Patient Care in Rad Onc: Exam 3

Childhood cancer makes up less than what percent of all cancers diagnosed each year?

1%

More than what percent of children with cancer now survive 5 years or more?

80%

**Approximately what percent of all new pediatric oncology patients diagnosed this year will require upfront radiation therapy.

25%

Proton therapy

A type of radiation treatment that uses protons from a Hydrogen atom rather than x-rays to treat cancer

True or False: Protons can be directed to reach only the areas of the body affected by cancer, minimizing damage to surrounding healthy tissue.

True

Proton Benefits

- Precisely target tumors

- Limiting radiation exposure to healthy tissues decreases acute and late toxicity

True or False: Side effect toxicity is indirectly related to the amount of radiation therapy tissues receive.

False; directly

True or False: Radiation side effects are never related to the location of the radiation.

False; always

Medulloblastoma

- **Most common malignant pediatric brain tumor

- Occurs near the base of the skull and can spread to the spine or to other parts of the body.

- Prone to leptomeningeal spread ot drop metastasis

What can cranial radiation cause damage to?

Hypothalamus

Leukoencephalopathy

This is damage to the cells that surround and support neurons called glial cells

Hormonal Changes

Damage to the part of the brain producing growth hormone (the pituitary gland) can affect a child's height. Other hormones produced by the pituitary and hypothalamus can also be affected by radiation, depending on radiation doses to these structures. Radiation for spinal cord tumors can also cause growth deficits due to direct affects on bone growth

The brain producing growth hormone

pituiatry gland

Memory loss

Effect on learning and memory depends on radiation dose, volume, and age of the child. Younger patients (less than 7 years of age) have a higher rate of neurocognitive deficits. Eventually, brain cell damage can lead to learning problems

What is anesthesia used for in pediatric patients?

replication purposes for accurate delivery of RT

How long are kids NPO before an anesthesia procedure?

8 hours

What are kids monitored with during treatment?

camera, pulse oximetry, cardiac monitoring, and intercom

Sedation medications

- Propofol (Diprivan)

- Midazolam (Versed)

(Valium)

Does propofol or Midazolam have a faster recovery and is more common?

Propofol

Antiemetics

Ondansetron (Zofran)

Side Effects from Anesthesia

Nausea

Vomiting

Drowsiness

Dizziness

Sore throat

Shivering

Aches and pains

Discomfort during injection of drugs

Agitation upon awakening from anesthesia

How long before the procedure do they need to turn off NG feeds?

6 hours

How long before the procedure do they need to stop clear liquids?

2 hours

Total Body Irradiation (TBI) Purpose

myeloablation, immunosuppression, eradication of malignant cells

TBI Procedure

measurements taken of the patient's size in specific areas; compensator

Total Body Irradiation (TBI)

BID treatment usually for 3 days

Lateral, semi-reclined position; they keep pajamas on and can listen to favorite music

Possible side effects with TBI

Hair loss.

Discomfort in the throat and mouth.

Change in taste.

Mouth sores.

Nausea and vomiting.

Diarrhea.

Bone marrow suppression (low blood counts).

Sterility is an expected side effect.

About half of the patients will need thyroid supplements.

Inflammation of the sac that surrounds the heart.

Inflammation of the lungs.

Cataracts.

Second malignancies or new cancers.

Endogenous

infection caused by one's own bacterial flora or micro-organisms (candidiasis, staph aureus)

Exogenous

infections that result from transmission of organisms from another source (bloodborne from needlestick)

Direct

• Direct (wound care on patient) • Droplet (large, patient sneeze/cough on you)

Indirect

- Airborne - Vehicle Borne - Vector Borne

Airborne

aerosols released into air when infected person sneezes/coughs

Vehicle Borne

fomite: clothes, utensils

Vector borne

living organism that transmits pathogen (ex: tick with lyme disease)

Nosocomial Infections/Healthcare-Associated Infections (HAI's)

Acquired infection by both patients and healthcare workers

how many hospital patients have at least one healthcare-associated infection

1 in 25

the mode of transmission for organisms causing most preventable HAI

Health care worker hands

reduces the risk of HAI infections:

Hand Hygiene compliance disrupts transmission

When hands are not visibly soiled:

cleaning hands with either waterless hand rub or soap and water

When visible soil is present

hands MUST be cleaned with soap and water

Perform hand hygeine:

- Before patient care - Before clean/aseptic procedure - After body fluid exposure risk - After patient care - After contact with patient surroundings

What does PPE prevent?

contact with an infectious agent or body fluid that may contain an infectious agent, by creating a barrier between the potential infectious material and the healthcare worker

PPE includes:

gloves, gowns, shoe covers, head covers, masks, respirators, eye protection, face shields, and goggles

Standard Precautions

Basic infection control practices to prevent disease transmission: hand hygiene, respiratory etiquette, sharps safety, disposal, etc

Transmission-based Precautions

• Airborne • Contact • Droplet

Additional precautions

Protective Environment (reverse isolation)

What patients do you use standard precautions on?

All

Airborne Precautions

Used to prevent transmission of infections transmitted by the airborne route (Tuberculosis (TB), measles (rubeola))

Airborne Infection Isolation Room (AIIR)

• AKA negative pressure room • Private, specially vented room has a lower pressure in relationship to adjacent areas which keeps air from flowing out of the room

Employees - Fit-tested Respirator Mask

must be applied when entering pt room

Contact Precautions

• Transmission is by contact (direct or indirect), either with patient or patient's contaminated environment • Methicillin-resistant Staphylococcus aureus- MRSA • Vancomycin-resistant Entrococci- VRE • Multi-drug resistant gram negative bacilli

Caring for a patient on Contact Precautions

• Gown and gloves required before entering patient room. Apply gloves before entering room/before contact. • Avoid use of public areas and contact with other patients • Patients should be instructed on appropriate hand hygiene.

Droplet Precautions

• Transmission occurs when large droplets contact the conjunctivae of the eye or mucous membranes of the nose or mouth. • Sneezing, coughing, talking from infectious person • contact with respiratory secretions (or articles freshly soiled with respiratory secretions).

Caring for a patient on Droplet Precautions

• Promptly room patient. • Patient must wear mask and wash or sanitize hands before leaving room • Staff must wear mask, eye protection, and gloves. Gowns are to be used for patients under 5 years old

Protective Environment (neutropenic precautions)

• Patients with severely compromised immune system (Neutropenia; Post stem cell/bone marrow transplant) • Precautions initiated when the absolute neutrophil count (ANC) is

Caring for a Patient on Protective Environment

• Use standard precautions • Practice good Hand Hygiene • The door of the patient's room should remain closed. • Patient's wear mask when out of room • Staff must wear mask in room if patient is not

Linens

• Contain soiled linens with minimal handling and agitation • Handle wet linen with gloves and place in plastic bag before placing in soiled linen hamper/bag • Do not drag soiled linen or linen bag on floor when transporting

Needle/Sharps Safety

• Keep the exposed sharp in view • Be aware of people around you • Stop if you feel rushed or distracted • Focus on your task • Avoid hand-passing sharps and use verbal alerts when moving sharps • Watch for sharps in linen, beds, on the floor, or in waste containers • Activate safety features after use • Dispose in rigid sharps containers and DO NOT OVERFILL • Keep fingers away from opening of sharps containers

Pathogens

any organism or agent that can cause disease

Types of Pathogens

- Endogenous - Exogenous

What is Stomatitis/Mucositis?

Inflammation of the mucous membranes.

What is the first sign og stomatitis/mucositis?

Inflammation - redness

More severe symptoms of stomatitis/mucositis:

- ulcerations - bleeding

Mucositis: What are the symptoms?

1. Inflammation - red

2. Dryness

3. Tenderness/increased sensitivity

4. Burning sensation

5. Pain

6. Ulcerations

7. Bleeding * can affect swallowing

Mucositis

inflammation of mucosa of GI
Onset of symptoms 2 - 3 weeks after start of treatment

Mucositis: Resolution of symptoms

4 to 6 weeks after completion of treatment

Mucositis: How is it managed?

1. oral hygiene 2. denture wearers 3. adequate liquid and nutrition intake 4. Avoid trauma 5. Baking soda oral rinse 6. Topical anesthetics may be used to relieve oral pain 7. Analgesics or topical anesthetics may be prescribed. 8. Patient should wear fluoride mouthguard when treated if used in planning simulation.

Xerostomia: What is it?

dry mouth due to salivary gland dysfunction

Salivary glands are radiosensitive

◦ Parotid glands ◦ Submandibular glands ◦ Sublingual glands ◦ Minor salivary glands ◦ Von Ebner's glands

Xerostomia: Why is it a problem?

1. Increased risk of infections and caries. 2. The function of Saliva: (Lubricates; Helps with starch break down; Bacteriostatic; Slightly acidic; Keeps microbial flora in balance)

Xerostomia

Dry mouth
Onset can occur as early as 10 to 20 Gy (first few weeks of treatment)

With what dose may xerostomia be permanent?

if 40 Gy or more is received

Xerostomia: Resultant symptoms?

1. Thick, viscous saliva 2. Diminished salivary function 3. Burning sensation 4. Taste alterations 5. Difficulty mobilizing food in mouth/swallowing (symptoms vary)

Xerostomia: How is it managed?

1. 6 to 8 glasses of water a day 2. Humidifier or vaporizer at bedside 3. Dietary measures: (Avoid thick or dry foods; Liquids with meals; Add sauces and gravies; Avoid highly sugared candies and drinks) 4. Rinse mouth frequently throughout the day with an alcohol free mouth rinse or with a homemade mouth rinse of baking soda and warm water. 5. Other measures: (Pilocarpine hydrochloride (Salagen); Acupuncture; Biotene) 6. Artificial saliva

Oral candidiasis

It is a fungal infection that occurs when there is overgrowth of a yeast called Candida, Imbalance in the oral environment

Oral candidiasis: How is it treated?

Oral anti-fungal medications - Nystatin (swish and swallow) - Diflucan (pill, liquid or IV)

What is the concern when giving a patient Diflucan?

interactions with other medications

How many taste buds are on the tongue

soft palate, behind tonsil, & posterior pharynx?, 10,000

Life span of taste:

5-7 days

How many primary taste sensations are there?

4

What affects taste?

dry mouth

Incidence of taste changes

▪ Dose dependent. (May occur at 10 Gy).

▪ Loss of taste may be permanent.

▪ May take 3 months to one year to return.

▪ Taste may be permanently blunted.

ageusia

complete loss of taste

hypoguesia

partial loss or decreased taste

paraguesia

unpleasant taste

dysguesia

inaccurate taste (distorted)

Taste: How to manage changes?

1. Avoid foods that taste bad.

2. Identify foods that have (strong) taste.

3. Use plastic utensils.

4. Serve food hot or warm.

5. Rinse mouth before meals.

6. Eat regardless.

Skin changes: What occurs with RT?

1. Erythema 2. Swelling 3. Dermatitis/rash 4. Dry desquamation 5. Moist desquamation

Onset of skin changes

2 to 3 weeks into radiation therapy

Resolution of skin changes

Noticeable improvement can be seen in 2 weeks following treatment

Skin changes: How to manage them?

1. Skin moisturizers 2. Steroid cream for rash 3. Domeboro's solution 4. Xeroform dressing 5. Silvadene cream 6. Vinegar soaks

Mucositis is the inflammation of mucous membranes: What is the first sign of mucositis? A. Ulceration B. Dryness C. Erythema - redness D. Bleeding

C

When is mucositis likely to begin for head and neck cancer patients? A. After the first radiation treatment. B. After the 2nd or 3rd week of radiation treatment. C. At the end of treatment. D. It can occur at any point during radiotherapy.

B

When is mucositis from head & neck radiotherapy likely to resolve?

A. It tends to resolve within 4 to 6 weeks after radiotherapy.

B. It will not resolve for 2 to 3 months after radiotherapy.

C. It resolves within 2 to 3weeks after radiotherapy.

A

Xerostomia is dry mouth due to salivary gland dysfunction. What role does saliva play in oral health?

A. Helps with starch breakdown

B. Bacteriostatic

C. Lubricates

D. Keeps microbial flora in balance

E. All of the above

E

When is Xerostomia likely to occur?

A. It doesn't occur if you brush your teeth and use oral moisturizers.

B. It is expected to occur at 40 Gy or higher.

C. It can occur at doses of 10 to 20 Gy.

C

Radiotherapy and chemotherapy can affect patients sense of taste. What is the distortion of taste? A. Ageusia B. Hypogeusia C. Parageusia D. Dysgeusia

D

What skin changes occur with head & neck radiotherapy?

1. Erythema

2. Swelling

3. Dermatitis/rash

4. Dry desquamation

5. Moist desquamation

6. All choices 1- 5, 7.

All choices 1-5, 7

The onset of skin changes from head & neck radiotherapy occurs at ~2 to 3 weeks into radiation therapy. True or False

True

Side effects: Long-term?

1. Lymphedema 2. Trismus 3. Dental caries 4. Osteoradionecrosis 5. Tissue fibrosis 6. Electro-larynx devices