Skin cancer is the most common malignancy in the United States, accounting for over 50% of all diagnosed cancers. The majority of skin cancers (more than 90%) are classified as nonmelanoma skin cancers (NMSCs) of which there are two types: basal cell carcinoma (BCC) and squamous cell carcinoma (SCC). Approximately 75% of skin cancers are BCC; SCC is the next most common skin cancer, followed in frequency by melanoma. More than 1.3 million cases of NMSC are diagnosed annually. Other, less frequently occurring skin cancers include skin adnexal tumors, Kaposi’s sarcoma, various types of sarcomas, Merkel cell carcinoma, and cutaneous lymphoma, all of which together account for fewer than 1% of NMSCs.
BCC is a slow-growing, nonmetastasizing neoplasm of the nonkeratinizing cells of the basal layer of the epidermis, that extends wide and deep if left untreated. If distant metastasis does occur to the bone, brain, lung, and liver, the prognosis is grave. BCC is most frequently found on the head, neck, and on skin that has hair. There are two types of BCC. The nodular ulcerative BCC is a nodulocystic structure that begins as a small, flesh-colored, smooth nodule that enlarges over time. A central depression forms that progressess to an ulcer surrounded by a waxy border. The superficial BCC is often seen on the chest or back and begins as a flat, nonpalpable, erythematous plaque that enlarges and becomes red and scaly with nodular borders. Although BCC can be treated effectively, it is not uncommon for it to return after treatment. From 35% to 50% of people diagnosed with one BCC will develop a new skin cancer within 5 years of the first diagnosis.
SCC leads to an invasive tumor that can metastasize to the lymph nodes and visceral organs. SCC, which constitutes 20% of all skin cancers, is characterized by lesions on the squamous epithelium of the skin and mucous membranes. SCC appears as a red, scaling, keratotic, slightly
elevated lesion with an irregular border, usually with a shallow chronic ulcer. The risk of metastasis is associated with the size and penetration of the tumor, the tumor morphology, and the causative factors. Complications of NMSCs include disfigurement of facial structures and metastasis to other tissues and organs.
Because occurrence of NMSC is not reported, incidence can only be estimated. It is suspected that more than 1 million cases of BCC occur each year, and 1000 to 2000 deaths occur from BCC. The 5-year survival rate for patients with BCC is greater than 99%; although BCCs rarely spread to lymph nodes or other organs, those patients who do have metastasized BCC have a 5-year survival rate of only 10%. The overall 5-year survival rate for patients with SCC is more than 95%; for patients with spread of SCC to lymph nodes or other organs, the 5-year survival rate is 25%.
The cause of NMSCs may be environmental (ultraviolet [UV] radiation or UVB exposure), occupational (arsenic, mineral oils, or ionizing radiation exposure), viral (human immunodeficiency virus or human papillomavirus [HPV]), related to medical conditions (immunosuppression or scars from removed SCC or BCC), or related to heredity (xeroderma pigmentosum, or albinism). More than 90% of NMSCs are attributed to exposure to UV radiation from the sun.
Nursing care plan assessment and physical examination
Assess the patient for a personal or family history of skin cancer. Ask if the patient has an exposure to risk factors, including environmental or occupational exposure, at-risk medical conditions, or exposure to viruses. Note that outdoor employment and living in a sunny, warm climate such as the southeastern (Florida) or southwestern (New Mexico, Arizona, California) United States, Australia, or New Zealand place the patient at risk. Question the patient about any bleeding lesions or changes in skin color. Explore the history of nonhealing wounds or lesions that have been present for several years without any change. Question the patient about the presence of atypical moles, an unusual number of moles, or any noticeable change in a mole.
Inspect the patient for additional risk factors, such as light skin and hair (red, blond, light brown), freckling, and light eye color (blue or green). Examine the patient’s skin for the presence of lesions. Use a bright white light and magnification during the skin examination. Stretch the skin throughout the examination to note any nodules or translucent lesions. Examine folds or wrinkles in the skin. Assess the skin for ulcerations, sites of poor healing, old scars, drainage, pain, and bleeding. Because more than 70% of NMSCs occur on the face, head, and neck, closely examine these areas. Complete the skin assessment, considering that, in order of frequency, the remainder of NMSCs occurs on the trunk, upper extremities, lower extremities, and lastly, the genitals. Determine if the patient has precursor lesions of SCC, such as actinic keratoses (a hornlike projection on the skin from excessive sun exposure) and/or Bowen’s disease (intraepidermal carcinoma). No assessment of precursor lesions for BCC is necessary because no
equivalent lesions exist.
Assess for the characteristic lesions of BCC, which tend to be asymptomatic, grow slowly, be 0.5 to 1.0 cm in size, and have overlying telangiectasis (vascular lesions formed by dilated blood vessels). BCCs are classified as nodular (the most common type), superficial, pigmented, morpheaform, and keratotic. Nodular BCC appears as a translucent, nodular growth. Superficial BCC, frequently appearing on the trunk, presents as a scaly lesion with a distinct, raised, pearly margin. Pigmented BCC has a characteristic dark or bluish color with a raised and pearly border. The morpheaform BCC lesion is poorly demarcated, is light in color, and has a plaquelike appearance. Keratotic BCC lesions appear similar to ulcerating nodular BCC. Assess for the characteristic lesions of SCC, which are usually found on sun-damaged skin. The lesions tend to be scaly, 0.5 to 1.5 cm in size, and likely to metastasize; they also grow rapidly. SCC lesions are usually covered by a warty scale surrounded by erythema that bleeds easily with minimal trauma. The tumor appears nodular, plaquelike, and without a distinct margin. When SCC is invasive, the lesion appears firm, dome-shaped, erythematous, and with an ulcerating core.
Determine the patient’s willingness to follow primary prevention strategies and to institute changes that decrease the risk of skin cancer or its recurrence. Of particular concern are patients who are adolescents and young adults who place a high premium on physical appearance. If the patient has metastatic disease, assess the ability to cope with highly stressful situations. Determine if the patient has support systems and the ability to cope with major lifestyle changes.
Nursing care plan primary nursing diagnosis: Impaired skin integrity related to cutaneous lesions.
Nursing care plan intervention and treatment plan
Treatment depends on the patient’s characteristics; whether the lesion is a primary or recurrent tumor; and its size, location, and histology. For some primary SCCs and BCCs, therapies may include electrosurgery, surgical excision, cryosurgery, and radiation therapy, which all have comparable cure rates of greater than 90%. Tumors best suited to such methods are generally small, superficial, well defined, and slow growing. Treatment is done on an outpatient basis, unless the tumor involves deep anatomic sites and surgery cannot be performed under local anesthesia. Mohs’ micrographic surgery is the preferred procedure for invasive SCCs, incomplete excisions, and recurrences. The procedure is also preferred for BCCs that are greater than 2 cm, are located in high-risk areas, have aggressive morphology, or have ill-defined borders. This time-consuming procedure involves removing a layer of skin, immediately checking the removed tissue for cancer cells, and continuing this process until the removed skin samples are cancer free. Reconstructive surgery may be necessary after Mohs’ surgery or extensive excision.
Topical fluorouracil may be used to manage some SCC skin lesions. During treatment, the patient’s skin is more sensitive than usual to the sun. Healing generally occurs in 1 to 2 months. With metastatic SCC, radiation, chemotherapy, and surgery may be combined. The chemotherapeutic agent commonly used is cisplatin or doxorubicin, or both. External beam radiation therapy may be used in cases where a tumor is difficult to remove surgically because of its size or location and in situations in which the patient’s health precludes surgery. As an adjuvant therapy after surgery, radiation can be used to kill small deposits of cancer cells that were not visible during surgery. Radiation may also be used when NMSC has spread to other organs or to lymph nodes. If the patient undergoes radiation therapy, prepare the patient for common side effects such as nausea, vomiting, diarrhea, hair loss, and malaise.
Nursing care focuses on wound management, threats to body image and self-esteem, and prevention. Teach the patient how to care for the wound aseptically. Coordinate a consistent, standard plan so that the patient can begin to assume care for the wound. If the wound is large and infected, keep it dry and clean. If it has an odor, control the odor with odor-masking substances such as oil of cloves or balsam of Peru in the room.
Patients are often upset about the changes in their appearance. Listen to the patient’s fears and anxieties and accept the patient’s perception of her or his appearance. Assist the patient and significant others to have realistic expectations. Help the patient present a pleasant appearance by assisting with hair care and clothing. Some patients experience increased self-esteem when they wear their own clothing rather than hospital-issued clothing, if hospitalization is needed. If hair loss occurs during radiation, encourage the patient to wear any type of head covering that improves body image, such as baseball caps, wigs, scarves, or bandanas. If it is appropriate, arrange for the patient to interact with others who have a similar problem. If the patient has endstage disease, listen to the patient’s and significant others’ fears and concerns. Identify the needs of the family, and investigate mechanisms for support from the chaplain, the American Cancer Society, or a local hospice.
If the patient cannot continue with his or her present occupation, arrange for job counseling to evaluate possible occupational alternatives. Encourage the patient to avoid excessive sun exposure by using sunscreen and wearing protective clothing. Explain the necessity of examining the skin weekly or monthly for precancerous lesions and to obtain healthcare when any unusual skin changes occur.