Radiation symptom management

[RN416]

I have a question for all you radiation oncology nurses. How does your facility manage side effects of treatment, such as burning to the rectal/perineal area from rectal cancer treatment, or mucositis/mouth and throat pain from head and neck radiation, for example? What is your protocol, what products do you have patients use, etc? I am looking to try to help improve how we manage symptoms at my facility so I would love as much input as possible. Thanks!

[Oznurse94]

Hi RN461,

I work in rad onc based in Australia so our products may be different to what you have available in your country. However our basic management of side effects is as below;

Every patient is given a site specific (eg H+N, prostate, gynae) information booklet at their initial consult with their RO. Side effects and what to expect with treatment are outlined in this booklet.

On the day of the patients SIM CT appt they have a 45 minute individual education session with one of the ro nurses(we have 2 nurses each day allocated to sim education) . At this session we recommend products for skin and mouth care, along with how to manage any other additional short term side effects (eg loose bowels, nausea etc). Patients are also educated on what to look out for, and when they should be presenting to the ro nurses. We have a walk in nursing service at our clinch where 4 nurses are allocated to see any patients that choose to present. Patients are advised that they can see nurses at anytime without an appointment whilst they are on treatment if they have questions or are struggling with side effects.

Our general recommendations for skin care are:

- use a gentle soap free, pH balanced wash on the treatment field when showering (no soap or fragranced products)

-use warm water rather than hot or cold, pat dry with a towel post shower. NO SCRUBBING!

- moisturise with a basic aqueous cream (unfragranced) at least twice a day- but not in the 2 hrs leading up to treatment as cream must be absorbed prior to arriving for treatment

- no sunscreen in the tx field

- no deodorant (if treating auxilla) or perfumes in the tx field

-avoid underwire bras (if treating breast)

- avoid hair removal in the tx field, no shaving, waxing or hair removal creams. It is acceptable to use an electric razor on facial hair.

- if skin is red, hot or itchy a normal saline compress can be helpful BD-TDS for 15-20mins at a time.

Our machine RTs do weekly skin checks on all patients and will send anyone with grade 1 or higher skin to see the patients .

For gynae/ rectal patients they are seen week 3 of their treatment for a skin check with nurses irrespective of gender. All female pelvic patients are given their dilator and pelvic fitness education at this appointment as well.

If there is any signs of erythema, desquamation or pain the patient will then be seen at least weekly by the nurses for regular skin follow ups from then on. If we have to start dressings then they see nurses daily.

For skin reactions in the perineal/ lady partsl area we use a combination of

- sitz baths with saline

- saline compresses

- 5% xylocaine gel mixed 50/50 with solosite wound gel (an aqueous wound gel)

- padded dressings and non adherent pads to prevent skin from sticking to clothing.

We DO NOT use any form of barrier cream as the majority contain zinc which is contraindicated with radiotherapy.

For our head and neck patients we have a specialist head and neck clinical nurse who sees that patients on a fortnightly basis, as well as when they choose to present. Also every H+ N patient is referred at their sim appointment to the "nutrition and swallow clinic" which consists of a dietitian and a speech therapist. They are seen on a weekly basis by the N+S clinic.

To manage mucositis we recommend

- using a saliva substitute (eg biotene, oral balance)

- regular saline mouthwashes

-regular bicarbonate soda mouth washes

-cephasol

- use of mouth swabs rather than tooth brushes

In terms of pain relief our initial tx is soluble paracetamol 1g QID gargled and then swallowed.

When this is no longer enough then we use a combination of:

Fentanyl patches

Oxycodone elixir

Xylocaine viscous prior to meals

The N+s clinic also teaches the patients to modify their foods texture to make it easier to consume. If needed we also do insert NGTs or arrange for PEG tubes to be inserted.

Patients are seen by their RO on a fortnightly basis throughout treatment, and know that they can see nurses as needed.

Once they complete treatment every patient is given a 1 week follow up phone assessment by the nurses to check in and make sure they are ok. If they are having concerns they can then attend the clinic to see nursing or their ROs. Patients are also seen on the last day of tx by the nurses to be given their follow up appt with the ROs, check in on side effects, and advise them of what to do for the next few weeks in terms of managing any sideffects. If needed we will refer the patients to home care nurses for dressings etc.

Our centre is fairly big with approximately 200 patients through 4 linacs on a daily basis, as well as clinics, brachytherapy, and superficial skin treatment. we are super lucky that our will also take the initiative and send any patients to nurses that they are concerned about.

We have dedicated RO team of 9 nurses and ,not counting sim education patients, our 4 front end tx nurses see approximately 60-70 patients a day so I guess all that education about when to see nurses does work!

I hope that helps, happy to provide any more specific information if you want it

[RN416]

That is very helpful! Thank you for your detailed response!