Grier is a Clinical Nurse Specialist at Via Christi Health in Wichita, Kansas, where she supports the Via Christi Cancer Institute and the nurse residency program.