Journal of Community Nursing - page 20

20 JCN
2013,Vol 27, No 4
For example, it is important for
clinicians to ask what they are
assessing; why the skin damage has
happened; and how it should be
Even before radiotherapy
begins, it is essential to assess
patients’ current skin care practice
and the condition of their skin to
identify any influential factors that
may impact upon the reaction,
such as eczema or thinning elderly
skin. As with all care, documenting
the outcome of any assessments,
interventions and evaluations
provides a continuous record to
ensure consistent and effective
It is imperative that community
nurses have the relevant knowledge
and skills, or know where to find
guidance, if they are to provide
optimum care and a positive
patient experience. Predicting the
severity of skin reactions can be
difficult due to the varying radio-
sensitivity of the skin and a number
of contributing factors, such as age
of the skin and site of treatment
(Wells and MacBride, 2003).
A consistent approach to skin
assessment is essential to ensure
that the right interventions are
implemented at the right time
in response to changing needs
and regular evaluation. Without
accurate assessment and relevant
knowledge, interventions may be
inappropriate, ineffective and at
worst, harmful to the patient.
The use of an assessment
tool to grade radiotherapy skin
reactions is recommended to
promote consistency and treatment
continuity, both during, and
after, radiotherapy. The most
commonly used framework for
objective assessment of an acute
radiotherapy-induced skin reaction
is the Radiation Therapy Oncology
Group (RTOG) grading system
(Cox et al, 1995), which grades the
following stages:
RTOG 0: no visible change
to skin
RTOG 1: faint or dull erythema;
mild tightness of skin
and itching
technique that allows radiation
to be more closely shaped to fit
the tumour and spare nearby
critical normal tissue), can be less
damaging to the skin, however,
patients will still experience
skin reactions.
Goals of care
It is essential that patients
understand what can happen to
their skin as a consequence of
receiving radiotherapy. Patient
education is a key component of
holistic care and is of particular
importance when the patient
is receiving treatment as an
outpatient. Radiotherapy is
commonly delivered within
outpatient settings and self-
management is pivotal in achieving
optimum symptom control.
Preventing the skin reaction is
currently not an option, therefore,
goals of care should focus upon:
Patient involvement
and education
Promotion of measures to
improve comfort
Protection of the skin from
further trauma
Reducing potential for further
exacerbation of the skin reaction
Effective pain control
Support and reassurance
RTOG 2: bright erythema/dry
desquamation; sore, itchy and
tight skin
RTOG 2.5: patchy, moist
desquamation; yellow/pale
green exudate; soreness
with oedema
RTOG 3: confluent moist
desquamation; yellow/pale
green exudate; soreness
with oedema
RTOG 4; ulceration, bleeding,
necrosis (rarely seen).
However, this framework does
not consider the potential patient-
reported symptoms such as pain
and discomfort, therefore, it is
crucial that additional assessments,
for example, pain scores, are
undertaken and supportive
measures, such as analgesia,
initiated in response to
any findings.
Many approaches to skin
care have been advocated over
recent decades, resulting in
wide variations in protocols and
practice across healthcare settings.
A recent survey by Harris et al
(2011) found that despite emerging
evidence recommending changes
to guidelines, inconsistencies and
differences in practice still exist
across the UK. These disparities
in clinical practice and a lack
of evidenced-based care have
created a growing awareness of
the need for more research into
the management of radiotherapy-
induced skin reactions (Faithfull
et al, 2002). Although conclusive
evidence is lacking, clinicians must
attempt to base interventions
on the best available evidence,
sharing guidelines and best practice
statements where possible (NHS;
Quality Improvement Scotland
[QIS], 2010).
It has been well documented
that radiation skin changes cannot
be prevented (McQuestion, 2006;
Harris et al, 2011), so current
research is frequently focused upon
delaying the onset of symptoms,
minimising the severity of a
reaction and effective management.
Advanced delivery techniques, such
as intensity-modulated radiation
technique (IMRT, a radiotherapy
Answer the following questions
about this, either to test the new
knowledge you have gained or to
form part of your ongoing practice
development portfolio.
1 – What skin reactions are a common
side-effect of radiotherapy?
2 – What is the most severe?
3 – Can radiation-induced skin
changes be prevented?
4 – How do radiotherapy skin
reactions differ from burns?
5 – Do radiotherapy skin reactions
worsen as treatment progresses?
Five-minute test
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