(itching)

is an unpleasant sensation that elicits the desire to scratch. It is a distressing symptom that can cause discomfort and threaten the effectiveness of the skin as a major protective barrier.

Symptoms of generalized itching, without rash or skin lesions, may be related to anything from dry skin to an occult carcinoma, and the etiology of the symptoms should be explored. Common nonmalignant etiologic factors include drug reactions, xerosis, scabies, and primary skin diseases. The most common diagnosis related to pruritus in this population is simply dry skin.

skin accounts for 15% of the body's total weight and is the largest organ of the body. The skin has significant psychosocial and physical functions. Its function as a protective mechanism is the skin's most important role.

Various malignant diseases are known to produce pruritus. Hodgkin lymphoma causes pruritus in 10% to 25% of patients. Pruritus associated with Hodgkin lymphoma is characterized by symptoms of burning and intense itching occurring on a localized skin area, frequently on the lower legs. Other lymphomas and leukemias have been associated with a less intense but more generalized pruritus.

Adenocarcinomas and squamous cell carcinomas of various organs (i.e., stomach, pancreas, lung, colon, brain, breast, and prostate) sometimes produce generalized pruritus that is more pronounced on the legs, upper trunk, and extensor surfaces of the upper extremities. Pruritus associated with malignant diseases has been observed to diminish or disappear with eradication of the tumor and reappear with recurrence of disease.

Cytotoxic Chemotherapy antineoplastic agents (alkylating agents, antimetabolites, antibiotics, plant alkaloids, nitrosoureas, and enzymes) include drugs capable of producing cutaneous reactions including pruritus. Hypersensitivity to cytotoxic agents can be manifested by pruritus, edema, urticaria, and erythema. Hypersensitivity reactions vary in symptomatology and depend on the drug, the dosage, and the allergy history of the patient.

Radiation Therapy related pruritus is usually associated with dry desquamation of skin within the treatment field. Dryness and pruritus may occur and is caused by obliteration of sebaceous glands within the field. Combination Therapy combining radiation and chemotherapy plays a significant role in state-of-the-art cancer therapy. The synergism of these cytotoxic modalities enhances normal tissue reaction and can be expected to precipitate higher complication rates. Significant cutaneous reactions are thought to occur more frequently when chemotherapy and irradiation are administered concurrently

Other Pharmacologic Support During Cancer Treatment pharmacologic agents employed at any point during the cancer course, whether in a primary treatment plan or incorporated into a symptom control or supportive care program, are capable of eliciting a pruritic reaction. Drugs associated with secondary pruritus include opium derivatives (cocaine, morphine, butorphanol), phenothiazines, tolbutamide, erythromycin estolate, anabolic hormones, estrogens, progestins, testosterone and aspirin, quinidine and other antimalarials, biologics such as monoclonal antibodies, and vitamin B complex.

Therapeutic actions Completely blocks the effects of histmaine at peripheral H1 receptor sites, have anticholinergic (atropine-like) and antipruritic effects. Indications Relief of symptoms associated with perennial and seasonal allergic rhinitis; vasomotor rhinitis; allergic conjunctivitis; mild, uncomplicated urticaria andangioedema; amelioration of allergic reactions to blood or plasma;dermatographism; adjunctive therapy in anaphylactic reactions

Contraindications and cautions Contraindicated with allergy to any antihistamines, third trimester of pregnancy, lactation. Use cautiously with narrow-angle glaucoma, stenosing peptic ulcer, symptomaticprostatic hypertrophy, asthmatic attack, bladder neck obstruction, pyloroduodenalobstruction, pregnancy; elderly patients who may be sensitive to anticholinergiceffects.

Nursing considerations Assessment

History: Allergy to any antihistamines, narrow-angle glaucoma, stenosing peptic ulcer, symptomatic prostatic hypertrophy, asthmatic attack, bladder neck obstruction, pyloroduodenal obstruction, third trimester of pregnancy, lactation Physical: Skin color, lesions, texture; orientation, reflexes, affect; vision examination; P, BP; R, adventitious sounds; bowel sounds; prostate palpation; CBC with differential

Interventions

Administer with food if GI upset occurs. Administer syrup form if patient is unable to take tablets. Monitor patient response, and arrange for adjustment of dosage to lowest possible effective dose.

Teaching points

Take as prescribed; avoid excessive dosage. Take with food if GI upset occurs. Avoid alcohol; serious sedation could occur. You may experience these side effects: Dizziness, sedation, drowsiness (use caution driving or performing tasks requiring alertness); epigastric distress, diarrhea or constipation (take drug with meals); dry mouth (use frequent mouth care, suck sugarless lozenges); thickening of bronchial secretions, dryness of nasal mucosa (use a humidifier). Report difficulty breathing, hallucinations, tremors, loss of coordination, unusual bleeding or bruising, visual disturbances, irregular heartbeat.

corticosteroid preparation may be applied to the skin to reduce inflammation and thereby relieve itching caused by skin conditions such as psoriasis, contact dermatitis, or eczema. educe the production of substances called prosta-glandins that trigger inflammation.

Therapeutic actions Enters target cells and binds to cytoplasmic receptors; initiates many complex reactions that are responsible for its anti-inflammatory, immunosuppressive (glucocorticoid), and salt-retaining (mineralocorticoid) actions. Some actions may be undesirable, depending on drug use.

Indications Replacement therapy in adrenal cortical insufficiency Allergic statessevere or incapacitating allergic conditions Hypercalcemia associated with cancer Short-term inflammatory and allergic disorders, such as rheumatoid arthritis, collagen diseases (SLE), dermatologic diseases (pemphigus), status asthmaticus, and autoimmune disorders Hematologic disorders thrombocytopenic purpura, erythroblastopenia Trichinosis with neurologic or myocardial involvement Ulcerative colitis, acute exacerbations of MS, and palliation in some leukemias and lymphomas Intra-articular or soft-tissue administration: Arthritis, psoriatic plaques Retention enema: For ulcerative colitis, proctitis Dermatologic preparations: To relieve inflammatory and pruritic manifestations of dermatoses that are steroid responsive Anorectal cream, suppositories: To relieve discomfort of hemorrhoids and perianal itching or irritation

Topical dermatologic administration Contraindicated with fungal, tubercular, herpes simplex skin infections; vaccinia, varicella; ear application when eardrum is perforated. Use cautiously with pregnancy, lactation.

Nursing considerations Assessment Physical: Systemic administration: Weight, T; reflexes,

affect, bilateral grip strength, ophthalmologic examination; BP, P, auscultation, peripheral perfusion, discoloration, pain or prominence of superficial vessels; R, adventitious sounds, chest xray; upper GI x-ray (history or symptoms of peptic ulcer), liver palpation; CBC, serum electrolytes, 2-hr postprandial blood glucose, urinalysis, thyroid function tests, serum cholesterol. Topical, dermatologic preparations: Affected area, integrity of skin

Interventions

Topical dermatologic administration Use caution with occlusive dressings; tight or plastic diapers over affected area can increase systemic absorption. Avoid prolonged use, especially near eyes, in genital and rectal areas, on face, and in skin creases. Teaching points Topical dermatologic administration Apply sparingly, and rub in lightly Avoid contacting your eye with the medication. Report burning, irritation, or infection of the site, worsening of the condition. Avoid prolonged use.

Soothing preparations Itching, such as that caused by insect bites, sunburn, or an allergic rash such as urticaria, can often be soothed using calamine lotion or cream or an emollient. Emollient preparations reduce moisture loss from the skin, preventing dryness and easing itching, and can be used to relieve the symptoms of eczema, psoriasis, and other dry skin conditions.

Therapeutic actions Relaxes bronchial smooth muscle, causing bronchodilation and increasing vital capacity, which has been impaired by bronchospasm and air trapping; in higher concentrations, it also inhibits the release of slow-reacting substance of anaphylaxis (SRSA) and histamine.

Indications Symptomatic relief or prevention of bronchial asthma and reversible bronchospasm associated with chronic bronchitis and emphysema Unlabeled uses: Respiratory stimulant in Cheyne-Stokes respiration; treatment of apnea and bradycardia in premature babies Contraindications and cautions Contraindicated with hypersensitivity to any xanthine or to ethylenediamine, peptic ulcer, active gastritis; rectal or colonic irritation or infection (use rectal preparations). Use cautiously with cardiac arrhythmias, acute myocardial injury, CHF, cor pulmonale, severe hypertension, severe hypoxemia, renal or hepatic disease, hyperthyroidism, alcoholism, labor, lactation, pregnancy.

Nursing considerations Assessment

History: Hypersensitivity to any xanthine or to ethylenediamine, peptic ulcer, active gastritis, cardiac arrhythmias, acute myocardial injury, CHF, corpulmonale, severe hypertension, severe hypoxemia, renal or hepatic disease, hyperthyroidism, alcoholism, labor, lactation, rectal or colonic irritation or infection (aminophylline rectal preparations) Physical: Bowel sounds, normal output; P, auscultation, BP, perfusion, ECG; R, adventitious sounds; frequency of urination, voiding, normal output pattern, urinalysis,

Interventions

Administer to pregnant patients only when clearly neededneonatal tachycardia, jitteriness, and withdrawal apnea observed when mothers receivedxanthines up until delivery. Caution patient not to chew or crush enteric-coated timed-release forms. Give immediate-release, liquid dosage forms with food if GI effects occur. Do not give timed-release forms with food; these should be given on an empty stomach 1 hr before or 2 hr after meals. Maintain adequate hydration. Monitor results of serum theophylline levels carefully, and arrange for reduced dosage if serum levels exceed therapeutic range of 1020 mcg/mL. Take serum samples to determine peak theophylline concentration drawn 1530 min after an IV loading dose. Monitor for clinical signs of adverse effects, particularly if serum theophylline levels are not available. Ensure that diazepam is readily available to treat seizures.

Teaching points Take this drug exactly as prescribed; if a timed-release product is

prescribed, take this drug on an empty stomach, 1 hour before or 2 hours after meals. Do not to chew or crush timed-release preparations. Administer rectal solution or suppositories after emptying the rectum. It may be necessary to take this drug around-the-clock for adequate control of asthma attacks. Avoid excessive intake of coffee, tea, cocoa, cola beverages, and chocolate. Smoking cigarettes or other tobacco products impacts the drug's effectiveness. Try not to smoke. Notify your health care provider if smoking habits change while taking this drug. Frequent blood tests may be necessary to monitor the effect of this drug and to ensure safe and effective dosage; keep all appointments for blood tests and other monitoring. You may experience these side effects: Nausea, loss of appetite (taking this drug with food may help if taking the immediate-release or liquid dosage forms); difficulty sleeping, depression, emotional lability (reversible). Report nausea, vomiting, severe GI pain, restlessness, seizures, irregular heartbeat.