Clinical Guidelines (Nursing)

Perianal care for the Paediatric Oncology Patient

  • Note: This guideline is currently under review. 


    Parameters

    The aim of this guidelines is to provide recommended perianal care for the Paediatric Oncology Patient at the Royal Children's Hospital.  It  outlines the prophylactic and reactive management required for optimal skin and mucosal integrity 

    Definition of terms

    Perianal care involves maintaining the integrity and function of the skin and mucosal surfaces of the perineum and anal region.

    The skin and mucosal surfaces constitute the primary host defense against invasion by endogenous and acquired microorganisms. Any factor that bypasses or disrupts this integumentary barrier can mean there is increased susceptibility to infection.

    The paediatric oncology patient is extremely vulnerable to alterations in skin and mucosal surfaces due to the adverse effects of chemotherapy, radiotherapy, immunosuppression and alterations in nutritional status.

    Assessment

    The perianal region should be assessed daily by a clinician, either the treating doctor or the nurse managing the patients care.

    Report discomfort, erythema, burning, itching, swelling, vesicles, etc.

    Document all findings, decisions regarding management and proposed plan of care

    The goal is to initiate preventative care of the skin and mucosal surfaces when there is an anticipated risk to the perianal area.

    Management

    Recommended perianal care for the Paediatric Oncology Patient

    No neutropenia

    Asymptomatic

    • Daily bath/shower using a mild soap
    • If the patient has diarrhoea apply one of the following protective barrier creams to areas of intact skin
      • 10% dimethicone cream every 3 to 4 washes (e.g. Silicare or 3M Cavilon Barrier Cream)
      • 3M No Sting Barrier Film daily

    Mild Excoriation

    • Daily bath/shower using a mild soap
    • Gently cleanse with water/saline after voiding or each bowel action 
    • Pat dry or administer oxygen via tubing to thoroughly dry the area (using separate tubing for inhaled oxygen and topical oxygen).
    • Expose the area to air whenever possible
    • Apply protective barrier cream to areas of intact skin as above
    • For severe skin loss contact Stomal Therapist

    Neutropenic

    Asymptomatic

    • Daily bath/shower using a mild soap
    • If the patient has diarrhoea apply one of the following protective barrier cream to areas of intact skin 
      • 10% dimethicone cream every 3 to 4 washes (e.g. Silicare or 3M Cavilon Barrier Cream)
      • 3M No Sting Barrier Film daily


    Mild Excoriation

    • Daily bath/shower using a mild soap
    • Gently cleanse with water/saline after voiding or each bowel action and pat dry
    • Expose the area to air whenever possible
    • Apply a thin layer of mycostatin t.d.s on areas where candida suspected or present
    • Apply protective barrier cream to areas of intact skin as above


    Severe Excoriation

    • B.D. bath/shower using a mild soap
    • Gently cleanse with water/saline after voiding or each bowel action 
    • Pat dry or administer oxygen via tubing to thoroughly dry the area (using separate tubing for inhaled oxygen and topical oxygen).
    • Expose the area to air whenever possible
    • Apply a thin layer of mycostatin t.d.s on areas where candida suspected or present
    • Apply a thin layer of SSD cream only to areas of skin loss (discontinue when no  longer neutropenic)
    • Apply a 3 to 5 mm layer of SSD cream only to areas of skin loss (discontinue when no longer   neutropenic)
    • Apply protective barrier cream to areas of intact skin as above
    • For severe skin loss contact stomal therapist


    Analgesia regimen for pain associated with perianal excoriation

    • Xylocaine gel 2% may be applied to the external anal area prior to toileting for patients who have an anal tear
    • Systemic analgesics (paracetamol, codeine or morphine) may be required, and should be administered according to the degree of pain

    Considerations

    • PR medications or enemas, PR temperatures, rectal examinations or colonoscopies, tampons, pessaries and douches should not be used in the oncology patient. Use indwelling catheters only if unavoidable.
    • If perianal excoriation occurs, encourage use of disposable super absorbent gel nappies for infants or children to wear lightweight preferably cotton underwear or pyjamas
    • Change nappies frequently, and immediately after each bowel action. 
    • Avoid constipation. Chemotherapy agents such as vinca alkaloids (e.g. vincristine, vinblastine) or the use of narcotic analgesics may cause constipation, therefore aperients and stool softeners are often required. Once constipation occurs, it can be very difficult to treat, so prevention with stool softeners must be instituted early to reduce the risk of an anal tear. 
    • Intensive chemotherapy regimens (e.g. methotrexate, cisplatin and actinomycin-D), infections or diseases such as graft versus host may cause diarrhoea. Collect stool specimens to exclude infectious causes. Do not administer anti-diarrhoeal agents without fellow/consultant approval.
    • Many chemotherapy agents may contribute to perianal skin problems, producing erythema and desquamation (e.g. high dose thiotepa, cyclophosphamide and carboplatin).
    • Adolescents who are sexually active should discuss precautions with their consultants
    • Nonperfumed baby skin wipes may be used to cleanse the perianal area, however discontinue use if irritation occurs.

    Associated Documents

    • Nursing Care Plan- 6 East MR 51D
    • Febrile Neutropenia Path MR96I
    • Chemotherapy Clinical Path MR96J
    • RCH Clinical Practice Guidelines: Constipation

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