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Radiation therapy

• One of the oldest nonsurgical methods of cancer treatment
• 50% of all cancer patients will receive radiation therapy at some point in their treatment
• Radiation is emission of energy from a source and travels through space or some material
• Different types of ionizing radiation are used to treat cancer
• Technologic advances
  • Low-energy beams
    • Expend energy quickly
    • Penetrate a short distance
    • Useful for skin lesions
  • High-energy beams
    • Greater depth of penetration
    • Suitable for optimal dosing of internal targets while sparing skin
• Total doses divided into fractions
• Typically delivered once a day for 5 days a week for 2 to 8 weeks
  • Standard fractionation

• • Certain tumors are more susceptible to the effects of radiation than others
  • Simulation
    • A process by which radiation treatment fields are defined, filmed, and marked out on skin
    • Radiation oncologist specifies dose and volume of area to be treated
  • Immobilization device
    • The patient is positioned on a simulator, which is a diagnostic x-ray machine that recreates the actions of the linear accelerator and the radiation fields are marked on the patient’s skin.
    • Simulation uses immobilization devices to help the patient maintain a stable position.
    • In this example, a head holder and immobilization mask may be used to ensure accurate positioning for daily treatment of head and neck cancer.
  • Linear accelerator
    • A linear accelerator, which generates ionizing radiation from electricity and can have multiple energies, is the most commonly used machine for delivering external beam radiation.

• • Internal radiation
    • Patient is emitting radioactivity
    • Limit amount of time near patients being treated
      • Organize care
      • Use shielding
      • Wear film badge to monitor exposure

Gerontologic considerations

• Anesthetic drugs should be carefully titrated
• Assess for poor communication
• Risk from tape, electrodes, and warming/cooling blankets
• Osteoporosis and osteoarthritis
• Perioperative hypothermia

Catastrophic events in the OR

• Anaphylactic reactions
  • Manifestation may be masked by anesthesia
  • Vigilance and rapid intervention are essential
  • Symptoms include hypotension, tachycardia, bronchospasm, pulmonary edema
• Malignant hyperthermia
  • Rare metabolic disorder
  • Hyperthermia with rigidity of skeletal muscles
  • Often occurs with exposure to succinylcholine, especially in conjunction with inhalation agents
  • Usually occurs under general anesthesia but may also occur in recovery
  • Other triggers
    • Trauma
    • Heat
    • Stress
  • Autosomal dominant trait
    • Inherited hypermetabolism of skeletal muscle resulting in altered control of intracellular calcium
  • Tachycardia
  • Tachypnea
  • Hypercarbia
  • Ventricular dysrhythmias
  • Rise in body temperature NOT an early sign
  • Can result in cardiac arrest and death

Anesthesia

• Anesthetic technique and agents are selected by the ACP that consider
  • Physical and mental status
  • Age
  • Allergy and pain history
  • Expertise of the ACP
  • Factors related to operative procedure
• Classification of anesthesia
  • General anesthesia
    • Rarely use only one agent
      • Adjuncts
    • Dissociative anesthesia
      • Ketamine (Ketalar)
  • Adjuncts to general anesthesia
    • Opioids
      • Sedation and analgesia
      • Induction and maintenance intraoperatively
      • Pain management postoperatively
      • Respiratory depression
        • Assess respiratory rate and rhythm, monitor pulse oximetry, protect airway in anticipation of vomiting.
        • Use standing orders for antipruritics and antiemetics.
        • Reverse opioid-induced respiratory depression with naloxone (Narcan). If used, reversal of analgesic effects also occurs.
    • Benzodiazepines
      • Premedication for amnesia
      • Induction of anesthesia
      • Monitored anesthesia care
        • Monitor level of consciousness. Assess for respiratory depression, hypotension, and tachycardia.
        • Reverse severe benzodiazepine-induced respiratory depression with lumazenil (Romazicon).
    • Neuromuscular agents
      • Promote skeletal muscle relaxation (paralysis)
        • If intubated, monitor return of muscle strength, level of consciousness, and ventilation.
        • Maintain patent airway. Monitor respiratory rate and rhythm until patient able to cough and return to previous levels of muscle strength. Ensure availability of nondepolarizing reversal agents (e.g., neostigmine [Prostigmin]) and emergency respiratory support equipment.
        • Monitor temperature and levels of muscle strength with temperature changes.
    • Antiemetics
      • Prevent nausea and vomiting associated with anesthesia
        • Monitor heart rhythm, cardiopulmonary status, level of central nervous system excitation or sedation, ability to move limbs, presence of nausea or vomiting
  • Local anesthesia
    • Loss of sensation without loss of consciousness
    • Types
      • Topical
      • Ophthalmic
      • Nebulized
      • Injectable
  • Regional anesthesia
    • Loss of sensation in body region without loss of consciousness when specific nerve or group of nerves is blocked by administration of local anesthetic
    • Always injected

Nursing management

• Admitting patient
  • Reassessment
  • Last-minute questions
  • Review of chart
  • Review labs
  • Final questioning about valuables, prostheses, contacts, last intake of food/fluid
• Basic aseptic technique
  • Center of sterile field is site of surgical incision
  • Only sterilized items in sterile field
  • Protective equipment
    • Face shields, caps, gloves, aprons, and eyewear
• Preparing surgical site
  • Scrub or clean around the surgical site with antimicrobial agents
    • Use a circular motion from clean to dirty area
    • Allow to fully dry
  • Hair may be removed with clippers
  • Surgical site is draped
• Preventing hypothermia
  • Closely monitor temperature
  • Apply warming blankets
  • Warm IV fluids

Surgical team

• Perioperative nurse
  • Is a registered nurse (RN)
  • Prepares room with team
  • Serves as patient advocate throughout surgical experience
    • Maintains patient safety, privacy, dignity, confidentiality
    • Communicates with the patient
    • Provides physical care
• Scrub nurse
  • Follows designated surgical hand asepsis procedure
  • Gowned and gloved in sterile attire
  • Remains in sterile field
• Circulating nurse
  • Not scrubbed, gowned, or gloved
  • Remains in unsterile field
  • Documents
• LPN or surgical technician
  • Performs scrubbed or circulating function
  • Passes instruments and implements other technical functions during procedure
  • Supervised by RN
• Surgeon
  • Physician who performs the procedure
  • Is responsible for
    • Preoperative medical history
    • Physical assessment
    • Patient safety
    • Postoperative management
• Surgeon’s assistant can be a physician, RN, or PA who functions in assisting role
  • Holds retractors
  • Assists with homeostasis and suturing
  • May perform portions of procedure under direct supervision
• Registered Nurse First Assistant (RNFA)
  • Must have formal education
  • Works collaboratively with the surgeon, patient, and surgical team
    • Handles tissue
    • Uses instruments
    • Provides exposure to surgical site
    • Assists with homeostasis
    • Performs suturing
• Anesthesia care provider (ACP)
  • Administers anesthesia
  • Anesthesiologist, nurse anesthetist, or anesthesiologist assistant (AA)
  • Maintenance of physiologic homeostasis throughout intraoperative period
  • Provide care during recovery

• Physical environment
  • Unrestricted areas
    • People in street clothes interact with those in scrubs
      • Holding area
      • Locker room
      • Information areas
        • Nursing station
        • Control desk
  • Semi-restricted areas
    • Peripheral support areas and corridors with only authorized staff
    • Must wear surgical attire and cover all head and facial hair
  • Restricted areas
    • Operating rooms
    • Scrub sink areas
    • Sterile core
    • Surgical attire, head covers, and masks required
  • Holding area
    • Waiting area inside or adjacent to surgical suite
    • Final identification and assessment
    • Friends/family allowed
    • Application of sequential compression devices (SCDs)
    • Minor procedures
  • AOD area
    • Admission, observation, and discharge area
      • Early morning admissions
        • Outpatient surgery
        • Same-day admission
        • Inpatient holding
  • Operating room
    • Geographically, environmentally, and aseptically controlled
    • Restricted inflow and outflow of personnel
    • Preferred location is next to PACU and surgical ICU
    • Filters
    • Controlled airflow
    • Positive air pressure
    • UV lighting
    • No dust-collecting surfaces

• Transportation to the OR
  • Via stretcher or wheelchair
  • Communication “handoff”
    • Situation
      • J.D. is a 45 year-old female with history of breast biopsy positive for breast cancer. She is here today for a right breast lumpectomy to be performed by Dr. Evans.
    • Background
      • She has a family history of breast cancer and appeared anxious this morning, verbalizing this history and her own fears. She is married, with two daughters; her husband is here in the waiting area. She also has a history of hypertension, type 2 diabetes controlled with glipizide and diet.
    • Assessment
      • Her baseline vital signs were 36.8-78-122, 132/70. Her fasting blood glucose this morning was 82. She took her HCTZ, and held her glipizide, fish oil, and aspirin. Her right breast has been marked by Dr. Evans. Her IV, D5NS, is infusing at 100 mL/hr into her left hand.
    • Recommendation
      • J.D.’s IV antibiotic was started 5 minutes ago and is still infusing.
  • Caregivers directed to waiting room

• Day-of-surgery preparation
  • Final preoperative teaching
  • Assessment and report of pertinent findings
  • Verification of signed consent
  • Labs
  • History and physical examination
  • Baseline vitals
  • Proper skin preparation
  • Nursing notes
  • Hospital gown
  • Patient should not wear any cosmetics
    • Observation of skin color is important
    • Remove nail polish for pulse oximeter
  • Valuables are returned to family member or locked up
  • Dentures, contacts, glasses, prostheses are removed
  • Identification and allergy bands on wrist
• Void before surgery
  • Before medication administration
  • Prevents involuntary elimination under anesthesia
  • Reduces risk of urinary retention during early postoperative recovery
• Preoperative medication
  • Benzodiazepines – midazolam, diazepam (Valium), lorazepam (Ativan)
    • Reduce Anxiety
    • Induce sedation
    • Amnesic effects
  • Anticholinergics – atropine glycopyrrolate (Robinul), scopolamine (Transderm-Scop)
    • Reduce oral and respiratory secretions
    • Prevent nausea and vomiting
    • Provide sedation
  • Opioids – morphine (Duramorph), fentanyl (Sublimaze)
    • Relieve pain during preoperative procedures
  • Antiemetics
    • Prevent vomiting
  • Antibiotics – cefazolin (Ancef)
    • Prevent postoperative infection
  • β-Adrenergic blockers (β-blockers) – labetalol
    • Manage hypertension
  • Insulin
  • Eye drops

Nursing management

• Preoperative teaching
  • Patient has the right to know what to expect and how to participate
    • Increases patient satisfaction
    • Reduces fear, anxiety, stress, pain, and vomiting
  • Teach deep breathing, coughing, and early ambulation as appropriate
  • Inform if tubes, drains, monitoring devices, or special equipment will be used postoperatively
  • Provide surgery-specific information
• Ambulatory surgery information
  • Basic information before arrival
    • Time and place
    • What to wear and bring
    • Responsible adult needed
    • Fluid and food restrictions
• Legal preparation
  • Check that all required forms are signed and in chart
    • Informed consent
    • Blood transfusions
    • Advance directives
    • Power of attorney
  • Consent for surgery
    • Informed consent must include
      • Adequate disclosure
      • Understanding and comprehension
      • Voluntarily given consent
  • Surgeon responsible for obtaining consent
    • Nurse may witness signature
    • Verify patient has understanding
    • Permission may be withdrawn at any time
  • Legally appointed representative of family may consent if patient is
    • Minor
    • Unconscious
    • Mentally incompetent
  • Medical emergency may override need for consent
  • Immediate medical treatment needed to
    • Preserve life
    • Prevent serious impairment to life or limb

Fluid and electrolyte status

• • Vomiting, diarrhea, or preoperative bowel preps can cause imbalances
  • Identify drugs that alter F and E status such as diuretics
  • Evaluate serum electrolyte levels
  • NPO status
    • Surgery delay may also lead to dehydration
    • Patients with or at risk for dehydration  may require additional fluids and electrolytes before surgery