MODULE III: GENERAL SYMPTOM MANAGEMENT
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| GENERAL SYMPTOM MANAGEMENT |
How Radiation affects the body?
💦 Radiation can damage the DNA in our cells.
💦 High doses of radiation can cause Acute Radiation
💦 Syndrome (ARS) or Cutaneous Radiation Injuries (CRI).
💦 High doses of radiation could also lead to cancer later in life.
Symptom management during radiation therapy is critical to providing high-quality care for patients receiving treatment. Symptoms are varied and dependent on the site irradiated.
Treatment strategies include prevention, anticipation, and development of clinical practice enabling rapid identification and management of emerging symptoms. Understanding the spectrum of symptomatology affecting irradiated patients is integral to improved quality of life and treatment efficacy.
FATIGUE
Patients characterize fatigue as a feeling of overwhelming exhaustion and lack of energy and enthusiasm. Problems with this symptom are experienced from many months to years following the completion of the treatment.
It is a multidimensional symptom complex with subjective and objective components. Systemic manifestation of cancer causes excess demand on body resources on cell repair, uncontrolled growth with metabolite accumulation causing fatigue.
DEFINITION
National Comprehensive Cancer Network defines cancer-related fatigue as a ‘distressing persistent subjective sense of tiredness or exhaustion related to cancer or cancer treatment that is not proportional to recent activity and interferes with usual functioning.’
The definition according to the Oncologic Nursing Society is more descriptive.
“Fatigue is a feeling of debilitating tiredness or total lack of energy that can last for days, weeks or months; commonly caused by anaemia, fatigue is the side effect of chemotherapy that affects patients the most –more than nausea, pain or depression; symptoms include feeling weak or worn out, having difficulties in climbing stairs, walking short distances and performing simple daily tasks; proper nutrition, light exercise, short naps and medications may help alleviate the fatigue.
PATHOPHYSIOLOGY
The underlying etiology of fatigue in patients receiving RT is multifactorial; several theories have been proposed:
💦 Serotonin dysregulation
💦 Hypothalamic-pituitary-adrenal Axis (HPA) dysfunction
💦Circadian rhythm disruption
💦Muscle metabolism/ adenosine triphosphate dysregulation
💦Vagal afferent nerve activation
💦Cytokine dysregulation
RISK FACTORS
💦 Anaemia
💦 Nutritional disturbances
💦 Emotional distress
💦 Sleep disorders
💦 Nutritional deficits
💦 Comorbidities include diabetes, HTN, heart disease, arthritis, hypothyroidism, malnutrition and emotional distress.
ASSESSMENT
💦 Screening: Screen the patient for the presence or absence of fatigue using questions.
💦 Comprehensive evaluation:
💧 Focused history
💧 Review of systems
💧 In-depth fatigue history
💧 Assessment of treatable contributing factors
💦 Observe for:
💧 Pallor
💧 Blood loss
💧 Laboured breathing
💧 Poor capillary refill
💧 Poor posture
💧 Cachexia
💧 Altered mobility, gait
💧 Peripheral oedema
💧 Cognitive impairment
💧 Chest pain
Fatigue Grading Scale:
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| CTCAE (Common Terminology Criteria for Adverse Events) |
MANAGEMENT
⭐ Complete focus assessment
⭐ Exercise recommendations need to be individualized based on:
▶ Impairments (such as bone metastases, thrombocytopenia, anaemia, fever or active infection)
▶The patient’s treatment phase (pre-treatment, active treatment or post-treatment)
⭐ Progression of activity levels should be done purposefully using the principle of frequency, intensity, time and type (FITT). This can result in more physical energy, improved appetite and increased ability to perform ADLs.
⭐ Consider the initial plan discussed with the healthcare team and any relevant referrals to physiotherapy, occupational therapy or community-based programs
⭐ Energy conservation by pacing, planning, Priority setting, Posture, Proficiency.
⭐ Sleep hygiene
⭐ Psychological and wellness support
⭐ Encourage adequate nutrition and hydration
⭐ Patient education and follow-up
Fatigue is often treated by relieving related conditions:
PATIENT EDUCATION & HEALTH PROMOTION
SKIN REACTIONS
Radiotherapy is a primary cancer treatment along with surgery and chemotherapy. Radiotherapy causes biochemical changes within cells, as the DNA molecules are susceptible to radiation damage during mitosis. Radiobiological damage affects the regeneration of the skin by the process of repair, redistribution, repopulation and reoxygenation. Damaged cells are replaced by cells moving from the resting phase (G0) into the active cycle (Repopulation). Skin damage occurs when the rate or repopulation of the basal cell layer (Stratinium Germinativum) cannot match the rate of cell destruction by treatment.
For radical and adjuvant doses of radiotherapy, the skin reaction develops approximately 10-14 days following the first fraction of radiotherapy, corresponding with the time it takes for the damaged basal cells to migrate to the skin surface.
For elderly patients, this can be much later. Initially the skin will become warm, itchy and inflamed (erythema). As the skin reaction develops through further exposure to radiation, it tries to compensate by increasing mitotic activity in order to replace the damaged cells. If the new cells reproduce faster than the old cells are shed then the skin will become dry and flaky (dry desquamation).
As radiotherapy continues, the basal layer cannot produce enough new cells to replace the old ones and therefore the outer layer of the epidermis will become broken and oedematous with exudate (moist desquamation). This exudate is an expected part of the radiotherapy reaction and is rich in nutrients, which help the growth of new skin cells as part of the healing process.
Skin necrosis is rarely seen, primarily due to the advanced techniques used in the planning and delivery of radiotherapy.
The severity of skin reactions may increase for an average of seven to ten days after the course of radiotherapy has finished. Sometimes the reaction may take up to a month to appear. It can take this amount of time for the cells that have been affected by radiotherapy to reach the outer epidermis. Four to six weeks after treatment is completed, the skin should be healing well and may even be fully healed. The area may still look darker (hyperpigmented) as the basal cells of the epidermis recover and the new skin starts to grow and heal
Extrinsic and intrinsic factors may significantly increase the severity of radiotherapy skin reactions and can delay the healing process
Factors affecting the severity of radiotherapy skin reactions.
Intrinsic factors affecting the radiotherapy skin reaction
✨ Age: The natural ageing process affects the epidermal cell cycle, which can result in delayed onset of the reaction and extended healing times.
✨Nutrition: Adequate nutritional intake is necessary for optimum repair of tissue damage. The skin of undernourished patients may be at increased risk of damage
✨Smoking and Alcohol: Can decrease capillary blood flow and oxygen levels thus increasing the severity of the skin reaction and impairing the body’s ability to heal damaged tissues and fight infection.
✨Co-morbidities: Other illnesses and some medications can increase the risk and intensity of skin reactions and impact upon the healing process. Eg diabetes or steroids.
✨UV exposure: There is a suggestion that patients with long-term UV exposure will experience a more severe radiotherapy-induced skin reaction and impaired healing. Patients from Black or Minority Ethnic (BME) groups have reported more severe post-treatment skin reactions compared to those of white ethnic origin.
✨Obesity: Extra adipose tissue can affect healing and exacerbate skin toxicity due to the extra skin folds or areas where there is a natural skin fold e.g. natal cleft and inframammary fold.
✨Infection: The presence of bacterial and/or fungal infection can damage the cells in the basal layer resulting in delayed healing.
✨Irritants: Irritants can exacerbate the skin reaction and may delay the healing process.
Examples include: Chemical - cosmetics and toiletries with metallic ingredients e.g. perfume, talcum powder, aftershave, self-tan, gradual tanning creams
Thermal - extremes in temperature e.g. hot water bottles, ice packs.
Mechanical - friction by rubbing the skin or wearing tight-fitting clothing ie: bras (underwired).
Extrinsic factors affecting the radiotherapy skin reaction
Radiotherapy
👉 Dose
👉 Volume
👉 Bolus
👉 Modality
👉 Energy
👉 Delivery techniques
Higher doses, increased volume, electron therapy and the presence of bolus can all lead to an increase in the severity of the skin reaction.
The higher the energy of the x-ray beam, the lesser the skin reaction. Megavoltage x-ray therapy delivers the maximum dose below the skin surface. Electron therapy, used to treat skin cancers, delivers the maximum dose to the skin surface.
VMAT delivery techniques will reduce the severity of the skin reaction.
Radiosensitizers:
Some chemotherapy agents are radiosensitisers (e.g. 5-Fluorouracil, Mitomycin C, Cisplatin,) and can increase the severity of skin reaction.
Cetuximab can cause an acne-like rash on the face, neck and body. If this occurs within the treatment field, seek specialist advice.
Assessment
Management
Patient and Family Education
✨Gently wash the skin with tepid water, using a soft washcloth.
✨ Wear loose-fitting, natural-fiber clothing
✨ Avoid perfumed skin products and powders
✨ Use only recommended skin care products
✨ Avoid scratching the skin
✨ Use an electric razor instead of wet shaving
✨ Protect skin from wind, sun, and extreme temperatures
✨ Avoid putting anything hot or cold such as heating pads or ice packs directly on the treated skin
✨Being in a hot tub, swimming pool, or lake should be avoided
✨Avoid any adhesive tape or bandage within the treatment fields
✨ Try using gentle detergents
PAIN AFTER RADIATION THERAPY
Radiation therapy can cause massive scarring or adhesions deep in the body. Manual physio/physical therapy decreased pain and increased function in various areas of the body where tissues were previously diagnosed as “beyond repair.”
Causes and Frequency of Pain After Radiation Therapy
Frequently prescribed to treat cancer, radiation therapy can cause adhesions (internal scars) to form in the body. These adhesions can cause moderate to severe pain or dysfunction. Radiation therapy adhesions act like a very strong glue, adhering the irradiated tissues to nearby organs, muscles, bones and connective tissues.
Where adhesions occur, organs and muscles can become bound together, losing their ability to function normally. Pain or other symptoms are frequent results. Symptoms may appear far from the site of the original trauma as adhesions spread to neighbouring organs.
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| At a microscopic level, tiny cross-links, the building blocks of adhesions, form at the sites where the body needs to heal from the damage done by radiation therapy. These adhesions attach irradiated tissues with a tensile strength approaching 2,000 pounds per square inch (140 kilograms per square centimetre). |
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| In this broader view, cross-links join collagen fibers to create curtains or ropes of adhesions that bind large structures together – often causing significant problems. Doctors and patients may have difficulty diagnosing the problem because adhesions do not generally appear on diagnostic tests – MRI, CT or X-rays. |
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| Stepping back in magnification, cross-links bind the cells of individual muscles or organs to each other, creating pain or immobility within those structures. |
Treatments
Clear Passage Treatment
DISTRESS/COPING
Patients with cancer may experience one or more symptoms and distress associated with the symptoms. Symptoms are multiplicative in nature and may act as catalysts for the occurrence of other symptoms. Consequences include effects on mood state, psychological status, functional status, quality of life, disease progression, and survival.
The patients undergoing RT experienced common distress–similar to patients without RT. Some studies indicated great variability in reported results, but the global trends in psychological responses to RT prevailed.
The most common reactions reported by patients before starting a course of RT were feelings of anxiety rather
than depressive symptoms.
During the course of treatment, most studies indicated a decline in feelings of anxiety. An increase in depressive symptoms and negative mood was found during and after RT. It was also emphasized that the field lacks a systematic
overview of the empirical data regarding psychological functioning prior to, during and after RT.
Emotional distress is a negative emotional state of mind, most frequently expressed as anxiety or depression.
Coping is the constantly changing cognitive and behavioural efforts to manage specific external or internal demands that are appraised as taxing or exceeding the resources of the person.
Outcomes of distress
✨Before and within two weeks of RT, significant associations were found between emotional distress, depression, fatigue and diagnosis, physical distress, functional disability and quality of sleep.
✨Suicidal thoughts can be part of the stress
✨Depression has been strongly linked to mortality and possibly related to cancer progression.
Risk Factors of emotional stress
Sociodemographic variables
✨Sex: Women treated with RT report higher levels of emotional distress than men.
✨ Social status: Marriage and social sup port may protect against distress during RT.
✨ Age: Results are mixed regarding age as a risk factor. Some studies have found younger age to be a risk factor for distress, particularly among patients with breast cancer.
✨ Education: Most studies have found lower educational levels to be associated with emotional stress.
Stress management strategies
✨ Exercise regularly
✨ Spend time outside
✨ Schedule social activities
✨ Eat well
✨ Get plenty of sleep
✨ Join a support group
✨ Schedule daily relaxing time
Relaxation techniques
✨ Relaxed or deep breathing
✨ Mental imagery or visualization
✨ Progressive muscle relaxation
✨ Meditation
✨ Yoga
SEXUAL DYSFUNCTION
The effect of radiation therapy on sexual function can be different for everyone and will depend on the area being treated.
Patients can continue sexual activity without causing harm to their partners. However, it is important to use contraception to avoid pregnancy during treatment.
Radiation therapy to the prostate can affect the nerves that control erections and this may affect the ability to maintain an erection or may feel a burning sensation during ejaculation. The desire to have a sexual relationship may also decrease during treatment.
Fertility
Whether fertility is impacted by radiation therapy depends on the area that is receiving treatment. If the woman has radiation therapy to the abdomen or pelvis, the amount of radiation absorbed by the ovaries will determine the potential impact on her fertility. Radiation to the pituitary gland may also affect fertility, as this gland normally signals the ovaries to ovulate.
Radiation to both testes in men is rare, however, this will affect fertility. If the radiation fields include the pelvis, there may be scattered radiation doses to the testes that can affect fertility and this can be temporary or permanent depending on the radiation doses received.
Scar tissue from radiation therapy can cause many sexual side effects. Other problems, such as fatigue, pain, anxiety or depression, can also affect the interest in having sex. Some sexual and fertility changes also may experience include:
In Women:
✨ Pain during sex
✨ Vaginal stenosis (narrowing)
✨ Infertility
✨ Vaginal itching and dryness
✨ Symptoms of menopause
In Men
✨ Impotence (inability to keep an erection)
✨ Inability to get a woman pregnant due to fewer or less effective sperm
Contributing Factors
Body Image Disturbance- Related to weight changes, hair loss, surgical scarring, changes in elimination patterns (e.g. ostomies, catheters)
Partner Concerns- Emotional distress, fears about hurting the patient. Role shifting/confusion-intimacy can be difficult when the partner has various roles- caregiver, partner, or lover.
Management
✨ Communication
💫 The nurse’s role in intimacy/sexuality support is focused on communication:
🌸Raising the topic
🌸Assessing patients and if appropriate, their partner concerns
🌸Encouraging open communication where patients and their partners can communicate honest feelings, concerns, fears, and preferences
🌸Validating their concerns and sharing with other healthcare professionals as appropriate
💫Think broadly about intimacy and sexuality and the meaning for the patient and their partner (e.g. desire for closeness, affection, reproduction)
✨ Capacity for Sexual Activity or Desire
🌸 A person’s capacity and desire for sexual activity is very personal and individualized
🌸Explore goals and help the patient and their partner achieve their desires/mutual pleasure to the best of their ability.
🌸Patients and their partners may need assistance in accepting changes in patterns of desire and ability to engage in sexual activities. Do not minimize or overestimate these concerns.
✨ Patient Education: Birth Control and Fluid Protection
🌸Discuss the common sexual side effects of cancer treatments
🌸Prevent pregnancy while receiving chemotherapy or radiation treatment
🌸Speak with a healthcare provider to determine the best option for birth control
🌸Use a barrier (e.g. condoms, dental dam) and consider regular use of barriers to protect against sexually transmitted diseases/infections
✨ Reproduction
🌸Discuss sperm banking and freezing embryos as necessary prior to cancer-treatment delivery
🌸Referral to a fertility preservation specialist
NUTRITIONAL ISSUES
Many cancer patients lose weight unexpectedly during radiation therapy because they struggle with side effects caused by treatment. Maintaining proper nutrition during radiation therapy can increase the chances of successful treatment and improve the quality of life during and after treatment.
Pathophysiology
Side Effects Affecting Appetite, Digestion or Ability to Eat
💦 nausea & vomiting
💦 diarrhoea
💦 lack of taste
💦 gas & bloating
💦 sores in the mouth or throat
💦 dry mouth
💦 difficult to swallow
💦 painful jaw
Protein during Radiation therapy
Getting the right amount of protein is very important during radiation treatment. Each meal or snack should have some source of protein. This will help spare lean muscle mass while repairing damage from radiation.
Some good protein-rich foods to try are:
💫 eggs
💫 nuts/nut butter
💫 seeds
💫 soy/tofu
💫 dairy products
💫 meats
💫 poultry
💫 fish
Hydration during Radiation therapy
Staying hydrated makes side effects less severe and lowers the chances of missing or delaying cancer treatments. It’s important to avoid dehydration during treatment to protect the organs from long-term damage. The goal is for patients to drink enough liquids to allow for normal body functions.
All non-alcoholic beverages count toward keeping the patient hydrated. If the patient doesn’t enjoy drinking water, try flavoured waters or waters infused with fruit or vegetables to improve the taste. The average radiation therapy patient needs 8 to 12 cups of water per day.
If the patient going to consume caffeinated drinks like tea or coffee, recommend having no more than 1 to 2 glasses a day as it may make dry mouth worse. This is a common side effect during treatment. It’s also important to pay attention to the urine. If the urine is not a pale yellow, could be slightly dehydrated.
Patients can also get some of the fluid they need from milk, sports drinks, tea, and moist foods like soup, Jell-O, yoghurt, sherbet and pudding. Beverages containing alcohol do not count as part of daily hydration. Patients should talk to their doctor about the use of alcohol during treatment.
Supplements during Radiation therapy
Antioxidant supplements should be avoided during radiation therapy because they may end up protecting the cancer cells.
The goal is for patients to receive their daily vitamin and mineral intake from food and drinks. If a patient has a deficiency of a specific nutrient, the care team may recommend a supplement based on lab results and symptoms.
Manage side effects from radiation therapy
Side effects and diet recommendations vary based on the location of the tumour and the location of the body where receiving radiation. Here are some common radiation therapy side effects that can be managed by making changes to the diet:
Nausea and vomiting: Eat small, frequent meals throughout the day. Drinking clear liquids or eating bland foods such as dry toast or crackers may also help. Avoid fatty, fried, spicy or very sweet foods. Try drinking liquids between meals instead of with meals. Create a pleasant setting with soft music, conversation or other distractions to improve the experience.
Mouth/throat pain: Eat soft and moist foods that are easy to swallow. Avoid raw vegetables and fruits, and other hard, dry foods such as chips or pretzels. It’s also best to avoid salty, spicy or acidic foods if experiencing these symptoms. The care team can recommend nutrient-based oral care solutions if experiencing mucositis or mouth sores caused by cancer treatment.
Mouth dryness: Keep water nearby so the patient can take frequent sips and rinse their mouth between meals. Patients can also rinse or spray their mouths using artificial saliva or baking soda. Maintain good oral hygiene. Use baking soda and salt rinses four to six times a day. This helps the pH balance and reduces bacteria in the mouth. Brush teeth with a soft toothbrush after every meal and at bedtime. Avoid commercial mouthwashes that contain a large amount of salt or alcohol. Also try ice chips, sugarless hard candies or sugarless chewing gum. Add liquids to solid foods, such as gravy, sauce, milk or yoghurt.
Taste and smell changes: Reduce the smell of foods by eating cold or room-temperature meals. If the patient has a metallic taste in the mouth, try using plastic utensils and avoid canned foods. If salty or bitter taste, add honey, agave nectar or jam to foods. If foods taste too sweet, increase salty or tart flavours with lemon, citrus fruits, vinegar, pickled foods or salt. (Avoid these if the patient has mouth or throat sores.) If bad taste in the mouth, try sugar-free gum, peppermints, lemon drops, sorbet or frozen fresh fruit.
Gas: For prostate cancer patients, recommend avoiding foods that cause gas since this might affect preparation for treatment. Foods that cause gas include asparagus, beans, beer, broccoli, cabbage, corn, cucumbers, eggs, fish, milk, mushrooms, nuts, peppers and spicy foods. Also avoid foods that are labelled sugar-free, since these have ingredients, like sugar alcohols, that often cause gas.
REFERENCE:
https://clearpassage.com/services/post-radiation-therapy-pain/
https://pinkribbonrunner.com/eating-during-cancer-radiation-therapy/
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