Nursing Care Plan | NCP Melanoma Skin Cancer

Melanoma skin cancer is a type of skin cancer that originates from the melanocytes, frequently a nevus or mole. Melanocytes are melanin-producing cells that are interspersed in the inner layer of the epidermis. Melanin is a dark brown pigment that protects the epidermis and the superficial vasculature of the dermis. Nevi or moles are small, circumscribed aggregates of melanocytes. It is thought that the ultraviolet radiation (from direct sunlight or tanning beds) damages the DNA of melanocytes, impairing the DNA control over how and when cells grow and divide. These skin lesions tend to be hereditary, begin to grow in childhood, and become more numerous in young adulthood.

Skin cancer is the most common cancer in the United States, and melanoma accounts for 4% of all skin cancer cases. Although the lifetime melanoma risk for the overall population is only 1.4%, melanoma is responsible for 79% of skin cancer deaths. According to the American Cancer Society, approximately 59,580 new diagnoses of melanoma were expected in the year 2005, with 7700 deaths anticipated. Diagnoses of melanoma continue to increase; the number of new melanomas diagnosed per 100,000 people has jumped from 5.76 to 13.8 since 1973. The mortality rate per 100,000 people has increased by 50%; much of this increase in mortality is in older white males.

Characteristics that are associated with an increased risk for melanoma include fair skin that does not tan well and burns easily, blond or red hair, the tendency to develop freckles, and the presence of a large number of nevi. A strong association exists between exposure to ultraviolet light and the development of cutaneous melanoma, but the exact nature of this relationship is unclear. Other risk factors include a positive family history and immune suppression.

Nursing Care Plan Assessment and Physical Examination
Reports of a change in a nevus or mole or a new skin lesion require careful followup. Ask the patient the following questions: When did the lesion first appear or change? What is the specific nature of the change? What symptoms and characteristics of the lesion has the patient noticed? What is the patient’s history of exposure to ultraviolet light or radiation? What is the history of thermal or chemical trauma? What personal or family history of melanoma or precancerous lesions exists?

To identify potentially cancerous lesions, inspect and palpate the scalp, all skin surfaces, and the accessible mucosa. Examine pre existing lesions, scars, freckles, moles, warts, and nevi closely. The “ABCD rule” can be useful in identifying distinguishing characteristics of suspicious lesions.

For many people, the diagnosis of any type of cancer is associated with death. Because cancerous skin lesions are readily visible, the patient with melanoma may experience an altered body image. Ask open-ended questions as you assess the patient’s emotional response to the diagnosis of melanoma.

Nursing care plan primary nursing diagnosis: Impaired skin integrity related to cutaneous lesions.

Nursing care plan intervention and treatment plan
After diagnostic testing, the cancer is staged. Because the thinner the melanoma, the better the prognosis, the Clark level of a melanoma may be used. This system uses a scale of 1 to 5 to describe which layers of skin are involved. The higher the number, the deeper the melanoma.

The primary treatment for melanoma is surgical resection. Excision of the cancerous lesion with a 2- to 5-cm margin is recommended when feasible. The width of the surrounding margin should be wider for larger primary lesions. When the melanoma is on a finger or toe, surgical treatment is to amputate as much of the finger or toe as is necessary. Elective regional lymph node removal is controversial. Proponents believe that this procedure decreases the possibility of distal metastases, but scientific evidence to support this belief is lacking.

The prognosis for metastatic melanoma is poor; it is highly resistant to currently available chemotherapeutic agents. Radiation is not often used to treat the original melanoma, but is rather used for symptom management as a palliative measure if the cancer has spread to the brain.

Patient and family education is the most important nursing responsibility in preventing, recognizing, and treating the disorder. Educational materials and teaching aids are available from various community and national organizations, the local or state branch of the American Cancer Society, and online computer services. Nursing care of patients who have had surgery is focused on patient education because most of these patients are treated in an ambulatory or short-term stay setting. Instruct patients to protect the site and inspect the incision and graft sites for bleeding or signs of infection. Immobilize recipient graft sites to promote engraftment. Evaluate limbs that have surgical incisions or local isolated chemotherapy to prevent edema.

Reactions to skin disfigurement that occur with some treatments may vary widely. Determine what the cancer experience means to the patient and how it affects the patient’s perception of his or her body image. Help the patient achieve the best possible grooming as treatment progresses. Suggest a support group, or if the patient is coping ineffectively, refer for counseling.

Nursing care plan discharge and home health care guidelines
Teach the patient to protect the incision site from thermal, physical, or chemical trauma. Instruct the patient to inspect the incision site for signs of bleeding or infection. Teach the patient to notify the physician for fever or increased redness, swelling, or tenderness around the incision site. Provide instructions as indicated for specific adjuvant therapy: chemotherapy, radiation, immunotherapy. Teach the patient strategies for prevention and for modifying the risk factors: Skin self-examination and identification of suspicious lesions: Moles or nevi that change in size, height, color, texture, sensation, or shape; development of a new mole. Limitation of ultraviolet light exposure: Avoid the sun between the hours of 10 a.m. and 3 p.m. when the ultraviolet radiation is the strongest. Wear waterproof sunscreen with a sun protection factor of greater than 15 before going outdoors. Apply sunscreen on cloudy days because roughly 70% to 80% of ultraviolet rays can penetrate the clouds. Reapply sunscreen every 2 to 3 hours during long sun exposure. Be aware that the sun’s rays are reflected by such surfaces as concrete, snow, sand, and water, thereby increasing exposure to ultraviolet rays. Wear protective clothing when outdoors, particularly a wide-brimmed hat to protect the face, scalp, and neck area. Wear wrap-around sunglasses with 99% to 100% ultraviolet absorption to protect the eyes and the skin area around the eyes. Be aware of medications and cosmetics that increase the sensitivity to ultraviolet rays. Minimize ultraviolet exposure as much as possible and use sunscreen that contains benzophenones. Avoid tanning booths or sunlamps.