Chapter 11
Oncology: Nursing management in cancer care
241
explain the rationale for these precautions to keep the patient
from feeling unduly isolated.
Contacts with the healthcare team are guided by principles
of time, distance and shielding to minimise exposure of person-
nel to radiation because patients receiving internal radiation
emit radiation while the implant is in place. Safety precau-
tions used in caring for the patient receiving brachytherapy
include assigning the person to a private room, posting appro-
priate notices about radiation safety precautions, having staff
members wear dosimeter badges, making sure that pregnant
staff members are not assigned to the patient’s care, prohibit-
ing visits by children or pregnant women, limiting visits from
others to 30 minutes daily, and seeing that visitors maintain a
2-metre distance from the radiation source.
Patients with seed implants typically are able to return
home; radiation exposure to others is minimal. Information
about any precautions, if needed, is provided to the patient
and family members to ensure safety. Depending on the dose
and energy emitted by a systemic radionuclide, patients may or
may not require special precautions or hospitalisation (Bruner
et al., 2006). The nurse should explain the rationale for these
precautions to keep the patient from feeling unduly isolated.
Chemotherapy
In
chemotherapy
, antineoplastic agents are used in an attempt
to destroy tumour cells by interfering with cellular functions
and reproduction. Chemotherapy is used primarily to treat
systemic disease rather than lesions that are localised and
amenable to surgery or radiation. Chemotherapy may be
combined with surgery or radiation therapy, or both, to reduce
tumour size preoperatively, to destroy any remaining tumour
cells postoperatively, or to treat some forms of leukaemia. The
goals of chemotherapy (cure, control, palliation) must be real-
istic because they will define the medications to be used and
the aggressiveness of the treatment plan.
Cell kill and the cell cycle
Each time a tumour is exposed to a chemotherapeutic agent,
a percentage of tumour cells (20% to 99%, depending on
dosage) is destroyed. Repeated doses of chemotherapy are
necessary over a prolonged period to achieve regression of the
tumour. Eradication of 100% of the tumour is nearly impos-
sible, but a goal of treatment is to eradicate enough of the
tumour so that the remaining tumour cells can be destroyed by
the body’s immune system.
Actively proliferating cells within a tumour (growth fraction)
are the most sensitive to chemotherapeutic agents. Non-dividing
cells capable of future proliferation are the least sensitive to
antineoplastic medications and consequently are potentially
dangerous. The non-dividing cells must be destroyed, however,
to eradicate a cancer completely. Repeated cycles of chemother-
apy are used to kill more tumour cells by destroying these non-
dividing cells as they begin active cell division.
Reproduction of both healthy and malignant cells follows
the cell cycle pattern (Figure 11-1). The cell cycle time is the
time required for one tissue cell to divide and reproduce two
identical daughter cells. The cell cycle of any cell has four
distinct phases, each with a vital underlying function:
1. G
1
phase—RNA and protein synthesis occur.
2. S phase—DNA synthesis occurs.
3. G
2
phase—premitotic phase; DNA synthesis is complete,
mitotic spindle forms.
4. Mitosis—cell division occurs.
diarrhoea may occur if the stomach or colon is in the irradiated
field. Symptoms subside and gastrointestinal reepithelialisation
occurs after treatments are complete.
Bone marrow cells proliferate rapidly, and if bone-marrow
producing sites (e.g. sternum and iliac crest) are included in the
radiation field, anaemia, leucopenia (decreased white blood
cells [WBCs]) and
thrombocytopenia
(a decrease in platelets),
may result. Patients are then at increased risk for infection and
bleeding until blood cell counts return to normal. Chronic
anaemia may occur (Bruner et al., 2006).
Research to develop cytoprotective agents that can protect
normal tissue from radiation damage continues. The most
commonly used cytoprotectant is amifostine (Ethyol), which
is utilised in head and neck cancer patients to reduce acute
and chronic xerostomia while preserving anti-tumour efficacy
(Bruner et al., 2006; Hogle, 2007).
Certain systemic side effects are also commonly experienced
by patients receiving radiation therapy. These manifestations,
which are generalised, include fatigue, malaise and anorexia.
This syndrome may be secondary to substances released when
tumour cells break down. The effects are temporary and
subside with the cessation of treatment.
Late effects of radiation therapy may also occur in various
body tissues. These effects are chronic, usually produce fibrotic
changes secondary to a decreased vascular supply, and are
irreversible. These late effects can be most severe when they
involve vital organs such as the lungs, heart, central nervous
system and bladder. Toxicities may intensify when radiation is
combined with other treatment modalities.
Nursing management in radiation therapy
The patient receiving radiation therapy and the family often
have questions and concerns about its safety. To answer ques-
tions and allay fears about the effects of radiation on others, on
the tumour, and on the patient’s normal tissues and organs, the
nurse can explain the procedure for delivering radiation and
describe the equipment, the duration of the procedure (often
minutes only), the possible need for immobilising the patient
during the procedure, and the absence of new sensations,
including pain, during the procedure. If a radioactive implant
is used, the nurse informs the patient and family about the
restrictions placed on visitors and healthcare personnel and
other radiation precautions. Patients also need to understand
their own role before, during and after the procedure. See
Chapter 42 for further discussion of radiation treatment for
gynaecological cancers.
If systemic symptoms, such as weakness and fatigue, occur,
the nurse explains that these symptoms are a result of the treat-
ment and do not represent deterioration or progression of the
disease. The assessment and nursing management of fatigue is
discussed in more detail in the Plan of nursing care of patients
with cancer, Chart 11-4.
Protecting carers
When a patient has a radioactive implant in place, nurses and
other healthcare providers need to protect themselves as well
as the patient from the effects of radiation. Specific instruc-
tions are usually provided by the radiation safety officer from
the x-ray department. The instructions identify the maximum
time that can be spent safely in the patient’s room, the shield-
ing equipment to be used, and special precautions and actions
to be taken if the implant is dislodged. The nurse should
