Patient Care Test 3: Recognizing Treatment and Disease Side Effects

what are some major factors influencing side effects?

-tissue to be treated

-radiation dose

-radiation energy

-treatment method

-fractionaction

-combined modality therapy (CMT)

what are the two types of side effects we discuss?

treatment side effects and disease side effects

what does CMT stand for?

combined modality therapy

what is the premise of CMT?

the effects of systemic chemotherapy will interact with the local effects of the XRT and sensitize cells to radiation cell killing

the premise of CMT is that the effects of ________ ____________ will interact with the local effects of the _________ _______ and sensitize cells to _________ cell killing

systemic chemotherapy, radiation therapy, radiation

what is chemotherapy before radiation therapy usually aimed at?

decreasing the size of the tumor so smaller treatment fields can be used

why do we want to decrease the size of the tumor by using chemo before XRT?

so that smaller treatment fields can be used

when used in combination with XRT, what are chemotherapy agents usually known or expected to do?

sensitive cancer cells, often normal cells too

what is chemotherapy after XRT often used to control?

subclinical disease

what is seen when chemotherapy and radiation therapy ar ecombined?

very significant moridity

in general, what does CMT do to all tissues?

makes them more sensitive to radiation therapy

when using CMT, when are treatment side effects seen as opposed to giving the modality alone?

earlier

what kind of side effects does CMT bring out than if the modality is used alone?

more severe

what is skin redness?

erythema

what can be caused from the initial response of the skin to radiation?

erythema

what is erythema believed to be from?

increased capillary blood flow and extracapillary cell injury

what is erythema dependent upon?

total dose, beam type, and beam energy

if a patient is going to have erythema, when does it begin and when will it last until?

begins after about the third week of treatment and lasts about two weeks after treatment ends

what does it mean to remove a layer of the skin?

desquamation

why is dry desquamation?

dry or flaky peeling of the epidermis

what do cracks and fissures in the skin suggest?

dry desquamation

what is wet desquamation characterized by?

brilliant erythema and loss of epidermis

at what dose might moist desquamation occur at?

when doses to skin exceed 3,000 cGy

what is a moist desquamation comparable to?

a second-degree burn both in appearance and sensation

what does it mean that moist desquamation involves sloughing of skin and weeping of exudates?

skin is peeling off and leaking pus or fluid

what will form crusts around edges of the lesion for wet desquamation?

clear, leukocyte exudate

when moist desquamation occurs, what is the skin at risk of? how is this managed?

infection, usually put on a "break" for several days up to a week

how long does moist desquamation take to heal?

within 3 months

what is a long term side effect of moist desquamation?

permanent hyperpigmentation of the skin

how can we minimize skin trauma?

by reducing friction to the skin

what works well to reduce skin trauma?

loose, soft, cotton

for general skin care, what should be avoided?

sun exposure and temperature extremes (no heating pads or ice bags)

for general skin care, what should be avoided in the treatment area?

talc/powder, ointments, and cosmetics

for general skin care, what may be used in the treatment area?

mild soap

no ________ or _______-based products should be used in the treatment area

perfumes, alcohol

if doctors prescribe lotions or ointment for general skin care, when should they be applied?

AFTER treatment

once the skin becomes dry or itchy, what may the physician advise?

a lotion/cream or a prescription ointment

what works best on damp skin?

lotions

what should patients report about desquamation immediately?

skin breaks or drainage

what kind of tape should be used for dressings?

paper tape

what might the site require if desquamation occurs?

daily cleaning with 1/2 strength peroxide and sterile water several times a day

what are some examples of things that might be used to clean sites?

eucerin, lubriderm, vaseline, dove, dial

what is cancer-related fatigue defined?

tiredness to exhaustion, not precipitated by activity or, if after activity, out of proportion to the level of exertion

what is tiredness to exhaustion, not precipitated by activity or, if after activity, out of proportion to the level of exertion?

cancer-related fatigue

what may cancer-related fatigue results from?

cancer itself or from cancer therapy

what is interesting about cancer-related fatigue?

may not be relieved with rest, but worsened

what can worsen cancer-related fatigue?

mood disturbances such as depression and anxiety

what might fatigue be an indication of?

anemia (low RBC), but may just be result of body activities to repair damages epithelial tissue

what is the most commonly reported systemic side effect?

fatigue

what percent of radiation therapy patients report fatigue?

75%

what are the most recommended and effective interventions for fatigue?

rest and sleep

what is proven to be more effective in relieving fatigue than taking a nap?

going to bed earlier

what causes shortening of the villi in the small bowel?

destruction or irritation of the epithelium

when the villi is shortened, what happens to the total epithelial surface of the small bowel? what happens after this?

it is reduced and there is a decrease in the amount of intestinal enzymes. after this, inflammation of the mucosa occurs

at what dose is it not uncommon for diarrhea to occur?

3,000-5,000 cGy

what does toxicity for diarrhea depend on?

dose, dose rate, location, and volume of bowel irradiated

for diarrhea, what are at higher risk of long term complications?

fixed pelvic small bowel loops

at what dose does diarrhea occur and when does serious long term injury occur at?

1,500-3,000 cGy; 5,000 cGy

what might diarrhea be accompanied by?

tenesmus and cramping

what is tenesmus?

painful straining with stool

what are possible side effects with diarrhea?

enteritis, ulceration, stricture, and fistula formation

to avoid diarrhea, the physician will attempt to keep dose to _____ as low as possible

bowel

what can be added by a surgeon to avoid diarrhea?

a surgical sling

what kind of diet is needed to avoid diarrhea?

low residue (low fiber)

what kind of diet should be used from the beginning of treatment anytime the GI track is to be irradiated?

bland diet

what constitutes moderate diarrhea?

less than 3 stools per day

what is often prescribed for moderate diarrhea?

lomotil and immodium

what constitutes severe diarrhea?

8 or more per day

what might severe diarrhea require?

a break

when does diarrhea begin to resolve?

after about 2 weeks after completion of treatment

what causes nausea and vomiting when the stomach and small bowel are treated?

signals in the viscera travel along vagii and sympathetic nerves to the emesis center in the medulla

nausea and vomiting may occur when what areas are treated?

stomach, chest, large areas of the body, small bowel, or brain

what is nausea and vomiting dependent upon?

dose, dose rate, treatment volume, and area treated

when can nausea and vomiting start and when might it last until?

1-2 hours after treatment and can last 4-6 hours

the _________ of nausea and vomiting may decrease over time, but may still persist. what can we do to avoid this?

intensity, dose escalate to avoid

what are some common antiemetics?

zofran, compazine, phenergan

what might antiemetic medication be used for?

prophylactic and routine use

when should the patient take antiemetics?

one hour before treatment

what is xerostomia?

mouth dryness

when does mouth dryness occur?

when salivary glands are affected by radiation

how radiosensitive are salivary glands?

highly radiosensitive

what are the major salivary glands?

parotid, submandibular, and sublingual

together, how much saliva do the salivary glands produce daily?

1 Liter

when radiated, what happens to saliva production results in dry mouth?

it drops significantly

what is saliva important for?

lubrication of food, chemical digestion, denture stability and retention, and taste

what does dry mouth increase the risk of?

dental caries, peridontal disease, and other serious side effects

what kind of treatment is xerostomia a side effect of?

head and neck treatment

when does xerostomia begin and how long does it last?

begins within a couple weeks of treatment and may continue for 6 months after treatment or never end

from beginning to end of treatment, what changes happen to the saliva?

its quality and quantity is progressively changing to a thick, ropy, acidic substance

what do patients call xerostomia?

"cotton mouth"

when do patients say xerostomia is worse?

worse at night and in the morning

what drug protects salivary function?

Amifostine

what can the patient suck on the help with xerostomia?

sugar-free hard candy, gum, or crushed ice

what helps stimulate salivary secretions that patients with xerostomia could try?

lemon-flavored water

what does drinking water do for xerostomia?

helps to wet the mouth, but does replace saliva

______ __________ may help xerostomia, but last only a few minutes

saliva substitute

what should patients with xerostomia avoid?

grapefruit and pineapple juices

why should a patient with xerostomia avoid grapefruit and pineapple juices?

they contain enzymes that break down oral mucosa

what forms do saliva substitutes come in to obtain temporary relief?

gel, spray, and liquid form

why might sugar-free gum not be the best option to help xerostomia?

causes increased gas