radiation oncology nursing

1. INTRODUCTION TO
RADIATION ONCOLOGY
NURSING
MATHEW VARGHESE V
MSN(RAK),FHNP (CMC Vellore),CPEPC
Nursing officer
AIIMS Delhi
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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.
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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.
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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.
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5. Sources of Radiation
 COLBALT 60
 CESIUM 137
 IODINE 131
 IRIDIUM 192
 RADIUM 226
 RADON 222
 STRONTIUM 90
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6. Gamma & X-rays
High Energy
Ionizing
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7. Goals of Radiotherapy
 Curative
 Control:
Adjuvant
Pre/Post Operative
Intraoperative
 Palliation
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8.  Radiation therapy may be in many types of
cancer if they are localized to one area of the body.
 It may also be used as a part of 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 , and has been
used before, during and after chemotherapy in
susceptible cancers.
 It may also be used as treatment where
cure is not possible and the aim is for local disease
control or symptomatic relief.
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9.  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.
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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).
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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.
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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.
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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.
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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.
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16. EXTERNAL BEAM RADIATION
THERAPY
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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)
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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
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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.
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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 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
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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.
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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.
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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.
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26. Symptom Management in
Radiation Oncology
 Nausea & vomiting
 Diarrhea
 Xerostomia
 Ocular symptoms ( edema, dryness, photophobia)
 Oral mucositis
 Alopecia
 Hyperthermia
 Headache
 Cystitis
 Esophagitis
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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.
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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)
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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.
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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.
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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
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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
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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:
o Hydrogen peroxide and saline or water (1:2 or 1:4).
o Baking soda and water (1 tsp in 500 ml).
o Salt (.5 tsp), baking soda (1 tsp), and water (100 ml).
 Keep lips moist.
 Avoid use of tobacco and alcohol.
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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
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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
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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
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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
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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
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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
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