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Unit One Care of Client with Cancer RADIATION

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1 Unit One Care of Client with Cancer RADIATION
More than 50% of all clients with cancer receive radiation at some point during the course of their disease. Radiation can be given by itself as a treatment for cancer (primary modality) it is the only treatment used and aims to achieve a cure for cancer (early Hodgkin's disease, skin cancer) , as an adjuvant treatment pre or post operatively. Ex. Colorectal cancer, early breast cancer. Or adjuvant with chemo. It can also be used as a palliative treatment modality relieving pain caused by obstruction, pathological fractures, sp. Cd. Compression and metastasis. Image of Cancer Cell

2 This Class Radiation (Chpt 16) Definition Sources of radiation
Uses of radiation principles of radiation protection Types of radiation therapy Care of clients receiving radiation therapy Side effects & symptom management

3 Class Objectives Describe radiation as a modality for cancer treatment, and the uses of radiotherapy Identify factors affecting cell response to radiotherapy. Discuss the principles of radiation protection Describe the types of radiation therapy and related nursing care. Discuss side-effects of radiation therapy and nursing care

4 RADIOTHERAPY: One way to stop the ca from growing is to interfere with the ca cell’s ability to multiply. Radiation at high dosages, causes changes in the ca cell’s that stops the cell’s ability to multiply and eventually kills the ca cell. In some cases destroys ca cell in others slows down growth. CANCER THERAPY Radiation/radiotherapy destroys cells ability to reproduce by damaging cell’s DNA (at the strands or bases) Picture of a Linear accelator

5 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. radiation destroys a cell’s ability to reproduce by damaging its DNA The relative susceptibility of tissues to radiation depends upon individual cells & characteristics of the tissue itself A highly radiosensitive tumor is greatly affected by radiation as because it is rapidly dividing, well-vascularized and has a high oxygen content (aerobic cells). Normal tissues are usually able to recover from radiation damage if therapeutic doses are kept within certain ranges.

6 Gamma & X-rays High Energy Ionizing
Ionizing radiation induces direct DNA damage and indirect damage through the radiolysis of water

7 Terms to Recognize Becquerel (Bq): unit of measure for the amount of of a radioactive nuclide in a particular energy state . One Bq= one nuclear disintegration per second Gray (Gy) Unit of radiation dose (one joule per kg). One Gy= 100 centigray (cGy) equals 100rad (1 rad= 1cGy) Rad (r) Acronym for radiation absorbed dose Roentgen (R) Unit of exposure to ionized radiation Sievert (Sv) The unit of dose equivalent to ionizing radiation is = one joule per kg. (used in radiation safety re occupational exposure) Gray is the most commonly used

8 Action of Radiation Prevents the reproduction of cells as breaks DNA strands Cells most sensitive to radiation M & G2 phases & least sensitive in S phase Cells that are rapidly dividing cells and undifferentiated are more sensitive to radiation. Cells treated in the M & G2 phase are more likely to suffer lethal damage. The amount of time that is required for the manifestations of radiation damage is determined by the miiotic rate of the tissue. EX GI tract cells& bone marrow (rapidly divide) will die fast & exhibit early responses to radiation whereas tissues like bone, & kidneys manifest late responses to radiation

RADIUM 226 RADON 222 STRONTIUM 90 COLBALT 60- machines Stress to the class that Cobalt-60 machines are no longer used in hospitals but it is still in Standard Grade Physics Textbooks. CESIUM 137- sealed in cervical cancer IODINE 131- thyroid cancer (po/IV) IRIDIUM 192-sealed- head/neck, breast, brain cancers RADIUM 226- cervical , sealed RADON 222 natural occurring gas that results as a decay uranium. Also emitted in rocks, soil, colorless, tasteless & odorless. Can enter homes in cracks in foundations or wells. When inhaled there is an increased incidence of lung ca & COPD. STRONTIUM 90- controls bone pain and patient’s with boney mets (Palliative)

10 Important to Know! RATE AT WHICH RADIOTHERAPY DELIVERED NOTED AS MILLION ELECTRON VOLTS ( CURRENTLY MEV’S USED) LINEAR ACCELERATORS DEVELOPED ALLOWING DEEPER PENETRATION AND LESS SUPERFICIAL TISSUE DAMAGE Linear accelerators are commonly used . They emit external beam radiation that creates high energy x-ray beams (photons) . The higher the energy produced by the machine the greater the depth of penetration of radiation beam. Major advantage: high energy radiation has a “Skin -Sparring effect” maximum radiation effects occurs at the tumor site, not on the skin surface. Linear Accelerator: After all medical information has been reviewed, and the computer plan completed, the "simulation" procedure is performed. This is essentially "a dry run" during which the specific angles needed to deliver the radiation safely, and accurate localization of the tumor (target) is accomplished

11 Three Goals of Radiotherapy
Curative Control: Adjuvant Pre/Post Operative Intraoperative Palliation Curative: radiation is a primary treatment ex. Skin cancer, early breast & prostrate. Normal grays given over 6-8 hours. Control: of the disease process for a period of time . Give a treatment at DX & additional treatments each time the symptoms recur. Adjuvant-given to enhance or assist primary radiation. Ex. ALL with chemo facilitates transfer of chem across blood/brain barrier. Pre-op: colorectal cancer- decrease tumor bulk. Post-op: lung cancer. Intraoperative is completed as some research centers. Rad. Is administered directly to the tumor site during surgery Ex small cell ca lung. Palliative: relieve of compression tumors, relief of pain boney mets, intestinal obstruction, spinal cord compression, – short intensive radiation want rapid results.


13 Radiation Protection: Principles
ALARA PRINCIPLE: TIME: longer time of exposure, greater amt. of rad. absorbed DISTANCE :intensity of rad. decreases as distance from source increases. SHIELDING: % of rad. penetration decreases as the shield thickness increases. There are three key principles to protect yourself and others for excessive radiation exposure: Time, distance, shielding. Pregnant nurses should not care for clients receiving radiation.

14 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).

15 Time Minimize time spent in close proximity to the client. Radiation exposure is directly related to the time spent within a specific distance of rad. Souce. 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. Time: aim to minimize the amount of time you are exposed to radiation source, must still meet client’s needs. Exposure should be limited to 30 mins of direct care per 8 hours shift. Organize supplies outside room & care for client rotated among staff to limit exposure for each employee.

16 Distance The amount radiation decreases Doubling the distance from the rad source Quarters the amt. of radiation received! If the exposure at 1 meter from the Rad. Source is X, the exposure at 2m is ¼ of x, and at 4m, one sixteenth. Interventions: Teach client self-care & rationale for isolation Limit client care by individual caregiver Use communication devices outside room when possible Distance: the greater the distance for the radiation source the less exposure. Ex when providing care to a client with uterine implant, less radiation received if you stand at the client’s bed rather than beside the client. The amount of radiation decreases as the distance from the radiation source doubles At double the distance you get ¼ or a quarter of the radiation

17 Shielding When used properly, lead shielding can provide added protection from radiation. In practice, nurses find lead shielding in be cumbersome to work with. Improper use leads to a false sense of security, and impedes rapid care. Nurses wear a film badge NB pregnant nurses should not care for radiation clients. Shielding: use of shielding devices whenever possible reduces rad exposure. Ex the dose of x-rays and gamma rays is reduced as the thickness of the lead shield increased. Institutions with high volume radiationimplants rooms have leaded shielded walls. Ex. Shielding wearing a lead vest for an x-ray.

18 Types of Radiation Therapy
External Beam or Teletherapy most common type of radiation using machines (linear accelerator) client is not radioactive Internal radiation or Brachytherapy implants (temporary/permanent) client is radioacive Teletherapy: tele; greek prefix meaning distance External radiation given by radiation from a machine & the client is never radioactive during this treatment. Internal Radiation/ brachytherapy means close treatment, is implantation or insertion of radioactive material directly into tumor or in close proximity to tumor. implant maybe temporary, source placed into catheter or tube inserted into tumor & left for few days. (head, neck tumors or gynecological) Implants maybe permanent (prostrate), insertion of radioactive seeds into tumors. Brachytherapy delivers more dose locally and less penetrating than external beam radiation.

19 Teletherapy Delivering radiation from a source a distance from the target Radiation department administers Advantage skin sparring effect giving max rad to tumor not the skin. Client monitored via TV or intercom Treatment approx. 10 mins. Not painful client feels heat or tingling. Therapist is not in the room with the client receiving the rad, ramifications of isolation & fear.. A lot of time is spent ensuring positioning of client & machine. During teletherapy the client is never radioactive.

20 Brachytherapy Delivers a high dose of radiation to a localized area
The specific radioisotope is chosen on the basis of its half-life May be implanted by means of needles, seeds, beads, or catheters into body cavities (vagina, abdomen, prostate, pleural space). May be given orally or IV (thyroid cancer) Half-life: the time it takes for half of its radioactivity to decay Patient is radioactive with brachytherapy. Source of radiation planted is radioactive isotopes. Can be permanent or temporary. Permanent seeds prostrate ca or temporary catheter or tube inserted into the tumor & left in place for several days Some of the implants remain in place permanently, while others are removed after 2 or 3 days. A source of rad in the shape of needles, catheter, tube or seeds is implanted near, in the tumor or into systemic circulation often given before or after external beam irradiation as a method of increasing the radiation dose directly to the tumor. Another form is systemic via oral or IV. cervical, uterine, prostrate ca and some head & neck ca and sarcomas. The implants (permanent/temporary) are placed in the client surgically in the OR.

21 Brachytherapy: Sealed PROSTATE BRACHYTHERAPY
Brachytherapy uses sealed radioactive sources, which places the radiation source near or in the tumour for a calculated period of time. This form of Radiation Therapy is most commonly used to treat some forms of skin cancer, prostate cancer and gynaecological malignancies. At the completion of each treatment, the radiation source is removed. This means that you will not be radioactive, and there is no need to alienate yourself from others. The number of treatments you require varies, depending on your diagnosis and treatment site.  You will be advised ahead of time on how many treatments you will have.

22 Brachytherapy SEALED: Interstitial Intercavity UNSEALED:
Brachytherapy may be sealed or unsealed: SEALED: Interstitial Intercavity UNSEALED: Systemic (IV, oral)

23 Types of Radiation: External: Beam radiation Teletherapy GAMMA RAYS:
penetrate deeply BETA RAYS: surface penetration Internal: Implanted Brachytherapy SEALED: Interstitial Intercavity UNSEALED: Systemic (IV, oral) Gamma rays: emitted as packets of energy called “photons” from nuclei of atoms. Travel at the speed of light Ex gold, cesium, I & radium. Beta rays: moderate to high speed electrons with -1 charge emitted by atoms. When they release energy limited range to the outer skin EX strontium 90 & phosphorous 32.

24 Interstitial & intracavity implants
Brachytherapy SEALED Emits low energy Continuous Interstitial & intracavity implants Ex. Seeds APPLICATORS CLIENT EMITS RADIATION but NONE IN EXCRETA UNSEALED Injected, instilled or oral. Systemically EX. I131 CLIENT AND EXCRETA are RADIOACTIVE Know about isolation requirements & role of nurse for both types sealed & unsealed Sealed source: radioactive material is enclosed in a sealed container sealed Radioisotopes enclosed by non-radioactive material can’t circulate through the body (not in urine, blood, stool, vomit) Unsealed: radioactive material is administered systemically such as an injection or orally. Radioactive source is contained in the from of a needle, seeds, beads, wire or catheter placed into the tumor directly. Can be temp (needle) or permanent (prostrate seeds). The radioisotope in unsealed circulates through the clients body & used for systemic therapy. In remote brachytherapy, a computer sends the radioactive source through a tube to a catheter that has been placed near the tumor by the patient's doctor. The procedure is directed by the brachytherapy team who watch the patient on closed-circuit television and communicate with the patient using an intercom. The radioactivity remains at the tumor for only a few minutes. In some cases, several remote treatments may be required and the catheter may stay in place between treatments. Remote brachytherapy may be used for low dose-rate (LDR) treatments in an inpatient setting. High dose-rate (HDR) remote brachytherapy allows a person to have internal radiation therapy in an outpatient setting. High dose-rate treatments take only a few minutes. Because no radioactive material is left in the body, the patient can return home after the treatment. Remote brachytherapy has been used to treat cancers of the cervix, breast, lung, pancreas, prostate, and esophagus.

25 Sealed Brachytherapy:
Intracavity: Radioisotopes (cesium or radium) put in applicator & placed in body cavity for a specific amount of time (24-72hours) When treatment completed applicator & radioactive material removed treats ca uterus & cervix Interstitial: Placed needles, beads, seeds, ribbons or catheters placed directly into tumor (breast, prostrate) Radioisotopes iridium,cesium, gold, radon Can be temporary or permanent placement treats Prostrate cancer Know about isolation requirements & role of nurse for both types sealed & unsealed Sealed source: radioactive material is enclosed in a sealed container Radioisotopes enclosed by non-radioactive material can’t circulate through the body (not in urine, blood, stool, vomit) Unsealed: radioactive material is administered systemically such as an injection or orally. Radioactive source is contained in the from of a needle, seeds, beads, wire or catheter placed into the tumor directly. Can be temp (needle) or permanent (prostrate seeds). The radioisotope in unsealed circulates through the clients body & used for systemic therapy. NB (24-72hours) ordered by DR Iridium 192, I 125 ,cesium 137, gold 198, radon222 Temp placement ribbons, needles, catheters and permanent prostrate seeds. NB sealed sources internal radiation: radioisotope is enclosed in nonradioactive material. Therefore can’t circulate through client's body nor get in urine, bld etc. Although secretions are not radioactive, rad exposure can result from direct contact with the sealed isotope touching the container with bare hands or long exposure to sealed isotope Afterloading devices developed (empty applicator the product that holds the radiation source) is placed OR & radioactive source is not loaded until pt. returns to room or radiation department. Remote after loading maybe used to give high doses short-term directly to a tumor. Hollow applicators are surgically placed then the radioactive source is inserted into applicator , left in place for a certain amount of time. After treatment source is removed, applicator left in place for more than one planned treatment. Client then goes to room. When brachtherapy done in pts room radioactive source can be returned to the brachytherapy device while you are doing care. Afterloading devices decreases radiation exposure to staff but lengthens time needed to deliver the dose. client radioactive, excreta not

26 Brachytherapy for prostate cancer
Brachytherapy for prostate cancer. Lithotomy positioning and graphic representation of how brachytherapy occurs 1. Lithotomy positioning and graphic representation of how brachytherapy occurs Needle insertion of radioactive implants.

27 BRACHYTHERAPY Interstitial seed implantation
Emits low energy Continuous EX: SEEDS in this case for 1 year. Watch for symptoms of irritation or problems voiding (swelling) Seeds have a short half-life so that the dose received by the pt. is limited Radioactive isotope decays over a period of time to a specific element. Radioactive seeds implanted in prostate

28 Nursing Care of the Client with Sealed Implant
Private room with bathroom Radioactive material sign 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 Private room with bathroom: is due to risk of implant dislodging & exposure to others Rooms have leaded shields lining the walls Rooms located at end of halls lessening chance of exposure. Dosimeter: monitoring device worn personnel who are exposed to rad. During course of work. Ex pocket dosimeter, film badge. Dose summed over three month period 30 MSV /3 mon (max) 50MSV 1 year(safety standards). Never take dosimeter to beach sun and do not use any one elses. All dressings & linens saved until implant removed- then can be exposed of in usual manner once source is removed & accounted for. DISLODGEMENT: never touch with hands notify radiation officer & tech. LEAD CONTAINER & LONG HANDLED FORCEPS,LEAD GLOVES KEPT IN ROOM IN EVENT OF DISLODGEMENT; if dislodged pick it up with forceps and place in lead container, notify safety officier, radiation therapist and they will retrieve and secure the source. some automatic remote control in rooms loads radioactive sources once loaded nurse should limit time in room. Radioactive inserts abd cavityremain in bed, have a foley & low-fiber diet after insertion of implant to prevent BM before device removed.

29 Nursing Care of Client with UNSEALED Implant
Presents potential contamination hazard/ all articles in room are considered contaminated After d/c articles are discarded but taken to protected area ‘til detectable radioactivity decays Rubber gloves worn with direct care No pregnant staff Articles in room phone, call light, floors covered plastic disposable plastic /paper used for dietary trays & utensils pts. Flush toilet several times Keep linen & gowns kept in separate isolation bags Private room and bath All body secretions are radioactive. All surfaces and floor covered with paper or protective coverings. Trash & linens left in room until discharge and upon d/c the client is scanned by safety officier to determine decrease and safe radiation level to go home. Precautions for room continue post d/c until cleared by safety officier. Beds only changed when linen soiled to reduce contaimination Limited visitors- Everyone entering the room wear a new booties each time Wear gloves to avoid exposure to bodily fluids Vomit after ingested oral isotope cover pad and call safety officer Follow hospital policies everyone has a film badge to measure whole body exposure. Client & excreta radioactive!

30 Loss of Radioactive Material:
Considered an emergency Search initiated by radiation staff Nothing moves from the room while client has radioactive material in place If found radioactive material use forceps & gloves Notify Atomic Energy Canada

31 Factors affecting cell response to Radiotherapy:
Histological type of cell Oxygen effect Type of radiotherapy used Rate at which radiotherapy is delivered Histological type of cell: cells in the resting phase of cell are less sensitive to radiation than those in active in cellular division. Oxygen effect: well O2 tissue are more sensitive to rad due to oxygen being needed to from free radicals Type of radiotherapy used: sealed low energy while external high energy Rate at which radiotherapy is delivered: more often have greater cell kill.

32 Rate of Delivery of Radiation: Teletherapy
FRACTIONATION- administering radiation in divided doses rather than single doses to minimize side effects by allowing normal cells time to recover. Dividing total dose radiation into smaller frequent doses. Fractionation allows normal cells time to repair. Increases chance of getting the cells in the vulnerable G2 & M phases. FRACTIONATION: refers to dividing the total radiation doses into small frequent doses to minimize side effects and allow normal cells to recover. Also increases the probability that tumor cells will be in a vulnerable phase of cell cycle (G2 & M). .


34 Chemical Modifiers: Compounds used to increase the radiosensitivity of tumor cells or protect normal cells from the effects of radiotherapy.

35 Types Chemical Modifiers:

36 Radioprotector: Protects cells from radiation
Pilocarpine (Salagen) administered orally decreases xerostomia from salivary gland dysfunction related to head/neck radiation. decreases chance of mucositis, fungi, infections and ulcers of mouth Important! Cholingeric: acts by stimulating cholingeric receptors, which stimulates exocrine glands to increase salivary glands secretion. Xerostoma: dry mouth from dysfunction of salivary glands.

37 Pilocarpine

38 Factors influencing degree & occurrence of side effects 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. The goal of RT is to destroy the cancer while keeping the dosages within the normal tissue tolerance to avoid harming surrounding normal tissues. Certain normal tissues are more sensitive and may incur permanent damage: spinal cord, GI, integumenatry. Dose and technique for administration is very important Side effects are related to the total dose 3. Size of field will affect the amount of dose and what can be tolerated. 4. Method in terms of systemic local etc will impact on side-effects experienced.(depth of penetration) 5/6 both affect the client’s ability to tolerate RT. 7. Person receiving chemo may experience increased side effects due to overlapping or synergistic effects. 8 greatest effect on rapidly dividing cells

39 Phases of Radiation Injury:
Early (acute): occurs within weeks and resolve 4-6 weeks post radiation. Usually temporary and effect tissue 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.


41 Symptom Management Nausea & vomiting Diarrhea Xerostomia
Ocular symptoms ( edema, dryness, photophia) Oral mucositis Alopecia Hyperthermia Headache Cystitis Esophagitis In general skin reactions and fatigue may occur with RT to any site but many other side effects depend on the specific areas involved in the treatment field.

42 Skin Reactions Acute or Chronic :
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. With external radiation, the beam must penetrate the skin. Because of the rapid turnover of cells in the skin, skin reactions and changes to the skin over the area are common. Factors affecting skin reactions include: Total radiation dose Type and energy of radiation (high energy xrays have skin sparing effects) Site of body (skin folds, head & neck, chest wall) Patient-related factors Concurrent treatment (chemo) Erythema: redness of the skin Desquamation: shedding of epithelial cells in scales or sheets.

43 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. Erythema: reddness of the skin (mild soap and water) Desquamation: shedding of epitheal cells in scales or sheets.(Tisone)

44 Wet desquamation Result of complete destruction of the basal cell layer Blister, vesicles, and serous oozing 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) .

45 General Skin Care Radiation Client
Wash daily with water or mild scent-free soap soap (not dove as has creams added) Use hand to wash Rinse soap well If tatooing used so not to worry re washing simulation marks Pat skin dry No powders, ungs, creams unless ordered by Oncologist Use hand or soft cloth to wash, to minimize abrasion. Avoid exposing area of treatment to direct shower stream. Use lukewarm water.

46 Skin Care cont’d Avoid sun exposure Shave with electric razor
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

47 Skin Changes Recommendations
Little or no skin changes – just starting treatment Cornstarch dusting in treatment area will prevent rubbing/irritation from clothes. Do not use in moist or open areas. Slight redness, slight warmth, mild itchiness Stop cornstarch Use pure Aloe Vera to moisten skin and help with the itchiness Dry desquamation Stop aloe vera gel Use 1% hydrocortisone cream twice daily Moist desquamation Stop hydrocortisone cream Intra-site gel or flamazine Saline compresses may be used (Radiation therapy, Biotherapy and Gene Therapy, CCNS 2004)

48 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 XRT is often used as an abbreviation for radiation therapy Permanent hair loss is more likely with larger doses of radiation i.e. > 6,000 cGy’S (units 0f Gray) Many patients find it helpful to have their hair cut short before it falls out. Some patients may choose to wear a wig.

49 Mucositis Inflammation of the mucosal lining of the G.I. tract
If oral cavity - stomatitis If esophagus – esophagitis Common in patients receiving XRT to head & neck Severity depends on dose, size of field, and fractionation schedule of XRT The rapidly dividing cells of the mucosa are very sensitive to radiation Stomatitis refers to inflammation of the oral cavity only Esophagitis refers to inflammation of the mucous membrane lining the esophagus

50 Mucositis Symptoms include: Soreness or burning in mouth or throat
Difficulty swallowing Sensation of having”lump in throat” Redness, tenderness, or ulcerations in the mouth Patients undergoing combined chemotherapy and radiation may experience more severe mucositis

51 Assessment of mucositis
History - Oral symptoms Food and fluid intake Difficulty swallowing

52 Assessment of mucositis (cont’d)
Physical Assess oral cavity for redness, inflammation, ulcers, infection Investigations Swab lesions if candida or herpes suspected

53 General Interventions
Scrupulous oral care Soft tooth brush No commercial mouthwashes – use normal saline, club soda, or baking soda solution No lemon and glycerin mouth swabs Consider pain relief mouthwash Soft, bland diet baking soda solution – ¼ tsp per liter of waterq2-4 h helps to loosen debris, break up mucous and is bacteriostatic

54 Xerostomia Dryness in the mouth caused by lack of normal secretion of saliva Salivary glands very sensitive to XRT Severity related to dose May be permanent with higher doses

55 Xerostomia 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 peridontal disease

56 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 Pilocarpine is a cholinergic that stimulates salivary flow from any residually functioning salivary glands. May take up to one month to be effective. Dose needs to be titrated up. Contraindicated in pts with glaucoma and cardiac problems Patients may experience side effects of sweating, flushing, nausea, and diarrhea R/T parasympathetic stimulation

57 Diarrhea Passage of frequent (more than 3/24hrs), loose, watery stool
Can lead to dehydration, malabsorption, fatique, hemorrhoids, and perianal skin breakdown Caused by irritation/inflammation of the bowel lining

58 Risk for Diarrhea Higher in patients undergoing chemo or XRT to abdomen or pelvis With XRT usually develops days into treatment Lasts 2-3 weeks after treatment

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

60 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

61 Interventions cont’d 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 Loperamide – if patient has more than 3 watery B.M.’s per day Loperamide helps to decrease peristalsis in the colon and increases anal spincter tone. Should not be used if signs of infection or possible obstruction present

62 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 Other complications radiation treatment depend on area of body radiated for example Cystitis if bladder is included in treatment field Lhermitte’s syndrome, temporary condition resulting in shock-like sensation down the spine and limbs on flexion of the neck – after spinal cord radiation- due to demyelination of the sensory neurons from radiation Vaginal stenosis – after XRT to pelvis Radiation fibrosis – after XRT to lungs symptoms usually develop 1-3 months post-treatment. Symptoms mimic infection but do not respond to antibiotics, but often responds to steroids

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