Unit One Care of Client with
Cancer
RADIATION
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
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
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.
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.
High Energy
Ionizing
Gamma & X-rays
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)
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.
Radiation SOURCES
 COLBALT
60
 CESIUM 137
 IODINE 131
 IRIDIUM 192
 RADIUM 226
 RADON 222
 STRONTIUM 90
Important to Know!

RATE AT WHICH RADIOTHERAPY
DELIVERED NOTED AS MILLION ELECTRON
VOLTS ( CURRENTLY 2- 40 MEV’S USED)
 LINEAR ACCELERATORS DEVELOPED
ALLOWING DEEPER PENETRATION AND
LESS SUPERFICIAL TISSUE DAMAGE
Three
Goals of Radiotherapy
 Curative
 Control:
Adjuvant
Pre/Post Operative
Intraoperative
 Palliation
 http://www.youtube.com/watch?v=Ii-
rgH6SAp4&feature=related
 http://www.youtube.com/watch?v=lZ9cGV
axOes&feature=relmfu
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.
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).
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.
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
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.
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
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.

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)
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.
Brachytherapy
Brachytherapy may be sealed or unsealed:
SEALED:
Interstitial
Intercavity
UNSEALED:
Systemic (IV, oral)
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)
Brachytherapy
SEALED
Emits low energy
Continuous
Interstitial & intracavity
implants
UNSEALED
Injected, instilled or oral.
Systemically
EX.
I131
Ex. Seeds
APPLICATORS
CLIENT EMITS
RADIATION but NONE IN
EXCRETA
CLIENT AND EXCRETA
are RADIOACTIVE
Sealed Brachytherapy:
Intracavity:
 Radioisotopes (cesium or radium) put in applicator &
placed in body cavity for a specific amount of time (2472hours)
 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
Brachytherapy for prostate cancer
Brachytherapy for prostate
cancer. Lithotomy
positioning and graphic
representation of how
brachytherapy occurs
Needle insertion of radioactive
implants.
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)
Radioactive seeds
implanted in prostate
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




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
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
Factors affecting cell response to
Radiotherapy:




Histological type of cell
Oxygen effect
Type of radiotherapy used
Rate at which radiotherapy is delivered
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.
CELL / TISSUE
RADIOSENSITIVITY
HIGH
MODERATE
LOW
RESISTANT
LYMPHATIC
SKIN
HEART
MUSCLE
G.I.
EPITHELIUM
KIDNEY
MUCOUS
MEMBRANES
LIVER
GONADS
LUNG
MATURE
BRAIN
BONE
CARTILAGE
PERIPHERAL CONNECTIVE
NERVES
TISSUE
Chemical Modifiers:
Compounds used to increase the
radiosensitivity of tumor cells or protect
normal cells from the effects of
radiotherapy.
Types Chemical Modifiers:
RADIOSENSITIZERS - INCREASE CELL
KILL
RADIOPROTECTORS- PROTECT CELLS
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!
Pilocarpine
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.
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 microcirculation. Affect any/all tissues especially:
lymph, thyroid, pituitary, breast, brain, bone,
cartilage, pancreas and bile ducts.
SYMPTOM MANAGEMENT IN
RADIATION ONCOLOGY
Symptom Management










Nausea & vomiting
Diarrhea
Xerostomia
Ocular symptoms ( edema, dryness, photophia)
Oral mucositis
Alopecia
Hyperthermia
Headache
Cystitis
Esophagitis
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.
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
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)
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
Skin Care
cont’d

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
Skin Changes
Recommendations
Little or no skin changes – just
starting treatment
Cornstarch
Slight redness, slight warmth, mild
itchiness
Stop
Dry desquamation
Stop
Moist desquamation
Stop
dusting in treatment
area will prevent rubbing/irritation
from clothes. Do not use in moist
or open areas.
cornstarch
Use pure Aloe Vera to moisten
skin and help with the itchiness
aloe vera gel
Use 1% hydrocortisone cream
twice daily
hydrocortisone cream
Intra-site gel or flamazine
Saline compresses may be used
(Radiation therapy, Biotherapy
and Gene Therapy, CCNS 2004)
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
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
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
Assessment of mucositis
 History
- Oral symptoms
- Food and fluid intake
- Difficulty swallowing
Assessment of mucositis (cont’d)
 Physical
-
Assess oral cavity for redness,
inflammation, ulcers, infection
Investigations
Swab lesions if candida or herpes suspected
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
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
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
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
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
Risk for Diarrhea
 Higher
in patients undergoing chemo or
XRT to abdomen or pelvis
 With XRT usually develops 10-15 days
into treatment
 Lasts 2-3 weeks after treatment
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
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
Interventions cont’d
– 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
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