Integumentary, Ostomy, Lymphedema, and Wound Care
Key Takeaways
- Radiation dermatitis progresses from erythema to dry then moist desquamation; protect the field, avoid friction/adhesives, and never apply metallic or unapproved products before treatment.
- Extravasation of a vesicant is an emergency: stop the infusion, leave the catheter to aspirate, do NOT flush, and apply agent-specific antidote and thermal measures (cold for most vesicants, warm for vinca alkaloids).
- A healthy stoma is moist and pink-to-red; dusky/black tissue or no output with cramping and distention signals ischemia or obstruction and needs urgent evaluation.
- Ileostomies produce high, watery output (often 800-1200 mL/day) creating dehydration and electrolyte risk; barrier opening should clear the stoma by about 1-2 mm.
- Lymphedema risk reduction emphasizes skin protection and early reporting; cellulitis (redness, warmth, fever, rapid swelling) is urgent.
Integumentary, Ostomy, Lymphedema, and Wound Care
Skin, Wounds, and Radiation Dermatitis
Cancer care injures skin through surgery, radiation, systemic therapy, vascular devices, immobility, edema, malnutrition, and tumor invasion. Assess color, temperature, moisture, turgor, rash pattern, pain, pruritus, open areas, drainage, odor, bleeding, surrounding erythema, and functional impact, and document location, size, and the plan for wound, radiation, surgery, or provider follow-up.
Radiation dermatitis appears in the treatment field and progresses predictably; know the stages for grading questions:
| Stage / CTCAE grade | Appearance | Nursing focus |
|---|---|---|
| Grade 1 | Faint erythema, dry desquamation | Gentle cleansing, moisturize as approved |
| Grade 2 | Brisk erythema, patchy moist desquamation, edema | Non-adherent dressings, manage pain |
| Grade 3 | Confluent moist desquamation, bleeding with trauma | Wound care referral, infection watch |
| Grade 4 | Necrosis, full-thickness ulcer | Urgent escalation |
Teach gentle cleansing, no friction or adhesive trauma in the field, sun protection, and no heating pads, ice, or metallic-based products (some deodorants/zinc) before daily treatment because they can increase the surface dose. Other patterns: hand-foot syndrome (palmar-plantar redness, swelling, peeling from capecitabine, 5-FU, liposomal doxorubicin, and some TKIs), acneiform rash from EGFR inhibitors, and malignant fungating wounds (control odor with metronidazole or charcoal dressings, manage bleeding and dignity).
Vesicant Extravasation: An Emergency
Extravasation of a vesicant (a drug that causes tissue necrosis if it leaks) is an oncologic emergency. The exam-tested sequence: STOP the infusion immediately, disconnect tubing but leave the catheter in place to aspirate residual drug, do NOT flush the line, notify the provider, and apply agent-specific measures. Thermal and antidote choices differ by drug:
- Anthracyclines (doxorubicin): cold compress; antidote dexrazoxane; topical DMSO per policy.
- Vinca alkaloids (vincristine, vinblastine): warm compress and hyaluronidase (cold is contraindicated).
- Mark and photograph the site per policy, and document drug, volume, site, and interventions.
Ostomy Care and Fluid Risk
A healthy stoma is moist and pink to red; a dusky, purple, or black stoma signals ischemia and is urgent, as is no output with cramping, vomiting, and distention (obstruction). Teach pouch emptying and changing, measuring the barrier so the opening clears the stoma by about 1-2 mm, peristomal skin protection, odor control, and supply ordering. Ileostomy output is high and watery (often 800-1200 mL/day), so teach signs of dehydration and electrolyte loss and encourage oral rehydration; output above ~1500 mL/day is a high-output ileostomy needing provider contact.
Urinary diversions require attention to mucus, flow, and infection. Normalize body-image and sexuality concerns and refer to a Wound, Ostomy, and Continence Nurse (WOCN).
Lymphedema
Lymphedema follows lymph-node surgery, radiation, tumor obstruction, or infection and may affect a limb, breast, trunk, or head/neck. Early signs are subtle: rings, sleeves, or watch feeling tight, heaviness, and aching. Risk reduction: meticulous skin care, prompt treatment of cuts, sun and burn protection, gradual activity, and early reporting. Compression garments, manual lymphatic drainage, and complete decongestive therapy are directed by trained clinicians. Cellulitis (redness, warmth, fever, pain, rapid swelling) in an at-risk limb is urgent.
Follow institutional policy on blood pressures and venipuncture in the at-risk limb rather than promising they always cause lymphedema. Reassess all skin and appliance care: is pain improving, is drainage increasing, can the patient perform care, are supplies available, and is swelling responding to the plan?
Targeted-Therapy Skin Toxicities
Modern regimens bring distinct dermatologic patterns that OCN candidates must recognize. Epidermal growth factor receptor (EGFR) inhibitors (cetuximab, erlotinib, panitumumab) commonly cause an acneiform (papulopustular) rash on the face and trunk, paronychia, and dry, fissured skin; interestingly, rash severity often correlates with treatment response, so the goal is to manage it, not to stop therapy reflexively. Teaching includes gentle skin care, broad-spectrum sunscreen, and using prescribed topical or oral antibiotics rather than over-the-counter acne products, which dry the skin further.
Multikinase inhibitors (sorafenib, sunitinib) cause a hand-foot skin reaction with painful, hyperkeratotic, callus-like areas at pressure points, managed with cushioning, urea-based creams, and pressure offloading. The nurse distinguishes these from chemotherapy hand-foot syndrome and from cellulitis, because the management and escalation triggers differ.
Body Image, Self-Care, and Reassessment
Skin, wound, ostomy, and lymphedema changes carry heavy psychosocial weight, and ignoring that weight undermines adherence. A new ostomy, a fungating wound with odor, hair and nail changes, or a swollen limb can isolate a patient and erode self-esteem and sexual confidence. The nurse normalizes these reactions, invites questions without judgment, includes the caregiver when the patient agrees, and connects the patient to support resources and the WOCN.
Practical self-care assessment matters as much as wound staging: can the patient see the stoma, manage the barrier with their hand dexterity, afford and obtain supplies, and reach help after hours? Reassessment then verifies real outcomes, not just intentions, confirming that the dermatitis is healing, the stoma output and skin are stable, the limb measurements are improving with therapy, and the patient can actually perform the care taught. Visible findings always get tied back to the treatment history so the team can act on the underlying driver.
The nurse also documents objectively, using consistent measurements, wound descriptors, and photographs only where policy permits, so that change over time, healing, worsening, or a new infection, is unmistakable to every clinician who follows.
During administration of vincristine through a peripheral IV, the patient reports burning and the nurse notes swelling at the site. After stopping the infusion and aspirating residual drug, which intervention is correct?
Which postoperative ostomy finding requires urgent escalation?
A patient who had axillary lymph-node dissection reports tightness of her wristwatch and a feeling of heaviness in that arm. What is the best nursing response?