Presentation on theme: "Unit One Care of Client with Cancer RADIATION"— Presentation transcript:
1Unit 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
2This Class Radiation (Chpt 16) Definition Sources of radiation Uses of radiation principles of radiation protectionTypes of radiation therapyCare of clients receiving radiation therapySide effects & symptom management
3Class ObjectivesDescribe radiation as a modality for cancer treatment, and the uses of radiotherapyIdentify factors affecting cell response to radiotherapy.Discuss the principles of radiation protectionDescribe the types of radiation therapy and related nursing care.Discuss side-effects of radiation therapy and nursing care
4RADIOTHERAPY: 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 THERAPYRadiation/radiotherapy destroys cells ability to reproduce by damaging cell’s DNA (at the strands or bases)Picture of a Linear accelator
5RadiotherapyRADIOTHERAPY 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 DNAThe relative susceptibility of tissues to radiation depends upon individual cells & characteristics of the tissue itselfA 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.
6Gamma & X-rays High Energy Ionizing Ionizing radiation induces direct DNA damage and indirect damage through the radiolysis of water
7Terms to RecognizeBecquerel (Bq): unit of measure for the amount of of a radioactive nuclide in a particular energy state . One Bq= one nuclear disintegration per secondGray (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 doseRoentgen (R) Unit of exposure to ionized radiationSievert (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
8Action of RadiationPrevents the reproduction of cells as breaks DNA strandsCells most sensitive to radiation M & G2 phases & least sensitive in S phaseCells 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
9Radiation SOURCES COLBALT 60 CESIUM 137 IODINE 131 IRIDIUM 192 RADIUM 226RADON 222STRONTIUM 90COLBALT 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 cancerIODINE 131- thyroid cancer (po/IV)IRIDIUM 192-sealed- head/neck, breast, brain cancersRADIUM 226- cervical , sealedRADON 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)
10Important 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 DAMAGELinear 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
11Three Goals of Radiotherapy CurativeControl:AdjuvantPre/Post OperativeIntraoperativePalliationCurative: 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.
13Radiation Protection: Principles ALARA PRINCIPLE:TIME: longer time of exposure, greater amt. of rad. absorbedDISTANCE :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.
14ALARA PrincipleThe 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).
15TimeMinimize 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 entryIn 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.
16DistanceThe 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 isolationLimit client care by individual caregiverUse communication devices outside room when possibleDistance: 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 doublesAt double the distance you get ¼ or a quarter of the radiation
17ShieldingWhen 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 badgeNB 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.
18Types of Radiation Therapy External Beam or Teletherapymost common type of radiationusing machines (linear accelerator)client is not radioactiveInternal radiation or Brachytherapyimplants (temporary/permanent)client is radioaciveTeletherapy: tele; greek prefix meaning distanceExternal 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.
19TeletherapyDelivering radiation from a source a distance from the targetRadiation department administersAdvantage skin sparring effect giving max rad to tumor not the skin.Client monitored via TV or intercomTreatment 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.
20Brachytherapy Delivers a high dose of radiation to a localized area The specific radioisotope is chosen on the basis of its half-lifeMay 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 decayPatient 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 daysSome 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 circulationoften 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.
21Brachytherapy: 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.
22Brachytherapy SEALED: Interstitial Intercavity UNSEALED: Brachytherapy may be sealed or unsealed:SEALED:InterstitialIntercavityUNSEALED:Systemic (IV, oral)
23Types of Radiation: External: Beam radiation Teletherapy GAMMA RAYS: penetrate deeplyBETA RAYS:surface penetrationInternal:ImplantedBrachytherapySEALED:InterstitialIntercavityUNSEALED: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.
24Interstitial & intracavity implants BrachytherapySEALEDEmits low energyContinuousInterstitial & intracavity implantsEx. Seeds APPLICATORSCLIENT EMITSRADIATION but NONE IN EXCRETAUNSEALEDInjected, instilled or oral.SystemicallyEX. I131CLIENT AND EXCRETA are RADIOACTIVEKnow about isolation requirements & role of nurse for both types sealed & unsealedSealed source: radioactive material is enclosed in a sealed containersealed 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.
25Sealed 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 removedtreats ca uterus & cervixInterstitial:Placed needles, beads, seeds, ribbons or catheters placed directly into tumor (breast, prostrate)Radioisotopes iridium,cesium, gold, radonCan be temporary or permanent placementtreats Prostrate cancerKnow about isolation requirements & role of nurse for both types sealed & unsealedSealed source: radioactive material is enclosed in a sealed containerRadioisotopes 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 DRIridium 192, I 125 ,cesium 137, gold 198, radon222Temp 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 isotopeAfterloading 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
26Brachytherapy for prostate cancer Brachytherapy for prostate cancer. Lithotomy positioning and graphic representation of how brachytherapy occurs1. Lithotomy positioning and graphic representation of how brachytherapy occursNeedle insertion of radioactive implants.
27BRACHYTHERAPY Interstitial seed implantation Emits low energyContinuousEX: 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 limitedRadioactive isotope decays over a period of time to a specific element.Radioactive seeds implanted in prostate
28Nursing Care of the Client with Sealed Implant Private room with bathroomRadioactive material signWear dosimeterNo pregnant staffVisitors limited to 30 mins per dayVisitors are restricted and must remain at 6 feet distanceAll dressings & linens saved until implant removedLEAD CONTAINER & LONG HANDLED FORCEPS,LEAD GLOVES KEPT IN ROOM IN EVENT OF DISLODGEMENTREMEMBER ALARATIMEDISTANCESHEILDINGPrivate room with bathroom: is due to risk of implant dislodging & exposure to othersRooms have leaded shields lining the wallsRooms 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.
29Nursing Care of Client with UNSEALED Implant Presents potential contamination hazard/ all articles in room are considered contaminatedAfter d/c articles are discarded but taken to protected area ‘til detectable radioactivity decaysRubber gloves worn with direct careNo pregnant staffArticles in room phone, call light, floors covered plasticdisposable plastic /paper used for dietary trays & utensilspts. Flush toilet several timesKeep linen & gowns kept in separate isolation bagsPrivate room and bathAll 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 contaiminationLimited visitors-Everyone entering the room wear a new booties each timeWear gloves to avoid exposure to bodily fluidsVomit after ingested oral isotope cover pad and call safety officerFollow hospital policies everyone has a film badge to measure whole body exposure.Client & excreta radioactive!
30Loss of Radioactive Material: Considered an emergencySearch initiated by radiation staffNothing moves from the room while client has radioactive material in placeIf found radioactive material use forceps & glovesNotify Atomic Energy Canada
31Factors affecting cell response to Radiotherapy: Histological type of cellOxygen effectType of radiotherapy usedRate at which radiotherapy is deliveredHistological 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 radicalsType of radiotherapy used: sealed low energy while external high energyRate at which radiotherapy is delivered: more often have greater cell kill.
32Rate 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). .
34Chemical Modifiers:Compounds used to increase the radiosensitivity of tumor cells or protect normal cells from the effects of radiotherapy.
35Types Chemical Modifiers: RADIOSENSITIZERS - INCREASE CELLKILLRADIOPROTECTORS- PROTECT CELLS
36Radioprotector: 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 mouthImportant!Cholingeric: acts by stimulating cholingeric receptors, which stimulates exocrine glands to increase salivary glands secretion.Xerostoma: dry mouth from dysfunction of salivary glands.
38Factors influencing degree & occurrence of side effects Radiotherapy: Body site irradiatedDosageExtent of body area treatedMethod of radiation deliveryAge of clientGeneral health of clientPrevious surgeries & chemotherapyRadiosensitivity 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 importantSide effects are related to the total dose3. 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
39Phases 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.
41Symptom Management Nausea & vomiting Diarrhea Xerostomia Ocular symptoms ( edema, dryness, photophia)Oral mucositisAlopeciaHyperthermiaHeadacheCystitisEsophagitisIn 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.
42Skin 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 desquamationChronic: 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 doseType and energy of radiation (high energy xrays have skin sparing effects)Site of body (skin folds, head & neck, chest wall)Patient-related factorsConcurrent treatment (chemo)Erythema: redness of the skinDesquamation: shedding of epithelial cells in scales or sheets.
43Dry desquamation Begins within 7-10 days of treatment Erythema that may progress to dry, itchy skinMay be scaling, flaking, peelingResult 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)
44Wet desquamationResult of complete destruction of the basal cell layerBlister, vesicles, and serous oozingPain may occur if nerve endings are exposedOccurs more often in areas of friction & moisture (skin fold, groins)Increased risk of infection (may require break in treatment).
45General Skin Care Radiation Client Wash daily with water or mild scent-free soap soap (not dove as has creams added)Use hand to washRinse soap wellIf tatooing used so not to worry re washing simulation marksPat skin dryNo powders, ungs, creams unless ordered by OncologistUse hand or soft cloth to wash, to minimize abrasion.Avoid exposing area of treatment to direct shower stream.Use lukewarm water.
46Skin Care cont’d Avoid sun exposure Shave with electric razor Wear soft clothing over radiation site (cotton)Avoid belts, straps & tight clothingAvoid sun exposureShave with electric razorDo not use tape over site
47Skin Changes Recommendations Little or no skin changes – just starting treatmentCornstarch dusting in treatment area will prevent rubbing/irritation from clothes. Do not use in moist or open areas.Slight redness, slight warmth, mild itchinessStop cornstarchUse pure Aloe Vera to moisten skin and help with the itchinessDry desquamationStop aloe vera gelUse 1% hydrocortisone cream twice dailyMoist desquamationStop hydrocortisone creamIntra-site gel or flamazineSaline compresses may be used(Radiation therapy, Biotherapy and Gene Therapy, CCNS 2004)
48Alopecia May occur within the treatment field Extent depends upon area of treatment and dose of XRTOften patchy in appearanceUsually begins 2 weeks after start of XRTUsually temporary, but may be permanentRegrowth usually begins 3-6monthsXRT is often used as an abbreviation for radiation therapyPermanent 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.
49Mucositis Inflammation of the mucosal lining of the G.I. tract If oral cavity - stomatitisIf esophagus – esophagitisCommon in patients receiving XRT to head & neckSeverity depends on dose, size of field, and fractionation schedule of XRTThe rapidly dividing cells of the mucosa are very sensitive to radiationStomatitis refers to inflammation of the oral cavity onlyEsophagitis refers to inflammation of the mucous membrane lining the esophagus
50Mucositis Symptoms include: Soreness or burning in mouth or throat Difficulty swallowingSensation of having”lump in throat”Redness, tenderness, or ulcerations in the mouthPatients undergoing combined chemotherapy and radiation may experience more severe mucositis
51Assessment of mucositis History- Oral symptomsFood and fluid intakeDifficulty swallowing
52Assessment of mucositis (cont’d) PhysicalAssess oral cavity for redness, inflammation, ulcers, infectionInvestigationsSwab lesions if candida or herpes suspected
53General Interventions Scrupulous oral careSoft tooth brushNo commercial mouthwashes – use normal saline, club soda, or baking soda solutionNo lemon and glycerin mouth swabsConsider pain relief mouthwashSoft, bland dietbaking soda solution – ¼ tsp per liter of waterq2-4 h helps to loosen debris, break up mucous and is bacteriostatic
54XerostomiaDryness in the mouth caused by lack of normal secretion of salivaSalivary glands very sensitive to XRTSeverity related to doseMay be permanent with higher doses
55XerostomiaLack of moisture to mucosa causes irritation to the mucosa, fissures may develop on the corners of the mouthXerostomia promotes accumulation of bacteria and plaque increasing susceptibility to infection, dental caries, and peridontal disease
56Xerostomia Interventions Good oral hygieneFrequent sips water, sugarless gum, avoid dry foods, liquids with mealsAvoid alcohol and smokingHumidifierArtificial saliva i.e. Moistir ac meals, hs, & prnPilocarpine for radiation induced xerostomiaPilocarpine 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 problemsPatients may experience side effects of sweating, flushing, nausea, and diarrhea R/T parasympathetic stimulation
57Diarrhea Passage of frequent (more than 3/24hrs), loose, watery stool Can lead to dehydration, malabsorption, fatique, hemorrhoids, and perianal skin breakdownCaused by irritation/inflammation of the bowel lining
58Risk for DiarrheaHigher in patients undergoing chemo or XRT to abdomen or pelvisWith XRT usually develops days into treatmentLasts 2-3 weeks after treatment
59Assessment of Diarrhea History - onset, pattern, number of B.M.’s/24 hrs.Physical – vital signs, abdominal assess.,hydration statusPsychological – anxiety, stressInvestigations – serum electrolytes, creatinine & urea, stool cultures & stool for c. difficileInvestigations – serum electrolytes, creatinine & urea ( to assess for dehydration)
60InterventionsRadiation induced diarrhea usually managed initially with dietary changesSmall freq. mealsDrink 8-10 glasses of fluidsLow fat, low fiber dietAvoid gas producing foodsAvoid caffeinated beverages
61Interventions cont’dLoperamide – if patient has more than 3 watery B.M.’s per dayProtect peri-anal area form skin breakdownKeep area clean and drySitz bathes several times a day can ease discomfortLoperamide – 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
62Other complications radiation treatment Cystitis (usually occurs 1-2 weeks post XRT and subsides 2 weeks after XRT completeLhermitte’s syndrome – after spinal cord radiationVaginal stenosis – after XRT to pelvisRadiation pneumonitis – after XRT to lungsOther complications radiation treatment depend on area of body radiated for exampleCystitis if bladder is included in treatment fieldLhermitte’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 radiationVaginal stenosis – after XRT to pelvisRadiation 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