8. Radiation therapy: used in high doses to kill cancer cells, or palliatively for pain relief. Side effects of radiation therapy depend on site of therapy (side effects are variable in each individual): nausea, vomiting, stomatitis, esophagitis, dry mouth, diarrhea, depression of bone marrow, suppression of immune response, decreased life span, and sterility.
   1. External radiation: cobalt or linear accelerator machine.
      • Procedure: daily treatments, Monday through Friday, for prescribed number of times according to size and location of tumor (length of treatment schedule is usually 4-6 weeks). Patient remains alone in room during treatment. (Nurse, therapist, family members cannot stay in room with patient due to radiation exposure during treatment.) Patient instructed to lie still so exactly same area irradiated each treatment. Marks (tattoos or via permanentink markers) are made on skin to delineate area of treatment; marks must not be removed during entire treatment course.
      • Nursing care plan/implementation:
        1. Goal: prevent tissue breakdown.
           • Do not wash off site-identification marks (tattoos cannot be removed); dosage area is carefully calculated and must be exact for each treatment.
           • Assess skin daily and teach patient to do same (most radiation therapy is done on outpatient basis, so patient needs skills to manage independently).
           • Keep skin dry; cornstarch usually the only topical application allowed:
           • Contraindications:
             1. Talcum powders, due to potential radiation dosage alteration.
             2. Lotions, due to increased moistening of skin.
           • Reduce skin friction by avoiding constricting bedclothes or clothing and by using electric shaver.
           • Dress areas of skin breakdown with nonadherent dressing and paper tape.
        2. Goal: decrease side effects of therapy.
           • Provide meticulous oral hygiene.
           • If diarrhea occurs, may need IV infusions, antidiarrheal medications; monitor bowel movements, possible adhesions from surgery and radiation treatments.
           • Monitor vital signs, particularly respiratory function, and BP (sloughing of tissue puts patient at risk for hemorrhage).
           • Monitor hematological status - bone marrow depression can cause fatal toxicosis and sepsis.
           • Institute reverse isolation as necessary to prevent infections (reverse isolation usually instituted if less than 50% neutrophils).
        3. Goal: health teaching.
           • Instruct patient to avoid:
             • Strong sunlight; must wear sunblock lotion, protective clothing over radiation site.
             • Extremes in temperature to the area (hot-water bottles, ice caps).
             • Synthetic, nonporous clothes or tight constrictive clothing over area.
             • Eating 2-3 hour before treatment and 2 hour after, to decrease nausea; give small, frequent meals high in protein and carbohydrates and low in residue.
             • Strong alcohol-base mouthwash; use daily salt and soda mouthwash.
             • Fatigue, an overwhelming problem. Need to pace themselves, nap; may need someone to drive them to therapy; can continue with usual activities as tolerated.
             • Crowds and persons with upper respiratory infections or any other infections.
           • Provide appropriate birth control information for patients of childbearing age.
   2. Internal radiation: sealed (radium, iridium, cesium):
   • Used for localized masses, e.g., mouth, cervix, breast, testes. Due to exposure from radiation source, precautions must be taken while it is in place. Health care personnel and family must adhere to principles of time, distance, and shielding to decrease exposure (shortest amount of time possible, stay as far away as possible from the source of radiation, and wear protective lead apron, gloves). If source of radiation accidentally falls out, it should be picked up only with forceps. Radiation officer should be notified immediately. Patient should be notified immediately. Patient should be in private room, and bed should be in the center of the room, if possible, to protect others. Unless the walls are lead lined, radiation will penetrate them; placing the bed in center of room will decrease exposure. Once the source of radiation has been removed, there is no exposure from patient, excretions, or linens.
   • Nursing care plan/implementation:
     1. Goal: assist with cervical radium implantation (cervical radium is used here as the most common example of internal radiation source).
        • Before insertion - give douche, enema, perineal prep; insert Foley, as ordered.
        • After implantation - check position of applicator q24h.
          • Keep patient on bed rest in flat position to avoid displacing applicator (may turn to side for eating).
          • Notify physician if temperature elevates, nausea and/or vomiting occur (indicates radiation reaction or infection.
          • After removal of implant (48-144 hours) - bathe, douche, and remove catheter as ordered.
     2. Goal: health teaching.
        • Explain that nursing care will be limited to essential activities in postinsertion period.
        • Signs and symptoms of complications so patient can notify staff if something unusual happens (bleeding, radiation source falls out, fever, etc.).
   • Nursing precautions for sealed internal radiation:
     1. Never handle radium directly - if applicators should accidentally be removed, pick up applicator by strings with long-handled forceps and notify radiation officer.
     2. Linen must remain in patient’s room and not be sent to laundry until source of radiation has been accounted for and returned to its container.
     3. Time, distance, and shielding are factors that increase or decrease potential effects on personnel. Need to minimize exposure of nursing staff, patient’s family, and other health professionals. Nurses who may be pregnant should not care for patients with radiation because of possible damage to the fetus from radiation exposure. Children under 16 should not be allowed to visit while internal radiation is in use.
   3. Internal radiation: unsealed (radioisotope/ radionuclide)
      • Source of radiation is given orally or intravenously or instilled into a cavity as a liquid.
      • Nursing care plan/implementation: Goal: reduce radiation exposure of others.
      1. Isolate patient and tag room with radioactivity symbol.
      2. Rotate personnel to avoid overexposure (principles of time, distance, and shielding). Staff should use good handwashing technique. Patient should be in a room with running water. (Nurse who may be pregnant should not care for patient while radiation source still active.)
      3. Encourage family to maintain telephone contact or use intercom, to decrease exposure to others.
      4. Plan independent diversional activities.
      • Specific nursing precautions (post in chart, on patient’s door).
      1. Radioactive iodine (¹³¹I): half-life 8.1 days; excreted in urine, saliva, perspiration, vomitus, feces.
         • Wear gloves and isolation gowns when handling patient, excreta, or dressings directly.
         • Collect paper plates, eating utensils, dressings, and linen in impermeable bags; label and dispose according to agency protocol.
         • Collect excreta in shielded container and send to lab daily to monitor excretion rate and disposal.
      2. Radioactive phosphorus (³²P): half-life 14 days; injected into cavity or given IV or orally.
         • If injected into cavity, turn patient q10-15min for 2 hours to ensure distribution.
         • No radiation hazard unless leakage from instillation site or from patient’s excreta, which are collected in lead-lined containers and brought to the radioisotope laboratory for disposal. Linen is collected in container, marked radioactive, and brought to the radioisotope lab for special handling.
         • Seepage will stain linens blue; wear gloves when handling contaminated linens, dressings. Excreta disposed of as in (b).
      3. Radioactive gold (^l98Au): half-life 2.7 days; usually injected into pleural or abdominal cavity.
         • May seep from instillation site or drainage tubes in cavity; stains purple.
         • Turn patient q15min for 2 hours, as in (2)(a).
         • Same precautions regarding handling excreta as in (1)(a) and (2)(b).
      4. Precautions for nurses:
         • Use principles of time, distance, and shielding when caring for patients who are having active radiation therapy treatments.
         • Nurses who may be pregnant should not accept an assignment caring for patients who have active radiation in place.
         • Always use gloves, gowns to protect skin and clothing.
         • Wear detection badge to determine exposure to energy source.