Med-Surg Immune System, part 10: Chemotherapy, Radiation, Malnutrition, Mucositis

October 07, 2020 Updated: September 23, 2021 9 min read

In this article, we cover what you need to know about chemotherapy and radiation, including what they are, important nursing precautions, and patient teaching. Learn about the difference between internal and external radiation, and two common side effects of chemotherapy, including malnutrition and mucositis—and nursing care and patient teaching for each.

These cancer treatments, their side effects, nursing precautions, and patient teachings are covered in our Medical-Surgical flashcards (Immune system), and Cathy’s videos follow along with the cards.

Chemotherapy

Chemotherapy is a cancer treatment that uses specialized drugs to kill cancer cells. These drugs are cytotoxic, which means they kill cells. Because these drugs are inherently toxic to the body’s cells, it is important for people who handle them, like nurses and other healthcare professionals, to take certain precautions.

Chemotherapy and other cancer treatments are rough on the body. Chemotherapy targets and kills rapidly dividing cells, because this is what cancer cells are. But it causes some major side effects because there are many types of rapidly dividing normal cells in the body as well, such as epithelial tissue lining the mouth (causing mucositis) and the stomach (causing nausea, malnutrition), and the hair follicles (causing alopecia)!

Nursing precautions

If you are caring for a patient undergoing chemotherapy, there are certain precautions you need to follow to protect yourself from its effects. Your facility will likely have a policy around this, so you should check internally.

It’s important to wear the appropriate PPE, which can include special gowns and special gloves.

When you are bagging up linens in the room, make sure to double-bag with an impervious bag on the outside, so that nothing is able to leak out.

Chemotherapy spills do happen. You will also need to be aware of, and follow, spill management guidelines. Be prepared for that occurrence, know your facility’s policy, and make sure to follow it. Examples of spill management guidelines include double flushing toilets and using a splash guard prior to flushing, knowing the appropriate solution to spray, and use of correctly labeled “hazardous waste” bags.

Common complication: Malnutrition

Malnutrition occurs when the body is not getting the nutrients it needs to be healthy.

Chemotherapy can cause nausea and vomiting, which often leads to malnutrition. If a patient is nauseous, they may have no appetite. And if they do manage to eat, but they are afflicted by vomiting, they may not be able to keep food down. In either case, they are at risk of malnutrition.

Nursing care

To combat vomiting, you will want to provide an antiemetic about 30 minutes prior to chemotherapy. One common antiemetic is ondansetron.

Ondansetron (Zofran) is one of the many medications covered in our Pharmacology flashcards. These cards can help you memorize the meds you need to know for your pharmacology coursework as well as in your nursing career.

Another medication that can be provided is an appetite stimulant, megestrol. This is a synthetic form of the body’s hormone progesterone.

Patient teaching

When a patient is experiencing chemotherapy-related nausea/vomiting/appetite loss, encourage them to avoid drinking liquids with their meals. Drinking liquids with meals makes your stomach feel more full, and we do not want this patient to feel artificially full. Since they are at risk of not getting adequate calorie intake, we want them to focus on consuming a high-calorie, high-protein, nutrient-dense diet.

One tip for a nauseous patient is that room temperature or cool foods are sometimes easier to get (and keep) down when they are nauseous.

Common complication: Mucositis

Mucositis is another unfortunate complication often seen in patients undergoing chemotherapy. Mucositis is when mucosal membranes in the mouth become inflamed, irritated, and ulcerated.

Have you ever burned your mouth in a rush to eat your food that was too hot? And it takes days to heal, and if you’ve burned it bad enough, it hurts when food touches it? Imagine that, but much, much worse. Mucositis is very painful and lowers quality of life because you cannot enjoy eating. But there are ways to mitigate mucositis pain.

Nursing care

For a patient with mucositis, ensure you are providing meticulous oral care before and after meals.

Patient teaching

For a patient with mucositis, there are some important teachings to pass along.

Let the patient know that they should avoid any mouthwash that contains glycerine or alcohol because they may burn.

They should rinse their mouth with a saline solution twice a day. Salt is found naturally in the body, so a saltwater rinse should not irritate the mouth in the same way a commercial mouthwash might.

A patient with mucositis should use a soft toothbrush, and avoid foods that can cause more pain and damage to the mucosa in the mouth. For example, if your mouth hurts, it’s going to hurt more if you poke it with the sharp corner of a tortilla chip. Something like scrambled eggs would be a much better choice. They are soft, nutrient dense, and will be easier on the patient’s mouth.

Radiation

Radiation, in general, is the transmission of energy in the form of waves through space or through an object. Radio waves from a radio, microwaves from a microwave, UV light from the sun, and radiation therapy for cancer are all examples of radiation that lives along the electromagnetic spectrum.

Radiation therapy for cancer uses beams of intense energy to point at, and then kill, cancer cells. Radiation therapy can be either internal, or external, which refers to the source that emits radiation and whether it is inside of or outside of the body.

Internal Radiation/Brachytherapy

Internal radiation is when a radioactive substance is applied either on, or very close to, the cancer inside the body, whether through a seed-like surgical implant, or administered temporarily via needles or catheters.

Internal radiation therapy causes the patient’s body to give off radiation — meaning their body is actually radioactive, which is why there are special nursing precautions to follow when you are caring for this type of patient.

Precautions

When you are caring for a patient undergoing internal radiation therapy, there are steps you will need to follow to protect yourself.

Keep the door closed to a patient’s room. Post a warning sign on the door so passersby will understand the patient is undergoing internal radiation and that they should also take precautions.

Limit visitors to 30 minutes, and make sure they stay at least six feet away from the patient.

When you are caring for the patient, make sure you wear a lead apron and a dosimeter film badge, which helps to track how much radiation exposure you are getting. A dosimeter monitors cumulative radiation exposure.

The lead apron only covers your front (so you can move) but that means you must be facing the patient to receive the protection from the apron. If your back is uncovered and your back is facing the patient, then you can absorb some of the radiation that way.

External radiation

External radiation delivers radiation to the cancer cells from a machine outside the body. The main difference between internal and external radiation as it pertains to nursing precautions, is that patients who undergo external radiation do not become radioactive.

Patient teaching

There are some important points to reinforce with patients who are undergoing external radiation therapy. The area that is receiving radiation will be marked. It’s important that your patient not wash off these markings.

This patient should be very gentle with their skin over the area receiving radiation. They will need to clean it with a gentle soap and pat dry. They should not apply any lotions, powders, or ointments over the area unless specifically prescribed by the provider.

In some cases of radiation therapy, the provider may in fact instruct the patient to apply something over the area, but patients should not apply anything topically that the provider has not okayed.

Advise your patient undergoing external radiation therapy to wear loose and soft clothing, because the area will be very sensitive. Finally, they should avoid sun and heat exposure to the area undergoing radiation.

Cathy’s teaching on cancer treatment and complications is intended to help prepare you for Medical-Surgical nursing exams. The Medical-Surgical Nursing video series is intended to help RN and PN nursing students study for nursing school exams, including the ATI, HESI and NCLEX.


Full Transcript

Alright. In this video, we are going to talk about nursing care and patient teaching associated with cancer treatment. So in this specific video, we'll be talking about chemotherapy, internal radiation, external radiation, as well as malnutrition and mucositis.

So let's first talk about chemotherapy. If you are taking care of a patient who is undergoing chemotherapy, you need to make sure you're wearing the appropriate PPE that is required. So you should check with your facility policy. But typically this involves special gowns and special gloves.

In addition, when you are bagging up linens in the room, you want to make sure you double-bag these linens with an impervious bag on the outside. So by impervious, I mean something where substances aren't going to leak through. Basically, it's going to hold everything in and nothing's going to leak out.

Then you want to definitely follow spill-management guidelines. So chemotherapy spills do happen. You need to be prepared for that occurrence and know what those guidelines are and just follow your facility policy with that.

And then you want to make sure to double flush toilets and use a splash guard prior to flushing.

Okay, if your patient is getting internal radiation, so that is something called brachytherapy. This is where they put a radioactive substance either on or very close to the cancer internally. So if your patient has that internal radiation, you need to take steps to protect yourself.

So you always want to keep the door closed to the patient's room.

You want to have a warning sign on the door so that anybody who comes through understands that the patient has internal radiation going on.

You want to limit visitors to 30 minutes, and you want to make sure they stay at least six feet away from the patient.

And then when you are caring for the patient, you need to make sure you are wearing a lead apron as well as a dosimeter film badge, which will help to track how much radiation exposure you're getting.

And then you always want to face the patient so that that lead apron can do its job and protect you.

Alright. Now, let's talk about patient teaching for external radiation. So there's definitely some important points that you'll need to reinforce with your patient.

First of all, the area that will be undergoing radiation will be marked. And it's really important that your patient not wash off these markings.

In addition, they should be very gentle with the skin over the area that's going to receive radiation. So they should clean it with gentle soap and pat it dry. They should not apply any lotions, powders, or ointments over the area unless specifically prescribed by the provider.

So my mom just finished up her radiation therapy for breast cancer, and it went well. Her provider did have her actually put on Aquaphor ointment over the area, but in some cases, your provider may not want you to do that. So you never want to put anything on the area unless you check with the provider first.

In addition, you want to advise the patient to wear loose and soft clothing, because that area's going to be very, very sensitive.

And they should also avoid sun and heat exposure to the area that will be receiving radiation.

Alright. Now, let's talk about some of the nursing care and patient teaching we need to do for common complications of chemotherapy.

One such complication is malnutrition. Chemotherapy can cause nausea and vomiting, which can definitely lead to malnutrition.

So as a nurse, we're going to want to provide an antiemetic about 30 minutes prior to chemotherapy. And a common antiemetic that we use in the hospital is ondansetron, which is Zofran.

We can also give the patient an appetite stimulant. So one such medication that does that is called megestrol. And the way I remember this medication is, with megestrol, it will encourage the patient to ingest more food.

Alright. So in terms of patient teaching. We want to encourage the patient to avoid drinking liquids with their meals because we don't want them to fill up on liquids.

We really want them to focus on consuming a high-calorie, high-protein, nutrient-dense diet.

And then we can also advise them that room temperature or cooler foods are sometimes easier to get down when you're feeling nauseous.

And then in some cases, if they're still not eating enough, we may need to use supplements to help make sure they get enough calories and nutrients.

Okay, another common and awful complication with chemotherapy is something called mucositis. This is where the mucosal membranes in the mouth become inflamed, irritated, and ulcerated. Very, very painful.

So we want to make sure that we are providing meticulous oral care for our patient before and after meals.

We also want to do some important teaching, including letting the patient know that they should avoid any mouthwash that contains glycerine or alcohol.

They should also rinse their mouth with a saline solution twice a day.

And they should use a soft toothbrush and then avoid foods that can cause more pain and damage to that mucosa.

So if the patient was to eat some crackers or chips, those have sharp edges and they're hard. And that would not feel good on their mouth.

So scrambled eggs would be a much better choice because they're soft, they're nutrient-dense, and it will just be much easier on their mouth.

Okay, so I'm going to stop here. We will talk about more complications and how we care for those complications in my next video!


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