Oncology Nursing: Radiation and Chemotherapy Management
Radiation Therapy Classifications
Radiation is a primary treatment modality for oncology patients.
External radiation, also known as teletherapy, is the most frequently utilized form of radiation therapy.
Internal radiation is termed brachytherapy. While less common than teletherapy, it is frequently employed in treating prostate, breast, and lung cancers.
Clinical Nursing Care for External Radiation (Teletherapy)
Skin assessment is a priority nursing intervention, as the treatment site often presents with redness and pruritus (itching).
Patients must be instructed to avoid scratching or rubbing the irradiated area.
On the day of a scheduled treatment session, such as those at Dana Farber, specific topical restrictions apply to the skin site:
No petroleum-based jellies or ointments are permitted.
No lotions or creams should be applied to the site.
These substances can potentially cause skin burns when exposed to radiation.
All patches must be removed from the treatment area before radiation, including nicotine and lidocaine patches.
Nicotine patches may be reapplied in the evening but cannot be worn during the morning radiation session.
Hygiene for the radiation site should involve only lukewarm water. Nurses should test the water temperature on the back of their hand before use to ensure it is not too hot.
Restricted items for the radiation site include soaps, cotton, perfumes, powders, and hot or cold packs, as the skin becomes extremely fragile and sensitive.
Patients should avoid sun exposure to the treatment area and should not apply sunscreen unless specifically approved by an oncologist.
Nails should be filed rather than cut to prevent skin injury. If shaving is necessary in the treatment area, an electric shaver must be used rather than a manual razor.
Post-radiation skin care must be strictly governed by the oncologist. General practitioners or other physicians should not order topical treatments for the site.
If approved by an oncologist, Aquaphor or $A \text{ and } D$ ointment may be applied at night, but never in the morning before a session.
Wet reactions, characterized by blister formation, require the application of protective dressings such as Mepilex border dressings. These dressings prevent the blister from bursting and becoming an infected wound.
Head and Neck Radiation Management
Radiation directed at the head and neck requires frequent assessment of the oral mucosa for the development of mouth sores, which can impair nutritional intake.
Miracle mouthwash may be prescribed for these patients. This specialized mixture typically contains:
Lidocaine (to numb the area).
Nystatin (an antifungal).
Acyclovir (an antiviral).
Patients should use this mouthwash as an oral rinse before meals to facilitate eating.
Clinical Nursing Care for Internal Radiation (Brachytherapy)
Patient Environment:
Brachytherapy patients require a private room.
A lead-lined container and long-handled forceps must be kept in the room at all times to handle dislodged implants.
Radiation Safety Protocols:
Nurses must wear a dosimeter (or "Darcy meter") badge to monitor their cumulative radiation exposure.
Staffing assignments must exclude pregnant personnel, including nurses and PCAs, to protect the fetus from exposure.
Visitors must be at least years of age. Children are strictly prohibited.
A safe social distance of at least feet must be maintained from the radiation source (the patient).
Visitor time is limited to a maximum of minutes per day.
Nursing Workflow:
Care must be delivered using bundle care or cluster care techniques. This involves coordinating all tasks (medications, dressing changes, assessments) to be performed simultaneously to minimize the frequency of entering the room and the duration of exposure.
Patient Activity and Position:
Patients are typically on bed rest with limited movement.
Positioning should involve log rolling. Turning frequency may be reduced (e.g., every hours instead of every hours) to prevent the dislodgement of the implant.
Handling Dislodged Implants:
Radiation implants often resemble the lead point of a pencil.
If an implant is found in the bed or on the floor, it must never be touched with the hands.
Forceps must be used to pick up the implant and place it in the lead-lined container. The physician must be notified immediately.
Linens and Waste:
Linens must remain in the patient’s room until the radiation precautions are discontinued or the implants are removed.
Only personnel certified in handling radioactive waste are permitted to remove these materials.
Radiation Precautions for Body Fluids:
Body fluids, including urine and emesis (vomit), are considered radioactive.
Toilets should be flushed twice after use.
Chemotherapy Administration and Safety
Chemotherapy occurs in both inpatient and outpatient settings.
Medication safety requires a two-nurse verification process for all chemotherapy drugs.
Vascular Access:
Intravenous chemotherapy carries a high risk of extravasation, which involves the leakage of the medication into the surrounding tissue, causing severe skin breakdown.
Most oncology patients require a Porta-Cath (implanted port) for long-term access.
Alternatively, a Peripherally Inserted Central Catheter (PICC line) with double or triple lumens may be used.
General Side Effect Management:
Nausea and vomiting are the most common side effects. Patients are often managed with a BRAT diet (Bananas, Rice, Applesauce, Toast). /* Ondansetron (Zofran) is routinely administered before, during, or after treatment.
Because Ondansetron can prolong the QTC interval, a baseline -lead EKG is required, particularly for patients with a cardiac history.
Pharmacotherapy in Oncology
Cyclophosphamide:
Nursing focus: Monitoring for hemorrhagic cystitis.
Assess for dysuria and hematuria (blood in the urine). Encourage high oral fluid intake.
5-Fluorouracil:
Nursing focus: Monitoring for hepatotoxicity and bone marrow depression.
Methotrexate:
Nursing focus: Management of severe anemia.
Leucovorin (leucobaramine) or folic acid must be administered to prevent systemic toxicity.
Bleomycin:
Nursing focus: Monitoring for pulmonary fibrosis.
Assess for dyspnea (shortness of breath) and respiratory distress.
Doxorubicin:
Nursing focus: Cardiomyopathy monitoring.
While it can be used during the second and third trimesters of pregnancy, it must be discontinued by weeks of gestation.
Tamoxifen:
Action: Decreases estrogen levels.
Side effects: Induces premenopausal symptoms, including hot flashes, mood changes, irritability, and vaginal spotting.
Risks: Increased risk for thromboembolic events, such as Stroke, Deep Vein Thrombosis (DVT), and Pulmonary Embolism (PE).
Efficacy marker: Bone pain is often an indicator that the medication is effective.
Vincristine:
Nursing focus: Monitoring for neurotoxicity.
Assess for peripheral nerve damage, including numbness and tingling in the extremities. Monitor the Color, Movement, and Sensation (CMS) of the extremities.
Epoetin Alfa (Epogen/Procrit):
Action: Stimulates the bone marrow to produce red blood cells.
Administration: Subcutaneous injection. Must be stored in the refrigerator.
Nursing check: Verify hemoglobin levels; do not administer if hemoglobin is greater than .
Filgrastim (Neupogen):
Action: Stimulates the production of neutrophils (White Blood Cells).
Administration: Subcutaneous injection. Must be stored in the refrigerator.
Nursing check: Monitor WBC and neutrophil counts. In outpatient settings, it is often administered on the Friday following a week of radiation treatment. Hold if the WBC count is within the normal range of to .
Management of Bone Marrow Suppression
Bone marrow depression results in decreased levels of White Blood Cells (WBC), Platelets, and Red Blood Cells (RBC).
Leukopenia and Neutropenia:
Neutropenic precautions are initiated when the Absolute Neutrophil Count (ANC) falls below .
Protective/Reverse Precautions:
No sick visitors allowed.
Staff must wear full PPE (mask, gown, gloves).
The patient must wear a mask when leaving the room.
Use dedicated patient equipment (stethoscope, blood pressure cuff).
Strict hand hygiene for all entering the room.
Dietary and Environmental Restrictions:
No fresh flowers, live plants, or fresh fruits and vegetables.
Canned goods are permitted because the canning process reduces bacteria.
Certain fruits may be allowed if they can be peeled , such as oranges, but they must be peeled outside the patient's room.
No deli meats, cold cuts, sushi, or undercooked (poached) eggs.
Bottled water is required; once opened, it is only safe for hour due to bacterial growth.
Thrombocytopenia:
Normal platelet range for a healthy individual is to .
In oncology, thrombocytopenia is defined as a platelet count less than . Increased bleeding risk occurs severely when the count is below .
RANDY Precautions for Bleeding:
R: Razor must be electric (no straight razors).
A: Aspirin is prohibited.
N: Needles should be minimized (use smallest gauge possible if required).
D: Do prevent injury (minimize fall risk).
Y: You must report any bleeding (gums, blood in stool).
Treatment may include platelet transfusions or Fresh Frozen Plasma (FFP).
Stomatitis and Mucositis Management
Definitions:
Stomatitis: Inflammation of the mouth.
Mucositis: Inflammation affecting the entire Gastrointestinal (GI) tract, including the pharynx.
Treatment:
Nystatin: Patients with stomatitis use a "swish and spit" method. Patients with mucositis use a "swish and swallow" method to treat the GI tract.
Avoid glycerin-based or alcohol-based mouthwashes. Use non-alcoholic alternatives like Biotene.
Avoid acidic foods and high-Vitamin C juices.
Apply Miracle Mouthwash minutes before meals.
Alopecia (Hair Loss)
Hair loss typically begins within to weeks of starting chemotherapy.
Regrowth usually occurs to months after the completion of chemotherapy.
The texture or color of the regrown hair may differ from the original hair (e.g., thicker or a different shade).
Patients receiving both systemic chemotherapy and targeted radiation to the head and neck may experience permanent baldness.