Radiation & Chemotherapy
Internal Unsealed Radiotherapy
Treatment with unsealed radioactive sources that are ingested, injected, or instilled. Radiation is metabolized and absorbed by the body then concentrated in a specific target organ. Also called radiopharmaceutical therapy. Example: (FYI only) Oral Iodine-131 IV strontium-89
Safe Handling of Chemotherapy - Administration
- double glove with disposable, non-powdered, thick latex gloves (or gloves manufactured as chemo resistant). - long sleeve disposable gowns with elastic/knitted cuffs - absorbent, plastic backed liner under work surface - disposable-puncture proof, shatter proof, leak proof plastic container for waste. - Leur-Lok fittings for syringes, tubings - double bag contaminated linen. - keep "Spill Kit "available (Biohazard).
Nursing Interventions for chemotherapy and/or radiation side-effects - Diarrhea
Diarrhea Risk for impaired skin integrity Risk for Deficient Fluid Volume Knowledge deficient (self-care) NI: Assess number, amount and consistency of stool. Administer antidiarrheal medications as ordered. Maintain fluid intake by encouraging >2500 ml per day. Avoid greasy, spicy, fried foods, and dairy products. Encourage low residue, low-roughage, low-fat diet. BRAT diet helpful (bananas, rice, apples (peeled), and (dry) toast.) Teach/provide perianal skin care followed by moisture barrier creams. Administer anti-diarrheal medications as ordered. Teach signs and symptoms of dehydration to report.
Nursing Interventions for chemotherapy and/or radiation side-effects - Alopecia
Disturbed Body Image Knowledge deficient (self-care) NI: Brush and comb hair gently. Use gentle shampoo and wash hair only when necessary . Avoid hair dye, permanents, hair dryers, electric curling devices, and constricting clips or bands. Cut hair short prior to loss. May wear a wig, hat or scarf. Begin doing this before hair loss begins. Protect scalp from cold and sun.
Nursing Interventions for chemotherapy and/or radiation side-effects - Mucositis
Risk for imbalanced nutrition, less than body requirements Impaired oral mucous membrane Knowledge deficient (self-care) NI: Use soft bristle toothbrush after each meal and at bedtime. Rinse mouth four times/day with saline or 1 tsp. baking soda dissolved in 2 cups H2O. Avoid commercial mouthwashes, alcohol, tobacco, and irritating (spicy, acidic) foods. Use topical anesthetics and/or systemic pain medication for pain relief. Encourage fluids and soft or liquid high calorie high protein foods. Teach signs and symptoms to report (signs of fungal infections, inability to eat/drink.
Nursing Interventions for chemotherapy and/or radiation side-effects - Nausea & Vomiting
Risk for imbalanced nutrition, less than body requirements Nausea Risk for deficient fluid volume Knowledge deficient (self-care) NI: Assess nausea and vomiting on a 0-10 scale. Offer small frequent meals. Encourage high calorie, high protein foods. Bland, lukewarm, non-gas forming foods best tolerated. Ensure anti-emetics administered pre treatment when chemo or RT expected to cause nausea. Administer anti-emetics around the clock for 24-48o following chemotherapy which is expected to cause nausea. Nausea and Vomiting may need to be treated with multiple anti- emetics from different classifications to effectively alleviate symptom. Teach signs and symptoms of dehydration to report. (Ortho. hypotension, F&E imbalances -> hypokalemia)
Nursing Care Management: Radiation Side-Effects
Side-effects are local in nature (only related to the area irradiated). The exception is fatigue which is the one universal systemic side-effect.
Nursing Care Management: Chemotherapy Side-Effects
Systemic treatment that can cause a multitude of side-effects due to its effect on rapidly dividing cells. Different classes of chemotherapies have their own individual side-effect profile. Common side-effects may include nausea, vomiting, diarrhea, mucositis, and alopecia. (The cells in the GI tract, hair cells and bone marrow rapidly divide so they are most affected). Fatigue is a universal side-effect of all chemotherapy treatments.
Palliation
Palliative treatment is designed to relieve symptoms, and improve your quality of life. It can be used at any stage of an illness if there are troubling symptoms, such as pain or sickness. Palliative treatment can also mean using medicines to reduce or control the side effects of cancer treatments.
Safe Handling of Chemotherapy - Safety Tips
- Do not eat or drink in areas where antineoplastic agents are prepared or administered. - Become familiar with and be able to recognize sources of exposure to antineoplastic agents. - Wash hands before using and after removing personal protective clothing such as disposable gowns. - Handle wastes related to antineoplastic agents separately from other hospital trash. - - Treat them as hazardous waste. Utilize appropriate chemowaste disposal bags and chemowaste sharps container. - Clean up spills immediately using appropriate precautions. - Learn what written policies your unit has for the safe handling of antineoplastic agents.
Baseline Assessments Prior to Chemotherapy
* Lab values (H/H, WBC, platelet, absolute neutrophil count) - Rules out the possibility of anemia, leukopenia, and thrombocytopenia. May need to hold chemo if present. * Ordered doses appropriate for calculated Body Surface Area (ht/wt) - Prevents chemotherapy under dosing or overdosing. * Side-effects experienced - Determines if it is safe to administer next dose (manageable symptom or toxicity) Focuses teaching. * Vital signs - Allows comparison to baseline. Determines if it is safe to administer next dose (Ortho. Hypotension changes 10-15, incr. HR)
Carcinoma
A cancer arising in the epithelial tissue of the skin or of the lining of the internal organs.
Carcinogen
A substance capable of causing cancer in living tissue
Tumor
A swelling of a part of the body, generally without inflammation, caused by an abnormal growth of tissue, whether benign or malignant.
Primary Site
A term used to describe the original, or first, tumor in the body. Cancer cells from a primary tumor may spread to other parts of the body and form new, or secondary, tumors. This is called metastasis. These secondary tumors are the same type of cancer as the primary tumor. Also called primary cancer.
Tumor Marker
A tumor marker is a biomarker found in blood, urine, or body tissues that can be elevated by the presence of one or more types of cancer. There are many different tumor markers, each indicative of a particular disease process, and they are used in oncology to help detect the presence of cancer.
Polyp
Abnormal tissue growth on a mucous membrane.
Adjuvant Therapy
Adjuvant treatment is an addition designed to help reach the ultimate goal. Adjuvant therapy for cancer usually refers to surgery followed by chemo- or radiotherapy to help decrease the risk of the cancer recurring (coming back). - Chemotherapy - Hormone therapy - Radiation therapy. - Immunotherapy - Targeted therapy.
What is the most effective way to administer anti-emetics to treat chemotherapy induced nausea?
Administer prior to chemotherapy and then around-the-clock for 1-2 days as needed.
Neoplasm
An abnormal growth of tissue, benign or malignant, that serves no physiologic function. May also be referred to as tumor
In Situ
An early stage cancer in which the cancerous growth or tumor is still confined to the site from which it started, and has not spread to surrounding tissue or other organs in the body. When cancer in situ involves cells that line the internal organs, or epithelial cells, it is called carcinoma in situ.
A patient undergoing external radiation has developed a dry desquamation of the skin in the treatment area. The RN knows that teaching about management of the skin reaction has been effective when the patient says a. "I can use ice packs to relieve itching in the treatment area." b. "I can buy a lanolin-free cream to use on the itching area." c. "I will expose the treatment are to a sun lamp daily." d. "I will scrub the area with warm water to remove the scales."
Answer: B Rationale: Lanolin-free cream may be used to reduce itching in the area. Ice and sunlamps may injure the skin. Treatment areas should be cleaned gently to avoid further injury and scratching/rubbing should be minimized.
Which action by a patient care technician (PCT) caring for a patient with a temporary radioactive cervical implant indicates that the RN should intervene? The PCT a. places the patient's bedding in the laundry container in the hallway. b. flushes the toilet once after emptying the patient's bedpan. c. stands by the patient's bed for an hour talking with the patient. d. gives the patient an alcohol-containing mouthwash for oral care.
Answer: C Rationale: Because patients with temporary implants emit radioactivity while the implants are in place, exposure to the patient is limited. Laundry and urine/feces do not have any radioactivity and do not require special precautions. Cervical radiation will not affect the oral mucosa, and alcohol-based mouthwash is not contraindicated.
External-beam radiation is planned for a patient with endometrial cancer. The RN teaches the patient that an important measure to prevent complications from the effects of the radiation is to a. test all stools for the presence of blood. b. inspect the mouth and throat daily for the appearance of thrush. c. perform perianal care with sitz baths and meticulous cleaning. d. maintain a high-residue, high-fat diet.
Answer: C Rationale: Radiation to the abdomen will affect organs in the radiation path, such as the bowel, and cause frequent diarrhea. Stools are likely to have occult blood from the inflammation associated with radiation, so routine testing of stools for blood is not indicated. Radiation to the abdomen will not cause stomatitis. A low-residue diet is recommended to avoid irritation of the bowel when patients receive abdominal radiation.
A patient with metastatic cancer of the colon experiences severe vomiting following each administration of chemotherapy. An important nursing intervention for the patient is to a. teach about the importance of nutrition during treatment. b. have the patient eat large meals when nausea is not present. c. administer prescribed antiemetics 1 hour before the treatments. d. offer dry crackers and carbonated fluids during chemotherapy.
Answer: C Rationale: Treatment with antiemetics before chemotherapy may help to prevent anticipatory nausea. Although nausea may lead to poor nutrition, there is no indication that the patient needs instruction about nutrition. The patient should eat small, frequent meals. Offering food and beverages during chemotherapy is likely to cause nausea.
A patient is undergoing external radiation therapy on an outpatient basis. After 2 weeks of treatment, the patient tells the nurse, "I am so tired I can hardly get out of bed in the morning." An appropriate intervention for the RN to plan with the patient is to a. exercise vigorously when fatigue is not as noticeable. b. consult with a psychiatrist for treatment of depression. c. establish a time to take a short walk every day. d. maintain bed rest until the treatment is completed.
Answer: C Rationale:Walking programs are used to keep the patient active without excessive fatigue. Vigorous exercise when the patient is less tired may lead to increased fatigue. Fatigue is expected during treatment and is not an indication of depression. Bed rest will lead to weakness and other complications of immobility.
A patient receiving systemic chemotherapy has ulcerations over the oral mucosa and tongue and thick, ropey saliva. An appropriate intervention for the RN to teach the patient is to a. remove food debris from the teeth and oral mucosa with a stiff toothbrush. b use cotton-tipped applicators dipped in hydrogen peroxide to clean the teeth. c. gargle and rinse the mouth several times a day with an antiseptic mouthwash. d rinse the mouth before and after each meal and at bedtime with a saline solution.
Answer: D Rationale: The patient should rinse the mouth with a saline solution frequently. A soft toothbrush is used for oral care. Hydrogen peroxide may damage tissues. antiseptic mouthwashes may irritate the oral mucosa and are not recommended.
NIs during IV chemotherapy administration
Assess patent IV (follow peripheral line or central line protocols) Assess and manage side-effects Teaching as indicated (determined by side-effects of chemotherapy)
Biologic Response Modifier
BRM), also called immunotherapy, is a type of treatment that mobilizes the body's immune system to fight cancer. The therapy mainly consists of stimulating the immune system to help it do its job more effectively. Tumor Vaccines also work to stimulate the body's immune system.
Malignant
Cancer cell invade neighboring tissues, enter blood vessels, and metastasize to different sites
Staging Cancer
Cancer staging is the process of determining the extent to which a cancer has developed by spreading. Contemporary practice is to assign a number from I to IV to a cancer, with I being an isolated cancer and IV being a cancer which has spread to the limit of what the assessment measures.
**** Half Life....
Chemo: Carboplatin exhibits biphasic elimination, with an initial half life of 1.1-2 hours and final half life of 2.6-5.9 hours for patients with creatinine clearance greater than 60 ml/minute. The combination of carboplatin and paclitaxel is currently the standard of care for the first-line therapy of ovarian cancer Radiation: The time it takes for half of a material's radioactivity to disappear is called the half-life. Different radioactive materials have different half-lives. This information helps the radiation therapy team choose the type of material to use and to plan the treatment regimen. It also determines how long safety precautions must be taken following treatment with internal radiation.
Radiation-Theory Burst Safety precautions for the patient receiving - Internal unsealed radiation
Patient and his/her body fluids considered radioactive for a period of time, which is determined by the energy of the radionuclide and its ½ life. Initiate precautions time, distance, shielding
Safe Handling of Chemotherapy - Preparation
Class II biological safety cabinet or laminar airflow hood for all preparation by pharmacist or trained RN.
Ondansetron (Zofran)
Classification: Antiemetic, 5-HT3 antagonist Use: Treatment and prevention of nausea and vomiting . Often used for postoperative nausea and for nausea related to chemotherapy or radiation therapy. Action: Blocks the effects of serotonin at 5-HT3 receptor sites located in vagal nerve terminals and the chemoreceptor trigger zone in the CNS. Side/Adverse Effects: headache, dizziness, drowsiness, constipation, diarrhea, abdominal pain, dry mouth, extrapyramidal reactions (involuntary movement of eyes, face, limbs.) Nursing Implications: Administer prior to emetogenic event when possible (i.e. chemo, radiation, anesthesia induction) Assess daily bowel activity and stool consistency. Teach patient to notify health care provider if extrapyramidal symptoms occur. Safety precautions for dizziness and drowsiness
Cyst
Cysts are noncancerous and have a sac-like structure that can be filled with fluid, pus, or other gaseous material. Cysts are common and can occur anywhere on the body. Cysts are often caused by infection, clogging of sebaceous glands or around earrings
If the implant is NOT visualized, but patient states it "feels like implant came out when I coughed," what will you do?
DO NOT search for the implant if you can't visualize it (as you may inadvertently touch the implant). Notify radiation safety officer immediately.
FATIGUE r/t increased waste products of cell destruction
Definition: An overwhelming, sustained sense of exhaustion and decreased capacity for physical and mental work at the usual level that is not relieved by rest Assessment findings: (defining characteristics): inability to restore energy even after sleep lack of energy increase in rest requirements tired inability to maintain usual routines increase in physical complaints drowsy compromised concentration Outcome: Verbalizes increased energy and improved well-being. Describes factors that cause or increase fatigue. Describes factors that conserve energy. Nursing Interventions: Provide information about fatigue Assess fatigue using 0-10 scale, ability to perform ADL's, mood and concentration abilities Allow patient time to express feelings, concerns about fatigue Help patient establish small, easily achievable short-term goals Help patient identify essential and nonessential tasks, prioritize as needed and determine what can be delegated. Schedule priority activities at times of peak energy. Teach strategies for energy conservation Assist to follow healthy lifestyle - adequate nutrition and rest, and appropriate exercise (studies show exercise fatigue) Give patient permission to limit social and role demands Manage pain, n/v, other symptomatology
Radiation Safety Officer
Develops and implements proper radiation safety procedures to help assist health care workers to keep their doses ALARA. Ensure policy adherence per federal/state guidelines. Must be notified of any incident in which worker and/or patient safety may be compromised.
Case #3: 55 year old male with metastatic lung cancer arrives to outpatient infusion clinic for his scheduled chemotherapy infusion today. Medical Orders: Premedication: Dexamethasone 8 mg po x1 Ondansetron 8 mg IV x1 Chemotherapy: Irinotecan 350 mg/m2 over 30 minutes PRN Medications: Atropine 1 mg IV prn diarrhea Home Prescription: Imodium 4mg at first sign of poorly formed or loose stool may repeat with 2mg every 2 hours until diarrhea free for 12 hours. Situation: Patient comes to the clinic three days after his infusion with complaints of dizziness. He has been taking the Imodium as prescribed but has not initiated any other self-treatment. The patient's blood pressure is 92/50 and his pulse is 104. Orders are received to infuse 1,000 ml of NS IV over one hour. In addition to a Fluid Volume Deficient nursing diagnoses, what additional nursing diagnosis should be added to the patient's care plan?
Diagnosis: Knowledge deficient (diarrhea self-care) r/t information misinterpretation. Outcomes: Describes strategies to reduce diarrhea and prevent dehydration. NI: Teach patient diarrhea NIs
Case #4: 59 year male with oropharyngeal cancer is to begin today daily radiation treatments for 5 weeks prior to having radical neck surgery. The patient smokes one pack of cigarettes per day and had done so for 35 years. He denies smoking currently. Situation: You are the RN providing the first teaching session to the patient prior to his beginning the radiation treatment. Develop a nursing care plan for this patient, identifying nursing diagnosis, outcomes, and NIs.
Diagnosis: Impaired oral mucous membranes r/t chemotherapy side-effect Knowledge deficient (mucositis self-care) r/t lack of exposure Outcomes: Describes actions to implement to regain intact oral mucous membranes NI: Teach patient mucositis NIs
If the patient instead developed dry desquamation, what nursing diagnosis and nursing interventions would be appropriate?
Diagnosis: Impaired skin integrity r/t destruction of epithelial cells. Nursing interventions: Gently cleanse using mild soap, using warm, not hot, water. Keep skin moisturized. Utilize moisturizing creams which are unscented, lanolin-free and water based. Avoid scratching and rubbing skin.
Case #6: 30 year old female with cervical cancer has completed two weeks of daily external beam radiation therapy. Situation: The patient arrives to the clinic today with c/o 5 episodes of loose stool yesterday. Develop a nursing care plan for this patient, identifying nursing diagnosis, outcomes, and NIs.
Diagnosis: Knowledge deficient (diarrhea self-care) r/t information misinterpretation. Outcomes: Describes strategies to reduce diarrhea and prevent dehydration. NI: Teach patient diarrhea NIs (as noted in conference module)
Case #5: A 62 year old female with metastatic gastric cancer has been receiving radiotherapy to the gastric area. She arrives at the clinic today to begin week three of radiotherapy. PRN Medications: Prochlorperazine 10 mg po every 4-6 hours prn nausea and vomiting Situation: Before her treatment, the patient states, "I was so nauseated all weekend. I have not eaten anything since yesterday because it makes me feel sick to my stomach." The RN determines that the patient's last medication for nausea was yesterday at 4 pm. Develop a nursing care plan for this patient, identifying nursing diagnosis, outcomes, and NIs.
Diagnosis: Knowledge deficient (nausea/vomiting self-care) r/t information misinterpretation. Nausea r/t chemotherapy side-effect Outcomes: Describes actions to implement to reduce incidence of nausea NI: Teach patient nausea/vomiting NIs
The patient develops moist desquamation. What nursing diagnosis applies and what nursing interventions are appropriate?
Diagnosis: Impaired skin integrity r/t destruction of epithelial cells. Nursing Interventions: Use moisture-permeable dressing; such as a hydrocolloidal dressing( i.e. Duoderm) or soft silicone foam dressing (i.e. Mepilex). Avoid dry sterile dressings because they may stick to the healthy tissues. Instruct patient regarding signs and symptoms of infection . Reassure patient that area should begin to heal in 1-3 weeks after completion of therapy. Encourage patient to leave healing area open to air several times a day to promote drying.
Knowledge Deficient (skin care) r/t lack of exposure - DO NOT
Do not remove ink or port marking from your skin until directed to by staff. Don't apply friction to the affected area. Avoid pressure or injury to the area, do not use adhesive tape, scrub or shave area. Do not expose the area to extremes of temperature. Avoid exposure to the sun, hot tubs, heating pads, or ice bags. Do not treat skin changes in the treatment area without discussing plans with the nurse.
Occupational Radiation Exposure Monitoring
Dosimeters: Radiation monitoring devices which measure radiation exposure. Do not offer protection from radiation. Guidelines for use: Do not share or exchange. Wear on front of body between collar and waist. Readings per institutional time schedule (usually monthly).
Radiation Therapy Administrative Methods - External Beam Radiotherapy or Teletherapy
External Beam Radiotherapy or Teletherapy Radiation treatment given by an external beam machine May use x-rays gamma rays, electrons, protons, or neutrons Example: (FYI only) - Linear accelerator - Cobalt - 60 machine
Fibroid
Fibroids, also known as uterine myomas, leiomyomas, or fibromas, are firm, compact tumors that are made of smooth muscle cells and fibrous connective tissue that develop in the uterus.
While caring for a patient you notice the Cesium implant in her linens. What will you do?
First, use long forceps to place source in lead lined container in room. Second, DO NOT touch implant! Call Radiation Safety Officer.
Knowledge Deficient (skin care) r/t lack of exposure - DO
Gently clean skin in treatment area with a mild soap. Rinse well with lukewarm water and pat dry. Use mild deodorant only on intact skin. Wear loose , non-constricting clothing over treatment area. Keep the treatment area free of all ointments, creams, lotions, deodorants or powders on day of treatment. May use plain, non-scented, lanolin- free, water based moisturizing cream if no skin breakdown present. Inspect treatment area every day and report any changes or problems to the nurse. Use an electric razor if necessary.
Grading
Grading systems differ depending on the type of cancer. In general, tumors are graded as 1, 2, 3, or 4, depending on the amount of abnormality. In Grade 1 tumors, the tumor cells and the organization of the tumor tissue appear close to normal. These tumors tend to grow and spread slowly. In contrast, the cells and tissue of Grade 3 and Grade 4 tumors do not look like normal cells and tissue. Grade 3 and Grade 4 tumors tend to grow rapidly and spread faster than tumors with a lower grade. GX: Grade cannot be assessed (undetermined grade) G1: Well differentiated (low grade) G2: Moderately differentiated (intermediate grade) G3: Poorly differentiated (high grade) G4: Undifferentiated (high grade)
RADIATION: PORTS AND SIDE-EFFECTS
HEAD Alopecia (hair loss) MOUTH & THROAT taste loss saliva mucositis dysphagia CHEST esophagitis dysphagia pneumonitis UPPER ABDOMEN nausea, vomiting LOWER ABDOMEN & PELVIS diarrhea vaginal dryness cystitis sterility BONE MARROW bone marrow suppression (or myelotoxicity or myelosuppression is the decrease in production of cells responsible for providing immunity (leukocytes), carrying oxygen (erythrocytes), and/or those responsible for normal blood clotting (thrombocytes).) SYSTEMIC fatigue
Chemotherapy Activity
High-alert medication - Use of medications or chemical agents to destroy or interfere with the replication of cancer cells. - Interferes with the cell's ability to replicate. - Normal and malignant cells are affected. - Normal cells that rapidly divide are more severely affected and are the basis for many of the side effects experiences. - Systemic treatment (travels through the bloodstream to affect cancer cells). - Goal is to destroy cancer cells while doing minimal damage to normal cells and to cure the individual. If cure is impossible, control or palliation becomes the goal. - May be used as a primary treatment, an adjuvant modality (combined with surgery, radiation, biologic-therapy), or a palliative therapy. - May be given prior to primary treatment to shrink the tumor (neoadjuvant)
Using the following key: E = external radiation source, I= internal sealed radiation source, U = internal unsealed radiation source, C = chemotherapy, label each nursing intervention (NI) with the corresponding treatment modality/modalities.
I, U, C - Utilize private room C, U - Implement body fluid precautions I , U - Spend maximum of 30 minutes with patient per shift C, E, I, U - Teach patient to cope with anticipated side effects I - Prevent dislodgement of radiation device C, U - Encourage increased fluids as tolerated E - Do not remove markings I, U - Implement visitation restrictions E, I, U - Wear dosimeter to monitor exposure U - Provide disposable eating utensils for meals E, I, U - Utilize lead shielding to minimize exposure E - Remove all lotions and creams prior to treatment E - Perform skin assessment C - Keep "spill kit" in room I - Keep lead container in room for possible dislodged implant C, E, I, U - Assess for fatigue
Remission
If you're in partial remission, it may mean you can take a break from treatment as long as the cancer doesn't begin to grow again. Complete remission means that tests, physical exams, and scans show that all signs of your cancer are gone. Some doctors also refer to complete remission as "no evidence of disease (NED)."
Differentiation
In cancer, this describes how much or how little tumor tissue looks like the normal tissue it came from. Well-differentiated cancer cells look more like normal cells and tend to grow and spread more slowly than poorly differentiated or undifferentiated cancer cells.
Chemotherapy Teaching Plan
Information to include in a teaching plan for the patient prior to chemotherapy administration: - action, side-effects of chemotherapy - self-care measures for anticipated side-effects - notify staff if IV chemotherapy becomes dislodged or IV site painful - double flush toilet x 48o (excreta hazardous to others)
You enter a patient's room and find the patient non-responsive without a pulse. The patient has a gynecologic radiation implant (brachytherapy). What will you do?
Initiate CPR (behind shields if possible). Avoid defibrillator to shield contact. Rotate Personnel performing CPR to maximize distance and minimize time. Post a staff member outside room to record names and time of all personnel entering room.
Radiosensitivity
Is the relative susceptibility of cells, tissues, organs or organisms to the harmful effect of ionizing radiation.
Radiation Skin Reactions & Skin Care
May occur 1-4 weeks after initial treatment and may persist for 2-4weeks after completion of treatment. 85-90% of those who receive RT will develop a skin reaction Basal layer of the epidermis proliferates rapidly. Epidermis is more sensitive to radiotherapy. Major acute side-effects to the skin: Erythema: redness Dry desquamation: dry, flaky or scaly skin due to damage of sweat and sebaceous glands. Moist desquamation: blistering, peeling and sloughing of skin.
Fatigue
Most frequently experienced symptom of cancer and cancer treatment, regardless of the treatment protocol being utilized. Universal symptom affects 70-100% of cancer patients.* Alters functional and cognitive status, sense of well-being, and relationships. Receives little attention and priority from the health care team. Consider this nursing diagnosis when you assess your patient.
Benign
Not cancer tumor cells grow only locally and cannot spread by invasion or metastasis
Mrs. Merza is beginning radiation to her left breast today. The radiation will be delivered by a linear accelerator. She will receive 6000cGy of radiation over 5 weeks. Before her treatment, she states: "I'm so nervous. I just don't know what to expect. My family is worried that I will be radioactive
Nursing Diagnosis: Knowledge deficient: self-care r/t lack of exposure Patient Outcomes: States interventions for anticipated side-effects. Demonstrates proper skin care. Nursing Interventions: Teach: Description of experience (equipment, positioning, sensations and sounds, duration, no staff permitted inside treatment room during dose delivery.) Not radioactive Interventions for anticipated side-effects Avoid using any topical skin care products on the day of treatment. Skin should be without any skin care products at least two hours before treatment. Do not wash off ink marking used to delineate area (tattooing now often used to delineate area and therefore washing not a concern).
Radiation-Theory Burst Safety precautions for the patient receiving - Internal sealed radiation
Only sealed source is radioactive, not the patients and his/her body fluids Initiate precautions of time, distance, shielding Prevent dislodgement of radiation source if placed in body cavity (i.e. vagina)
**** Cell Cycle
Or cell-division cycle is the series of events that take place in a cell leading to its division and duplication of its DNA (DNA replication) to produce two daughter cells.
Mr. Garcia had prostatic radiation seeds inserted due to prostate cancer. What type of radiation method is being used and what precautions are necessary?
Permanent sealed low dose radiation source. Only precautions necessary: use condoms for 2 months (as sperm may be altered causing birth defects)and reduce proximity to pregnant women and children for 2 months (no lap sitting). Seeds emit very low dose radiation which is mostly absorbed by patient's own body tissues.
Radiation-Theory Burst Safety precautions for the patient receiving - External beam radiation
Personnel not permitted in treatment room Patient NOT radioactive Individualized lead blocks are used to shield the patients vital organs from the radiation.
Malignant Neoplasm
Primary Treatment +/- Adjuvant treatment -> - Surgery - Pharmacologic Therapy - Radiation Pharmacologic Therapy -> - Chemotherapy - Hormonal Therapy - Biotherapy - Molecular targeted therapy Goals -> - Cure - Control - Palliation
Ms. Nicholson is admitted to your unit for a Cesium implant to treat her cervical cancer. The radiology oncologist has determined that the implant will be in place for 72 hours.
Radiation Method: Internal Sealed Source Nursing Diagnosis: Knowledge deficient: self-care r/t lack of exposure Patient Outcomes: States interventions for anticipated side-effects Discusses feelings related to radiation safety precautions Nursing Interventions: Explain rationale for the precautions taken and length of time precautions necessary. Implant radioactive only. Patient and body fluids not radioactive. Private room will be used. Nurse will spend limited time with pt. (Recommended 20-30 min/shift). How to cope during periods of precautions. Interventions for anticipated side-effects (GU, diarrhea) Prevent dislodgment of implant. o Patients with gynecologic implants: - strict bed rest (Foley often placed)-* be sure to initiate strategies to prevent complications of immobility - HOB elevated < 40o - log-roll when turning side to side - keep items within reach of patient - pre-treatment bowel preparation regimen (enema often given pre insertion) Children and pregnant visitors not allowed. Visitors remain 6 ft. from ct. behind shield. May only visit 10-30 min per day. Once implant is removed and placed in safe storage, no further radiation safety measures are necessary.
Mr. Pitt is admitted to your unit for treatment of his thyroid cancer. He is scheduled to receive Iodine 131.
Radiation Method: Unsealed Source Nursing Diagnosis: Knowledge deficient: self-care r/t lack of exposure Patient Outcomes: States interventions for anticipated side-effects Discusses feelings related to radiation safety precautions Nursing Interventions: Explain rationale for the precautions taken and length of time precautions necessary: Blood and body fluids radioactive: Double flushing for excretions (care providers to wash hands with gloves on after flushing, remove gloves, wash again) Disposable eating utensils and trays will be used. Private room; staff will gown and glove, and utilize shoe covers. Nurse will spend limited time with patient. Linen saved in tightly closed bags for 10-40 days before washing. Interventions for anticipated side-effects Visitation policy restricted 15-30 min per day. Children and pregnant visitors not allowed. Incr. fluids 3-4 L/d for 48 hours to remove agent from body.
Proliferation
Rapid increase in numbers. Cancer cell proliferation: A new ending to an old 'tail' ... In stark contrast to normal cells, which only divide a finite number of times before they enter into a permanent state of growth arrest or simply die, cancer cells never cease to proliferate.
A patient with thyroid cancer received I-131 (a radiopharmaceutical) two hours ago suddenly vomits while you are in the patient's room providing care. Although most of the emesis was contained in the emesis basin, some emesis is now on your protective gown. What will you do?
Stay calm. Remove contaminated clothing and isolate it in patient's bathroom. Don clean protective clothing. Put on the call light and have staff notify Radiation Safety Officer Remain in the patient's room until cleared by RSO.
A 55 year old patient is beginning radiation therapy following a lumpectomy. What is the primary action of the nurse to prevent or reduce the occurrence of a radiation skin reaction?
Teaching general skin care
Minimize Time
The amount of exposure is directly proportional to the amount of time spent near the source. Less time spent near source, less radiation received. The amount of time at a specific distance that can be spent with a patient is determined by the radiation safety officer. How will you apply this strategy to minimize self-exposure? - Organize care - Teach self-care measures - Rotate assigned staff - Communicate via intercom/phone
Maximize Distance
The amount of radiation exposure one receives is inversely related to the distance one is from the source (inverse square law). Small differences in distances are critical. How will you apply this strategy to minimize self-exposure? - Stand as far from the source as possible when delivering care - Example: stand at head of bed for patient with gyn. radiation implant. - Teach patient self-care measures
Use Shielding
The amount of radiation exposure received from a specified radioactive source can be decreased by the use of an absorbing material (shield) How will you apply this strategy to minimize self-exposure? - Keep shielding between source and personnel. - Select correct material for shielding based on type of radiation source (ex. lead for high energy gamma sources)
Metastasis
The development of secondary malignant growths at a distance from a primary site of cancer.
Oncology
The study and treatment of tumors.
Radiation Therapy Administrative Methods - Internal Sealed Radiotherapy or Brachytherapy
Therapeutic use of radionuclide that is sealed within metal container. Radioactive particles penetrate the container to treat the disease. Placed directly into or adjacent to tumors. Temporary or permanent High dose rate (HDR) or low dose rate (LDR). Temporary sealed radioactive sources removed after the prescribed dose is reached in the calculated number of hours. HDR allows localized doses of radiation to be delivered to the tumor quickly to reduce side-effects and allow therapy on an out-patient basis. Example: (FYI only) - Iridium-192 - Cesium-137 - MammoSite Targeted Radiation
Radiation
Use of high energy x-rays or particles to destroy tumor cells. Alters the cells ability to divide due to DNA damage. Cancer cells often cannot repair the radiation damage and cell death occurs. Normal tissue cells are often able to recover from the injury if therapeutic doses are maintained. Normal cells that divide rapidly (bone marrow, hair follicles, GI mucosa and mucous membranes) are more sensitive to the effects of radiation therapy. Local treatment (treats only a specific area of the body). Goal is to destroy cancer cells while sparing normal tissue and to cure the individual. If cure is impossible, control or palliation becomes the goal. May be used as a primary treatment, an adjuvant modality (combined with surgery, chemo, biologic-therapy) or a palliative therapy.
Case #1: 62 year old female with ovarian cancer arrives to outpatient infusion clinic for second chemotherapy infusion today (14 days after treatment #1). Medical Orders: Premedication: Ranitidine 50 mg IV x1 Diphenhydramine 50 g x1 Dexamethasone 12 mg x1 Ondansetron 8 mg x1 Chemotherapy Medications: Paclitaxel IV 175 mg/m2 over 3 hours Carboplatin AUC 6 IV day 1 over 30 minutes PRN Medications: Lorazepam 1 mg IV prn nausea/vomiting Prochloroperazine 10 mg IV prn nausea/vomiting Promethazine 25 mg IV prn nausea/vomiting Home prescription: Dexamethasone 8 mg po daily for 2 days Prochloperazine 10 mg po prn every 4-6 hours prn for 3 days Situation: the patient tells the RN "I am so happy that I haven't lost my hair. I'm glad I did not buy that expensive wig. My only worry is that I have a small mouth sore." How would you the nurse respond? Identify an appropriate nursing diagnosis with outcomes for the patient and appropriate NIs to initiate.
Use therapeutic communication techniques to allow patient to verbalize fears r/t alopecia and to reinforce previous teaching about alopecia self-care strategies. Diagnosis: Knowledge deficient (alopecia self-care) r/t information misinterpretation. Outcomes: States that alopecia begins 2-3 weeks after first chemotherapy treatment. Describes actions to implement for impending alopecia NI: Teach patient alopecia NIs Diagnosis: Impaired oral mucous membranes r/t chemotherapy side-effect Knowledge deficient (mucositis self-care) r/t lack of exposure Outcomes: Describes actions to implement to regain intact oral mucous membranes NI: Teach patient mucositis NIs(as noted in conference module)
Case #2: 35 year old female with breast cancer arrives to outpatient infusion clinic for third chemotherapy infusion today. Medical Orders: Premedication: Aprepitant 125 mg po x1 Dexamethasone 12 mg IV x1 Ondansetron 8 mg IV x1 Chemotherapy: Adriamycin 60 mg/m2 IVP over 15 minutes Cytoxan 600 mg/m2 IV over 60 minutes PRN Medications: Lorazepam 1 mg IV x1 Prochloperazine 10 mg IV x1 Promethazine 25 mg IV x1 Home prescription: Aprepitant 80 mg po daily x 2 days Dexamethasone 8 mg po daily x 2 days Prochlorperazine 10 mg po every 4-6 hours prn nausea and vomiting x 4 days Situation: when asked about nausea and vomiting experienced following the last chemotherapy treatment, the patient states "I had nausea for four days after my treatment but I did not vomit". The RN follows up by asking the patient to describe how she treated this symptom. The patient states "I took all of the medication they gave me in the morning when I got up before I ate breakfast but it never helped." How would you the nurse respond? Identify an appropriate nursing diagnosis with outcomes for the patient and appropriate NIs to initiate.
Use therapeutic communication techniques to determine what self-care strategies the patient used and if they were effective. Reinforce additional self-care strategies to relieve symptoms. Diagnosis: Knowledge deficient (nausea/vomiting self-care) r/t information misinterpretation. Nausea r/t chemotherapy side-effect Outcomes: Describes the rationale for taking the prochlorperazine around the clock for at least 24-48 hours following chemotherapy. NI: Teach patient nausea/vomiting NIs
Minimizing Radiation Exposure
Utilized by the RN to minimize self-exposure to the effects of radiation therapy. The goal is to keep exposure limits as low as reasonably achievable (ALARA).
To best evaluate the effectiveness of Zofran, the RN...
a. assesses the patient's intake and output for the shift b. asks the patient to rate their nausea using a 0 to 10 scale c. performs a calorie count for forty-eight hours d. determines the patient's current comfort level Answer b: evaluation of nausea requires use of a subjective symptom self-reporting scale
Multiple Combination Chemotherapy Protocols (using two or more chemotherapies together) may be used to...
o Kills more cancer cells (improved tumor response) o Reduces likelihood that cancer cells will become resistant o Different mechanisms of action and different toxicities limit the severity of side effects
