Introduction to radiation oncology nursing

radiation oncology nursing

1. INTRODUCTION TO RADIATION ONCOLOGY NURSING MATHEW VARGHESE V MSN(RAK),FHNP (CMC Vellore),CPEPC Nursing officer AIIMS Delhi 1

2. Radiation Therapy Definition Sources of radiation. Goals of radiotherapy. Mechanism of action. Principles of radiation protection. Types of radiation therapy. Care of clients receiving radiation therapy. Side effects & symptom management. 2

3. RADIOTHERAPY One way to stop the cancer from growing is to interfere with the cancer cell’s ability to multiply. Radiation at high dosages causes changes in the cancer cells that stops the cell’s ability to multiply and eventually kills the cancer cell. In some cases, it destroys cancer cell, while in others, it slows down the growth . 3

4. Radiotherapy RADIOTHERAPY is the treatment of neoplastic disease using high energy ionizing rays (x-rays or gamma rays) to kill cancer cells. These may be generated by radioactive sources or linear accelerators. THE HIGHER THE ENERGY OF THE PHOTON, THE DEEPER IT CAN PENETRATE THE BODY BEFORE LOSING ITS EFFECT. Radiation deters the proliferation of malignant cells by decreasing the rate of mitosis or impairing DNA synthesis. 4

5. Sources of Radiation COLBALT 60 CESIUM 137 IODINE 131 IRIDIUM 192 RADIUM 226 RADON 222 STRONTIUM 90 5

6. Gamma & X-rays High Energy Ionizing 6

7. Goals of Radiotherapy Curative Control: Adjuvant Pre/Post Operative Intraoperative Palliation 7

8. Radiation therapy may be curative in many types of cancer if they are localized to one area of the body. It may also be used as a part of adjuvant therapy, e.g.. after performing surgery for removing a primary malignant tumor, it can be used to prevent tumor recurrence ( for example, early stages of breast cancer). It is common to combine radiation therapy with surgery, chemotherapy, hormone therapy and immunotherapy. It is synergistic with chemotherapy , and has been used before, during and after chemotherapy in susceptible cancers. It may also be used as palliative treatment where cure is not possible and the aim is for local disease control or symptomatic relief. 8

9. MECHANISM OF ACTION Ionizing radiation works by damaging the DNA of cancerous tissue leading to cellular death. To spare normal tissues, shaped radiation beams are aimed from several angles of exposure to intersect at the tumor, providing a much larger absorbed dose there than in the surrounding healthy tissues. 9

10. Radiation Protection: Principles ALARA Principle The physical protection against external radiation is based on the following three principles: -distance from the source of radiation (distance), -limitation of the time of irradiation (time), -absorption of radiation (shielding). 10

11. Time Minimize time spent in close proximity to the patient. Radiation exposure is directly related to the time spent within a specific distance of radiation source. Care giver should not exceed 1/2 to 1 hour exposure per shift. Organize care, prior to entering room. Assemble all equipment, prior to room entry In room, place supplies/equipment within easy quick access. Post time guidelines on door . 11

12. Distance The amount of radiation decreases with increase in distance. Doubling the distance from the radiation source, Quarters the amount of radiation received. If the exposure at 1 meter from the Radiation Source is X, the exposure at 2m is ¼ of x, and at 4m, one sixteenth. Interventions: Teach patient self-care & rationale for isolation. Limit patient care by individual caregiver. Use communication devices outside room to interact whenever possible. 12

13. Shielding When used properly, lead shielding can provide added protection from radiation. In practice, nurses find lead shielding apron cumbersome to work with. Nurses wear a film badge. NB: Pregnant nurses should not care for radiation patients. 13

14. Types of Radiation Therapy External Beam or Teletherapy most common type of radiation therapy using machine (linear accelerator). patient is not radioactive. Internal radiation or Brachytherapy implant is placed inside patient temporary/permanent. patient is radioactive. 14

15. Teletherapy Delivering radiation from a source at a distance from the target. Radiation department administers the dose. Advantage: skin sparring effect, giving max radiation to tumor not the skin. Patient is monitored via TV or intercom Treatment approx. 10 minutes. Not painful, though patient may feels heat or tingling. 15

16. EXTERNAL BEAM RADIATION THERAPY 16

17. Brachytherapy Delivers a high dose of radiation to a localized area. The specific radioisotope is chosen on the basis of its half-life Brachytherapy may be sealed or unsealed: SEALED: Interstitial Intracavitary UNSEALED: Systemic (IV, oral) 17

18. Brachytherapy SEALED Emits low energy continuously Interstitial & intracavitary implants Ex. Seeds, APPLICATORS PATIENT EMITS RADIATION but NONE IN EXCRETA UNSEALED Injected, instilled or oral. Systemically EX. I131 PATIENT AND EXCRETA are RADIOACTIVE 18

19. Sealed Brachytherapy: Intracavitary: Radioisotopes (cesium or radium) put inside the applicator & placed in body cavity for a specific amount of time (24-72hours) When treatment completed, applicator & radioactive material removed treats cancer of uterus & cervix. Interstitial: needles, beads, seeds, ribbons or catheters are placed directly into tumor (breast, prostrate) Radioisotopes: iridium, cesium, gold, radon Placement can be temporary or permanent Treats Prostrate, cervical, esophagus cancer etc. 19

20. BRACHYTHERAPY APPLICATORS Fletcher-Suit applicator Radioactive seeds implanted in prostate 20

21. Nursing Care of the patient with Sealed Implant Provide Private room with bathroom Radioactive material sign should be placed outside Wear dosimeter No pregnant staff Visitors limited to 30 mins per day Visitors are restricted and must remain at 6 feet distance All dressings & linens saved until implant removed LEAD CONTAINER & LONG HANDLED FORCEPS,LEAD GLOVES KEPT IN ROOM IN EVENT OF DISLODGEMENT REMEMBER ALARA TIME DISTANCE SHEILDING patient radioactive, excreta not 21

22. Nursing Care of patient with UNSEALED Implant Presents potential contamination hazard. All articles in room are considered contaminated. After discharge, articles are discarded but taken to protected area ‘till detectable radioactivity decays’. Rubber gloves worn with direct care No pregnant staff Articles in room: phone, call light, floors covered with plastic. Disposable plastic /paper should be used for dietary trays & utensils. Flush toilet used by patient several times. Keep linen & gowns kept in separate isolation bags Patient & excreta radioactive! 22

23. Loss of Radioactive Material Considered an emergency. Search should initiated by radiation staff. Removes nothing from the room while patient has radioactive material in place. If radioactive material is found, use long handled forceps & gloves. Notify Atomic Energy Center. 23

24. RADIATION THERAPY : INJURY Phases of Radiation Injury: Early (acute) Phase: occurs within weeks and resolve 4-6 weeks post radiation. Usually temporary and affect tissues with rapidly dividing cells (skin, mucous membranes) Late Phase: may occur months/years later and usually result from damage to the micro-circulation. Affect any/all tissues especially: lymph, thyroid, pituitary, breast, brain, bone, cartilage, pancreas and bile ducts. 24

25. SIDE EFFECTS OF RADIATION THERAPY Factors influencing degree & occurrence of side effects due to Radiotherapy Body site irradiated Dosage Extent of body area treated Method of radiation delivery Age of client General health of client Previous surgeries & chemotherapy Radiosensitivity of tissue/organ treated. 25

26. Symptom Management in Radiation Oncology Nausea & vomiting Diarrhea Xerostomia Ocular symptoms ( edema, dryness, photophobia) Oral mucositis Alopecia Hyperthermia Headache Cystitis Esophagitis 26

27. Skin Reactions Acute: begin about 2 weeks after start of treatment and resolve over next 3-4 weeks. Reactions include erythema, dry desquamation, wet desquamation Chronic: may occur years later and include atrophy, pigment changes, fibrosis and telangiectasia. 27

28. Dry desquamation Begins within 7-10 days of treatment Erythema that may progress to dry, itchy skin May be scaling, flaking, peeling Result of partial loss of the epidermal basal cell layer. Wet desquamation Result of complete destruction of the basal cell layer Blister, vesicles, and serous oozing occur Pain may occur if nerve endings are exposed Occurs more often in areas of friction & moisture (skin fold, groins) Increased risk of infection (may require break in treatment) 28

29. General Skin Care Wash daily with water or mild scent-free soap Use hand to wash the area. Rinse soap well. Pat skin dry. Don't use powders, creams unless ordered by Oncologist. Wear soft clothing over radiation site (cotton). Avoid belts, straps & tight clothing. Avoid sun exposure. Shave with electric razor. Do not use tape over site. 29

30. Alopecia May occur within the treatment field. Extent depends upon area of treatment and dose of XRT. Often patchy in appearance. Usually begins 2 weeks after start of XRT. Usually temporary, but may be permanent. Regrowth usually begins 3-6months. 30

31. Mucositis Inflammation of the mucosal lining of the G.I. tract If oral cavity - stomatitis If esophagus – esophagitis Common in patients receiving RT to head & neck Severity depends on dose, size of field, and fractionation schedule of RT Symptoms include: Soreness or burning in mouth/ throat Difficulty swallowing Sensation of “having lump in throat” Redness, tenderness, or ulcerations in the mouth 31

32. Assessment of mucositis History - Oral symptoms Food and fluid intake Difficulty swallowing Physical Assess oral cavity for redness, inflammation, ulcers, infection Investigations -Take culture Swab of lesions if Candida or herpes suspected 32

33. MUCOSITIS INTERVENTION Instruct patient/caregiver to:  Gently brush all surfaces of teeth, gums, and tongue with a soft nylon brush.  Brush with a nonirritating dentifrice such as baking soda.  Remove and brush dentures thoroughly during and after meals and as needed.  Rinse the mouth thoroughly during and after brushing  Avoid alcohol-containing mouthwashes.  Use recommended mouth rinses: Hydrogen peroxide and saline or water (1:2 or 1:4). Baking soda and water (1 tsp in 500 ml). Salt (.5 tsp), baking soda (1 tsp), and water (100 ml). Keep lips moist. Avoid use of tobacco and alcohol. 33

34. Xerostomia Dryness in the mouth caused by lack of normal secretion of saliva Salivary glands very sensitive to RT Severity related to dose May be permanent with higher doses Lack of moisture to mucosa causes irritation to the mucosa, fissures may develop on the corners of the mouth Xerostomia promotes accumulation of bacteria and plaque increasing susceptibility to infection, dental caries, and periodontal disease 34

35. Xerostomia Interventions Good oral hygiene Frequent sips water, sugarless gum, avoid dry foods, liquids with meals Avoid alcohol and smoking Humidifier Artificial saliva i.e. Moistir ac meals, hs, & prn Pilocarpine for radiation induced Xerostomia 35

36. Diarrhea Passage of frequent (more than 3/24hrs), loose, watery stool Can lead to dehydration, malabsorption, fatigue, hemorrhoids, and perianal skin breakdown Caused by irritation/inflammation of the bowel lining Risk for Diarrhea Higher in patients undergoing chemo or RT to abdomen or pelvis With XRT usually develops 10-15 days into treatment Lasts 2-3 weeks after treatment 36

37. Assessment of Diarrhea History - onset, pattern, number of B.M.’s/24 hrs. Physical – vital signs, assess hydration status Psychological – anxiety, stress Investigations – serum electrolytes, creatinine & urea, stool cultures & stool for c. difficile 37

38. Interventions Radiation induced diarrhea usually managed initially with dietary changes Small freq. meals Drink 8-10 glasses of fluids Low fat, low fiber diet Avoid gas producing foods Avoid caffeinated beverages Loperamide – if patient has more than 3 watery B.M.’s per day Protect peri -anal area form skin breakdown Keep area clean and dry Sitz bathes several times a day can ease discomfort 38

39. Other complications radiation treatment Cystitis (usually occurs 1-2 weeks post XRT and subsides 2 weeks after XRT complete Lhermitte’s syndrome – after spinal cord radiation Vaginal stenosis – after XRT to pelvis Radiation pneumonitis – after XRT to lungs 39

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