Chemotherapy & Radiation Therapy

Oncology Nursing - treatment modalities.

1. Chemotherapy & Radiation therapy Presentation By Asokan R Associate Professor Kalinga Institute of Nursing Sciences, KIIT Deemed to be University, Bhubaneswar.

2. Radiation therapy Radiation therapy refers to the use of ionizing radiation to treat variety of cancers. It may be used to obtain a cure in combination with surgery or/and chemotherapy or for palliation of symptoms when cure is impossible.

3. Radiation therapy It can be administered from a variety of sources such as those outside the body (external radiation therapy) and those inside the body (Internal radiation therapy ).

4. External radiation therapy It is usually administered by high energy X-ray machines (Betatron and linear accelerator ) or machines containing a radioisotope (cobalt 60).

5. . The major advantage of high energy X-ray machines is this skin sparing effect. This means that the maximum effect of irradiation occurs within the tumor deep in the body and not on the skin. Patients receiving radiation therapy may experience various side effects.

6. Early, intermediate and late effects of external radiation therapy. Side effects of external radiation therapy Time of occurrence Side effects Early/acute: caused by death or normal cells. Skin reactions Dry desquamation Nausea Vomiting Diarrhea Fatigue Bone marrow suppression Cystitis Intermediate/chronic: caused by small-vessel changes resulting in decreased lumen thickened wall of vessel. Radiation pneumonitis Radiation-induced heart disease Radiation-induced paresthesia Late Tissue necroses Fistulas Fibrosis Bone necroses

7. Nursing intervention for external radiation therapy Nursing interventions for external radiation therapy Be sure you are familiar with the patient, his chart and problems: The type of radiotherapy prescribed The side of tumor undergoing radiation Purpose of therapy-palliate or curative Number of radiation planned

8. . Check the knowledge and understanding of patient about the therapy. Instruct about the skin markings that the radiotherapist makes and not to erase it until treatment is finished. Answer all the question in a pleasant way; give psychological reassurance like: Radiotherapy is painless, no sensation is felt as such, To be still on a special table.

9. To remain alone while X-ray/ teletherapy units are in operation, Can talk over an intercom to the technician outside observing through a window or television, Different ports (area through which rays pass into ) are used on different days – so position may be changed slightly at intervals.

10. Skin preparation Remove any ointment or dressings. cleaning of skin usually an alcohol rub is given. Get the area outlined – the area to be treated is usually outlined by the radiologist at the time of first treatment. Instruct the patient not to wash off the marks until the treatment is completed because they are important guides to the radiologist and also not to apply any medicated solution or ointments on the marked area until the series of treatment is completed.

11. Avoid constricting clothing as skin gets irritated and breaks down easily Avoid hot water bottle, ice caps, exposure to sunlight and wetting for 2 weeks. Give high protein diet, maintain fluid and electrolyte balance Nursing personnel to be protected by observing radiation protection principles of time, distance and shielding; wear a film badge to assess the amount of radiation received. Observe for local and systemic reaction Provide symptomatic and supportive care.

12. Internal Radiation Therapy

13. Internal Radiation Therapy It involves placement of specially prepared radioisotopes directly into or near the tumour itself or into the systemic circulation. They are called sealed source. Radioactive material is enclosed in a sealed container or unsealed sources in which radioactive material is administered directly such as by injection or orally.

14. Sealed source ( Brachytherapy ) Sealed source ( brachytherapy ) Includes intracavitary therapy in which the radio-isotope usually 137 cessium or 226 radium in sealed applicator are placed into the body cavity for calculated period of 24-72 hours. Applications may be inserted into the patient’s mouth, tongue, neck, vagina, cervix or other body cavity.

15. Interstitial therapy involves the packing of radio isotopes in needles, beads, seeds, ribbons or catheters and then implanting directly into the malignant tumors temporarily or permanently depending on the half life of the source being used.

16. The unsealed sources are used in systemic therapy, radioisotopes are administered intravenously or orally. For example iodine 131 is given orally in very low doses to treat Grave’s disease or in high doses to treat thyroid cancer.

17. Nursing interventions While giving nursing care to the patient undergoing radiation should learn how to avoid excessive exposure to radiation. This can be done by using three main principles of radiation protection. Distance-Greater the distance from the source of X-ray lesser will be the exposure. Time-less time you spend close to a radiation source, the less you will be exposed. Shielding: using lead or other materials to absorb radiant energy helps reduce radiation exposure.

18. Nursing interventions for Internal Radiation Therapy Be familiar with the patient, his condition and his file as to: what radioisotope is to be used type of source (sealed or unsealed) mode of action (interstitial, intracavitary , systemic) site of implantation if sealed number of days required isolation.

19. Give proper explanation about the purpose and procedure and reassure patient and significant others Preparation depends upon whether radioisotope is to be implanted or administered systemically. If sealed in needles, beads or wires prepare the patient for a surgery. No special preparation for systemic administration.

20. Strict isolation after implantation, in a bath attached room with another patient receiving the same. Keep radiation precaution sign at the door for restricting visitors. Explain the routine to the patient and the reason for the precaution (patient is a source of radioactivity as the implanted or injected radioisotope continues to emanate rays of radiant energy.

21. Provide a clear unit with extra articles (pillows, backrest, cardiac table) and facilities like intercom, television, radio, etc. Instruct the visitors to maintain some distance from the source; restrict pregnant women and children from visiting. Notify the radiation officer if a radioactive source is spilled, dropped to the floor, lost or accidentally discarded.

22. Use a long lead forceps in case of dislodged isotope. Save all dressings and bed linen till the radioactive source is removed. Encourage the patient for self care. Maintain measures of self-protection; limit time spent in the room, keep safe distance from the patient and use shielding (lead apron, gloves) devises.

23. Chemotherapy

24. Chemotherapy Chemotherapy evolved in the 1940s with the therapeutic application of nitrogen mustard. The objective of chemotherapy is to destroy all malignant tumour cells without destruction of normal cells.

25. Normally cells respond to body’s need for growth, repair or regeneration in an orderly manner and cease production by entering a resting phase or slowing growth when the need is met. Cancer cells reproduce in the same manner as normal cells. But the growth continues in an uncontrolled manner.

26. Well what does chemotherapy to do these cells?

27. Chemotherapy directly or indirectly disrupts reproduction of cells by altering essential biochemical processes, thereby-a control or eradication of all malignant cells is possible. The chemotherapeutic agents are generally classified according to their mechanism of action. A summary of the common chemotherapeutic drugs and their action is given below.

28. Classification of chemotherapy classification Frequently used medications Mechanism of action Nursing implications and general toxicities Alkylating agents ( ccns ) Chlorambucil ( Leukeram ) Cyclophosphamide ( cytoxan ) Nitrogen mustard 9Mustargen) Triethylenethiophospphoramide (thin-TEPA) Contain alkyi groups, which bind to DNA and prevent replication and mitosis May be unstable; check solutions for clarity; mix and administer without lengthily delay generi toxicities: 1.Bone marrow suppression 2.Nausea and vomiting 3.Alopecia 4. Hemorrhagic cystitis as a result of chemical irritation.

29. Antimetabolites Methotrexate 5-fluorouracil (d-FU) Cytarabine ( Ara -c) Interfere with synthesis of nucleic acids and proteins during 5 phase General toxicities: Anorexia, nausea, vomiting Bone marrow suppression Alopecia Skin rashes, dryness, nail changes Antitumor antibiotics ( ccns ) Doxorubicin hydrochloride ( adriamycin ) Mithramycin ( mithracin ) Bleomycin sulfate ( Blenoxane ) Inhibit DNA synthesis, which prevents mitosis Disrupt mitosis by binding with microtabular spindle Prevent extravasations: many drugs are vesicants General toxicities: Bone marrow suppression Nausea, vomiting Stomatitis Alopecia Cardiac abnormalities Fever and chills

30. Natural products ( ccs ) Vincristine sulfate ( Oncovin ) Vinblastine sulfate ( Velban ) Etoposide (VP-16) Interfere with subcellular hormone-receptor proteins Prevent extravasations. General toxicities; Bone marrow suppression Nausea and vomiting Stomatitis Hypotension Neurotoxicity Hormones ( ccns ) Diethystilbestrol (DBS) Estrogen megestrol acetate ( Megace ) Frednisone Dexamathasone ( Decadron ) General Toxicities: Nausea Fluid retention Mood changes Weight gain

31. Antihormones ( ccns ) Tamoxifen citrate aminoglutethimide General toxicities: Hot flashes Nausea/ vomiting Anorexia Required mineralocorticoid replacement Miscellaneous Hydroxyurea ( ccs ) General toxicities: Bone marrow suppression Mild nausea/ vomitting /anorexia Infrequent alopecia, skin changes

32. L- Asparaginase ( ccs ) Blocks essential amino acid General toxicities: Increasing risk of hypersensitivity Elevated liver function studies Nausea/ vomiting/malaise Procarbazine ( ccs ) Inhibits RNA,DNA, protein synthesis Monoamine oxidase inhibitor; restrict tyramine -rich foods General toxicities: Bone marrow suppression Malaise Nausea/ vomitting

33. Administration of drugs Chemotherapeutic drugs can be administered by variety of routes depending upon the property of the medication and the purpose of the therapy. It may be prescribed by oral intramuscular subcutaneous and intravenous routes and can be administered singly or in combination.

34. Presently, the combination chemotherapy is given as it decreases the potential for development of resistant cells and lowers the remission rate as compared to the drugs used singly. These drugs must be given with great caution and your major responsibility is to watch any side effect during therapy and report to the appropriate authority. These side effects can be the major limiting factor in their use.

35. Chemotherapy Drugs-related side-effects Target organ Toxicity Implicated drugs Bone marrow Leucopenia Most drugs, wich the exception of steroids Bleomycin , L- asparaginase Gastric intestinal tract Stomatitis Diarrhea Paralytic ileus Adriamycin , bleomycin , methotrexate , 5-fluorouracil, actinomycin . Methotrexate , 5-fluorouracil Vincristine

36. Skin Hyper pigmentation alopecia Bleomycin , busulfan adriamycin , cyclophosphamide , actinomycin D Nervous system Paresthesis peripheral-neuropathy deafness lethargy Vinceristine , Vanblastine Cis platinum L asparaginase Heart Cardiac failure with long term use Adriamycin , dannomycin

37. Lungs Fibrosis (late) Belomycin , busulfan , Methotrexate , cyclophosphamide Pancreas Pancreatitis L- Asparaginase Uterus Uterine bleeding Estrogens

38. Bladder cystitis Cyclophosphamide Liver Abnormal liver function L- Asparaginase , Mithramycin Kidney Abnormal kidney function Methotrexate , Cis Platinum, Mithramycin

39. Nursing guidelines for safe administration of Cytotoxic drugs Anticipate possibility of extravasations and/or hypersensitivity reactions and carry out immediate measures. Seek assistance of a co-workers after two unsuccessful vein punctures. Strict aseptic technique should be observed for each stage of the procedure. Prepare the medication with extreme concentration in a quiet, unhurried environment.

40. Never use chemotherapeutic agents to test the vein patency. Each vein must be tested with normal saline before and after the injection. Stop infusion anytime when vein patency is in question. Protect yourself by the use of aprons, masks and goggles. Give all chemotherapeutics agents slowly over a period of 2-5 minutes.

41. Monitor the patient results closely and notify the doctor if any leucopenia is present. Monitor the patient during the entire time of administration and assist with the all the side effects. Anaphylactic shock may occur with any drug; stop infusion immediately. Always be compassionate to such patients. Encourage them to continue the full course of treatment.