Nursing Responsibilities for Patients receiving Radiotherapy

and Chemotherapy

Marlon Rey Anacleto,RN,MAN

Radioactive Materials

Types of Radiotherapy

External

 where the radiation comes from a machine outside the body.

Internal

where the radiation comes from implants or liquids placed inside the body.

Types of Radiotherapy

Types of Radiotherapy

Who are the members of the radiation team? Oncologist—Diagnosis and treatments

Nurse—Nursing care (pre-radiation, during radiation and post-radiation)

Physics—Calculation on the amount of dose in radiation

Radiologist—Providing radiation regarding the physician’s order

Pre-Radiation Preparation of knowledge on radiotherapy by

assessing and giving informationWhat is radiotherapy? How much expenses for radiation?How long for the radiation? What will be complications? Preparation of patient (body) Laboratory tests—CBC, Electrolytes, Blood chemistry

Post TherapyHow to take care the treated area? Keep the skin dry Do not remove the ink marks Avoid using powder, lotions, creams, alcohol, and

deodorant Wear loose-fitting cloths Shave with an electric razor only Protect the skin from direct sunlight, chorine, and

extreme temperature

Side Effects Fatigue Anorexia Mucositis Xerostomia Alopecia

Skin reactionNausea & Vomiting Esophagitis &Dysphagia Diarrhea Cystitis Bone marrow

depression

Fatigue Factors contributing to fatigue: Surgery/Chemotherapy Pain Malnutrition Medications Anemia Normal lifestyle

Nursing Care

Assessing contributing factors, and encouraging patient to rest and limit daily activities.

Anorexia Factors contributing to anorexia␣Waste products of tissue destruction, anemia,

inactivity, medications, and psychological problems.

Nursing Care

* Eat small, frequent meals * Change diet and environment * Stimulate appetite * Eat nutritious and high protein snacks * Avoid fatty or greasy foods * Take nutritional supplements

Mucositis/StomatitisA patchy, white membrane become confluent and

may bleed if disturbed.

Nursing Care

* Avoid irritants—alcohol, tobacco, spicy, acid foods or hot drinks* Eat soft or liquid diet * Mouth care with saline or water frequently

Xerostomia Xerostomia is associated with the dry mouth that

results from radiation to salivary glands. It includes alterations in taste

Nursing Care

* Moisten foods * Use artificial saliva * Make foods easier to eat * Avoid dry foods * Soak foods in coffee, milk or warm drinks * Mouth care with saline frequently

Alopecia Alopecia is described as

the loss of hair that can occur with the radiation of the brain

Nursing Care

* Gently brush and comb, infrequently shampoo * Avoid the use of hair coloring and chemical * Give psychological support for change of body image * Give advice for using wig if necessary

Skin Reactions

Skin reactions include: erythema, dry and moist desquamation

Nursing Care

* Prevent increasing irritation and avoid scratch * Not to use any perfumed soap, ointments or deodorant * Use baby powder or maize starch* Wear loose-cloths and cotton made rather synthetic materials* Open to fresh air but not direct to sunlight* Teach patients about skin care—skin emulsion creamfor dry, and pain management and antibiotic spray for moist desquamation

Nausea & VomitingXerostomia is associated with the dry mouth that

results from radiation to salivary glands It includes alterations in taste Nursing Care

*Offer ice chips* Eat small, frequent meals * Eat salty foods, add salt in foods * Drink clear or cool beverages * Avoid overly sweet, greasy or high fat foods * Rest with the head elevated after eating * Mouth care * Take antiemetic medications if necessary.

Electrolytes imbalance Electrolyte imbalance is commonly caused by loss

of body fluids through prolonged vomiting, diarrhea, sweating, or high fever. All of these may be side effects of chemotherapy treatment.

The kidneys play a critical role in regulating electrolytes. They control the levels of chloride in your blood and “flush out” potassium, magnesium and sodium. Therefore, a disturbance in blood levels of these electrolytes may be related to kidney function.

Esophagitis & Dysphagia Firstly recognize “difficulty in swallowing solids”

and make swallowing painful resulting in decrease in intake foods and fluids.

Nursing Care

* Eat high-calorie, high-protein diet * Drink plenty of liquids * Eat soft and liquid foods * Blenderlize solid foods

DiarrheaCan occur if the areas of the abdomen and pelvis

are treated.

Nursing Care

* Drink plenty of fluids to avoid dehydration * Avoid milk or dairy products * Avoid foods high in fiber * Avoid high fat, spicy, and gas forming foods * Electrolyte replacement--potassium

CystitisCystitis and urethritis result from radiation to the

pelvic and bladder areas. Nursing Care

* Urine examination * Drink plenty of fluid* Observe infectious signs—fever, difficulty of voiding* Avoid moisture in the area treated * Take antibiotic as prescribed

Bone Marrow SuppressionCan occur if the areas of the abdomen and pelvis are

treated.Nursing Care

• Examine blood counts weekly. CBC• * Observe signs and symptoms of bleeding, and

infection, anemia,• * Teach patients to look for these signs• * Transfuse blood components as necessary• * Give health education on nutritious foods—egg

Observe for signs and symptoms of TLS

Tumor Lysis Syndrome: When cancer cells are killed by therapy, they may spill their inner (intracellular) contents, which accumulate in the body faster than can be eliminated. These excess intracellular contents cause the metabolic and electrolyte disturbances that result in tumor lysis syndrome (TLS). TLS can result in life-threatening complications if not managed appropriately. If TLS is untreated, its progression may cause acute kidney failure, cardiac arrhythmias, seizures, loss of muscle control or death.

S/S Nausea and vomiting Joint discomfort Shortness of breath Irregular heartbeat Lethargy Cloudy urineOther patients feel no symptoms of TLS in its early stages, but

have abnormal laboratory results. Laboratory results indicative of TLS show high potassium, uric acid and phosphorous levels and low calcium levels in the blood.

Nurses’ Roles Provision of nursing care

Emotional support

Monitoring/ Coordination

Health education

Follow up/ Referral system

Promotion of quality of life

Chemotherapyis the use of cytotoxic drugs in the treatment of

cancer. It is one of the four modalities- surgery, radiation therapy, chemotherapy and biotherapy- that provide cure, control, or palliation. Chemotherapy is systemic as opposed to localized therapy such as surgery & radiation therapy.

Paul Erlich, considered to be the father of chemotherapy.

Chemotherapy in 5 ways

1. Adjuvant therapy- A course of chemotherapy used in conjunction with another treatment modality.2. Neo-adjuvant chemotherapy- Administration of chemotherapy to shrink the tumor prior to surgical removal of the tumor.3. Primary therapy- The treatment of patients with localized cancer for which there is an alternative but less than completely effective treatment.4. Induction chemotherapy- The drug therapy is given as the primary treatment for patients with cancer for which no alternative treatment exists.5. Combination chemotherapy- Administration of two or more chemotherapeutic agents in the treatment of cancer, allowing each medication to enhance the action of the other or act synergistically with it. e.g. MOPP regimen for Hodgkin’s disease.

ROLE OF A NURSE

Prior to chemotherapy administration1 Review- The chemotherapy drugs prescription which should have:-Name of anti-neoplastic agent.-Dosage-Route of administration-Date and time that each agent to be administered.2. Accurately identify the client 3.Medications to be administered in conjunction with the chemotherapy e.g antiemetics, sedatives etc.

ROLE OF A NURSE

4.. Assess the clients condition including - Most recent report of blood counts including hemoglobin ,hematocrit, white blood cells and platelets. -Presence of any complicating condition which could contraindicate chemotherapeutic agent administration i.e. infection, severe stomatitis , decreased deep tendon reflexes, or bleeding .-Physical status-Level of anxiety-Psychological status.

5. Prepare for potential complicationsReview the policy and have medication and supplies available for immediate intervention the event of extravasation.Review the procedure and have medication available for possible anaphylaxis

6.Assure accurate preparation of the agent -Accuracy of dosage calculation -Expiry date of the drug to be checked -Procedure for correct reconstitution and -Recommended procedures for administration

7.Assess patients understanding of the chemotherapeutic agents and administration procedures.

*Aseptic technique should be followed.*Personal protective equipment includes disposable surgical gloves, long sleeves gown and elastic or knit cuffs.*Protective eye goggles *To minimize exposure

-Wash hands before and after drug handling.-Limit access to drug preparation area

*Keep labeled drug spill kit near preparation area.*Apply gloves before drug handling.*Open drug vials/ ampoules away from body.*Place absorbent pad on work surface.*Wrap alcohol wipe around neck of ampoule before opening.*Cover tip of needle with sterilize gauge when expelling air from syringe.*Label all chemotherapeutic drugs. *Clean up any spill immediately

Drug administration 1. Route- i) Oral - Emphasize the importance of compliance by the patient with prescribed schedule. Drugs with emetic potential should be taken with meals.Assure that chemotherapeutic agents are stored as directed by the manufacturer (refrigerate, avoid exposure to direct light,etc).

ii) Intramuscular and subcutaenous – Chemotherapeutic agents that can be administered I/M or subcutaneously are few in number. Non-vesicants like L-asperaginase, bleomycin, cyclophosphamide, methotraxate. Cyta arabine,and some hormonal agents are given I/M & /Or subcutaneously.

-Use the smallest gauge needle possible for the viscosity of the medication. -Change the needle after withdrawing the agent from a vial or ampoule.-Select a site with adequate muscle and/or SC tissue.iii) Intravenous – It is the most common method of administration of cancer chemotherapy. May be given through central venous catheters or peripheral access. Absorption is more reliable. This route is required for administration of vesicants and it also reduces the need of repeated injection. Because the I/V provides direct access to the circulatory system, the potential for infection and life threatening sepsis is a serious complication of IV chemotherapy.

Intrathecal- Infusion of medication can be given through an Ommaya reservoir, implantable pump and /or usually through lumbar puncture.

a) Wear protective equipment (gloves, gown and eyewear).

b) Inform the patient that chemotherapeutic drugs are harmful to normal cells and that protective measures used by personnel minimize their exposure to these drugs.

c) Administer drugs in a safe and unhurried environment.

d)Place a plastic backed absorbent pad under the tubing during administration to catch any leakage.

Do not dispose of any supplies or unused drugs in patient care

areas.

DocumentationRecord -chemotherapeutic drugs, dose, route ,and time

-Premedications, postmedications, prehydration and other infusions and supplies used for chemotherapy regimen.-Any complaints by the patient of discomfort and symptoms experienced before, during, and after chemotherapeutic infusion.

Disposal of supplies and unused drugsa)Do not clip or recap needles or break

syringes.b)Place all supplies used intact in a leak

proof ,puncture proof, appropriate labeled container.

c)Place all unused drugs in containers in a leak proof, puncture proof, appropriately labeled

container.d)Dispose of containers filled with

chemotherapeutic supplies and unused drugs in accordance with regulations of hazardous wastes