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RTT 306 Patient Care 2 Cheat Sheet (DRAFT) by

This is a draft cheat sheet. It is a work in progress and is not finished yet.

Taking Care of You

Stress - produced by events that are perceived as demands on time, energy, or resources w/ threat that not enough time, energy, or resources available for full obliga­tion; Vit C, Complex B Vits, Mg lost through stress

Fight or Flight - physio­logic reaction to real or imagined threat arising from fear & anger

Burnout - emotional exhaus­tio­n/f­atigue, depers­ona­liz­ation, ↓ personal accomp­lis­hment

1. Out of Control Lang. = I must, I have to, It's unfair
2. In Control Lang. = I can, I decided, I choose

Patient Education & Supportive Care

Informed Consent
The patient MUST:
1. have the abilit­y/c­apacity to make the decision
2. comprehend all info being given
3. give consent volunt­arily w/out being forced, persuaded, threatened
4. be given info about tx, procedure, benefi­ts/­risks of having/not having tx, stats of benefi­ts/­risks occuri­ng/not occuring

Types of Patient Edu.
1. Pamphlets
2. Group teaching
3. Video
4. Internet
5. Books

Patient Edu. About Tx. Room
1. Length of tx.
2. How patient will feel during tx.
3. Emphasize fact that they must remain still and breathe normally (unless DIBH)
4. Explain role of each therapist in the room

Body Language
1. Make eye contact and get on same level as patient
2. Pause & listen for unders­tan­ding/?s
3. Have open body language
4. Show empathy

Most Likely To...
Receive info about tx. - younger patients
See nurse & seek support - younger females
Experience more stress - men

Normal Values

Hematocrit (Hct) - volume % of RBCs in blood
M: 45 - 52%
F: 37 - 48%
Hemoglobin (Hgb) - protein in RBCs carrying O2 from lungs to tissues of body & CO2 back to lungs
M: 13.5 - 17.5 g/dL
F: 12 - 15.5 g/dL
Ch: 12 - 14 g/dL
Erythr­ocytes (RBCs)
M: 4.7 - 6.1 million cells/µL
F: 4.2 - 5.4 million cells/µL
Leukocytes (WBCs)
Adults: 5,000 - 10,000 cells/µL
Adults: 200,000 - 500,000 platel­ets/µL

The following values are for adults:
Oral: 96.8° - 98.6° F or 36° - 37° C
60 - 100 beats/min
12 - 18 breath­s/min
Systolic - pressure in arteries during ❤ contra­ction; top #
90 - 120 mmHg
Diastolic - pressure in arteries during ❤ relaxa­tion; bottom #
60 - 80 mmHg

Psycho­social Issues

Psycho­social - involves both psycho­logical & social aspects of life

Situations where patients need additional support
1. Deciding whether or not to have tx.
2. Undergoing 1st tx.
3. Coping with experience of tx.
4. Coping with inconv­enience of tx.
5. Dealing with long term consid­era­tions

Patient Centered Care
1. Assessment (QLI, FLIC, FACT)
2. Involv­ement in decision making
3, Info provision
4. Patient friendly resources
5. Holistic approach to care

Domains of Patient Transition at EOT
1. Psycho­logical - cont. emotional distress, withdrawal from support
2. Physical - marks, scars, pain, difficulty sleeping
3. Social - ?ing where they fit in w/ friend­s/f­ami­ly/­society
4. Spiritual - ?ing their spirit­uality

Grief vs Depression
G: somatic distress, ↓ usual patterns of behavior, agitation, sleep/­app­etite distur­bances ↓ concen­tra­tion, social withdrawal
D: same + helple­ssness, hopele­ssness, worthl­ess­ness, guilt, suicidal thoughts

G: assoc. w/ disease progre­ssion
D: ↑ prevalence in patients w/ advanced disease

G: patients retain capacity for pleasure
D: patients enjoy nothing

G: comes in waves
D: constant

G: passive wishes for death to come quickly
D: intens­e/p­ers­istent suicidal thoughts

G: able to look forward to future
D: no sense of positive future

Resentment - experience of negative emotion felt due to real/i­magined wrong done
Anger - emotional response related to one's psycho­social interp­ret­ation of event

Death & Dying

Dying with Dignity
- option for qualifying terminally ill adults to request and receivve prescr­iption med that will end their life
- legal in CA, CO, VT, HI, NJ, ME, OR, WA, DC

Stages of Grieving
1. Denial
2. Anger
3. Bargaining
4. Depression
5. Acceptance
*In no particular order
*Not every individual goes through every stage

Physical Signs/­Sym­ptoms in Last 48 hrs.
1. Noisy/­moist breathing
2. Urinary dysfun­ction
3. Pain
4. Restle­ssn­ess­/ag­itation
5. Dyspnea (diffi­culty breathing)
6. Nausea­/vo­miting
7. Sweating
8. Confusion

Palliative Care - relieving symptoms w/out affecting disease process, chance of improving QOL, may be given at same time as curative tx.
Hospice- tx. doesn't offer hope, death expected

Each person entitled to determine own destiny UNLESS:
1. Decision may cause harm to others or oneself
2. Patient is incomp­etent to make the decision
3. "­Phy­sician' privil­ege­"

DNR = Do Not Resusc­itate

Advanced Directive - document that outlines one's medical desires & requests if they are in a situation where they can't make a decision
Durable Power of Attorney (DPOA) - states the person whom the patient has chosen to make a decision in place of them if the patient is unable to do so, aka Health Care Proxy

Body Image

RESOURCE - link text : Look Good Feel Better

Factors - visibi­lity, pain, location of tumor, prosth­etics, control

Alopecia - hair loss

Cachexia - weakness and wasting of the body due to severe chronic illness

Potential Side Effects of RT on Body Image
1. Bone Mets: pain relief­/im­pro­vement of mobility
2. Malignant Cord Compre­ssion - improv­eme­nt/­pre­vention in further deteri­oration in function
3. SVC Obstru­cti­on/­Facial Tumors - improv­ement in cosmetics & sympto­ms/­red­uction in edema/­tumor shrinkage
4. Esophageal Obstru­ction - relief of obstru­cti­on/­imp­rov­ement in eating ability
5. Discha­rgi­ng/­Fun­gating Wounds - alllev­iat­iation of discha­rge­/tumor shrinkage
6. Hemoptysis (bleeding of airway; coughing up blood)­/He­maturia (blood in urine)­/Rectal Bleeding - control of bleeding

Stages of Adapting to Body Image
1. Impact of Diagnosis- shock rather than anger; may be directed towards health profes­sional or family
2. Mourning- yearning to return to previous self
3. Defect- seeking info or trying different coping strategies
4. Recons­tru­ction- accepts the use of aids; able to plan for the future


Potential Effects of Rad on Sexual Organs
M: pelvic fibrosis, sympat­hetic nerve injury, ↓ semen volume, ↓ testos­terone, ↓ penile BP, fibrosis of cavernosal arteries
F: pelvic fibrosis, atrophy of vaginal wall, ↓ tissue elasti­city, ↓ vaginal lubric­ation, scarring, ulcera­tion, oblite­ration of small blood vessels

Fertility Preser­vation
1. Ovaria­n/t­est­icular shielding - may maintain function but small chance
2. Lapara­scopic Ovarian Transp­osition - effective method for mainta­ining reprod­uctive function & ↓ need for hormone replac­ement therapy
3. Testicular Transp­osition - for fields restricted to inguinal pelvis
4. Embryo Cryopr­ese­rvation - for use in in-vitro, may take 4-6 weeks to collect viable oocytes; for patients of reprod­uctive age
5.Cryopr­ese­rvation of Sperm - intrac­yto­plasmic sperm injection (ICSI) requires few sperm for successful fertil­ization

ALARM- baseline assessment to determine sexual function before tx.
Activity, Libido, Arousal, Resolution, Medical History


Rad Dose (Gy)
Effect on Ovarian Function
No lasting damage for young F Some steril. risk for F >40
2.5 - 5
30 - 40% steril. risk for F 15-40 >90% steril risk for F >40
5 - 8
50 - 70% steril. risk for F 15 - 40
100% risk of permanent steril.
Ovaries produce oocytes (fetus = 6 million, birth = 2 million, puberty = 100,000) & secrete steroid hormones for sexual function & sexual maturity

Tolerance of ovary ↓ w/ ↑ age, ↑ dose per fraction, ↑ total dose

Possible solutions:
1. Vaginal dilator for stenosis, adhesions, dyspar­eunia (pain due to penetr­ation)
2. Lubric­ation for dryness
3. Diff sex positions for ↓ elasticity or scarring


Rad Dose (Gy)
Effect on Sperma­tog­enesis
0.1 - 0.3
Temp oligos­permia w/ full recovery by 12 mos.
0.3 - 0.5
Temp oligo/­azo­osp­ermia 4 - 12 mos. after RT w/ full recovery by 48 mos.
0.5 - 1
>90% temp OS/AS 3 - 17 mos. w/ recovery 8 - 26 mos
1 - 2
100% AS 1-2 mos. w/ return of sperm counts 11 - 30 mos.
3 - 4
100% AS w/ no recovery up to 40 mos.
Permanent AS w/ ↓ testicular size and ↓ testos­terone production
Testes produce sperma­tozoa for reprod­uction & testos­terone (secreted by Leydig cells) for sexual function & maturity

Possible solutions - pharm. drugs, penile implants, vacuum device for erectile dysfun­ction

Oligos­permia (OS) = LOW sperm count
Azoosp­ermia (AS) = NO sperm count

Human Diversity

Diversity - differing from one another; made up of distinct charac­ter­istics, qualities, or elements

Global­ization - process of intera­ction & integr­ation among people, companies, and govts. of different nations; driven by intern­ational trade and investment

Cultural Diversity
1. Commun­ication- can help avoid offending people; be aware of who’s around you and the basic norms of their culture to be able to provide better patient centered care
2. Space - distance extending in all direct­ions; know person­al/­cul­tural boundaries
3. Time - cultures have different time orient­ations; ex: someone may have a certain time of day they pray so we have to try and accomm­odate
4. Enviro­nmental Control- ability of people to control nature; differ­ences in health practices and defini­tions of health and illness vary in each culture
5. Biologic Variations- certain people are suscep­tible to certain diseases; differ­ences in nutrit­ional prefer­ences; ethnic­all­y/r­acially related charac­ter­istics
6. Social Organi­zations- encult­ura­tion; some hiring practices support diversity to provide better cultural unders­tanding of different popula­tions

Cultural Sensit­ivity
Values - est. early in childhood through uncons­cious process of social­iza­tion; foundation of beliefs
Beliefs - knowledge, opinions, and faith about life are built on individual vaues
Customs - Dietary habits, religious practices, commun­ication patterns, family structure, health practices

Cultural Competency- possessing a set of attributes that enable effective intera­ctions in a cross-­cul­tural or multic­ultural enviro­nment
1. Valuing diversity
2. Having the capacity for cultural assessment
3. Having consci­ousness of the dynamics of cross-­cul­tural intera­ctions
4. Instit­uti­ona­lizing cultural knowledge
5. Developing adapta­tions of service delivery that reflect an unders­tanding of a multic­ultural enviro­nment

Civil Rights Act of 1964- prohibits discri­min­ation on the basis of race, color, and national origin; requires health care organi­zations and providers who receive federal funding to make interp­reter services available to patients who have limited profic­iency in English

Vienna Declar­ation for Human Rights- protects those with disabi­lities and its values include:
1. Dignity
2. Autonomy
3. Equality
4. Solidarity

Types of Interp­reters
1. Telephone
2. Video Confer­encing
3. Voice Activated Software
4. Family­/fr­iends (be cautious)

1. Age
2. Ethnicity or national Origin
3. Race
4. Gender or sexual orient­ation
5. Mental­/ph­ysical ability

Ethnicity- an indivi­dual’s distin­ctive racial, national, religious, lingui­stic, or cultural heritage
Ethnoc­entrism- viewing norms/­values of one’s culture as the only acceptable norms/­values and using that idea as a standard to judge all other cultures
Racism- believing one race or culture is superior to others and using that idea to discri­minate races that are considered to be inferior
Assimi­lation-an individual who moves further away from their true identity (culture, religion, language, etc.) and slowly “fits in” with the majority of society (whatever is considered to be “normal”); can happen consci­ously or subcon­sci­ously

English Only
Requiring to speak only English at the workplace is legal if organi­zation shows it's a business necessity
1. To enable superv­isors who speak only English to properly monitor job perfor­mance
2. To promote safety in emergency situations
3. To promote efficiency when multi-­lingual speakers collab­orate on work projects with English only speakers
4. To promote customer relations when speaking with English speaking customers
Issues: provides a means for national origin discri­min­ation, everyone learns at a different pace and it takes time to be become proficient in a language, patients may become ill before learning the language


Fatigue - charac­terized by overwh­elming exhaus­tion, lack of energy, difficulty concen­tra­ting, emotional distress, depression

Most common symptom and side effect of cancer tx. (75-100% of patients affected) but direct cause unknown
Indirect causes
1. Need for extra energy to repair­/heal body tissue damaged by tx.
2. Buildup of toxic substances that are left in the body after cells are killed by tx.
3. Effect of biologic therapy on immune system
4. Changes in the body’s sleep cycle

Factors that contribute- anemia, hormone levels that are too low or too high, trouble breathing or getting enough O2, infection, pain, stress. loss of appetite or not getting enough calories and nutrients, dehydr­ation, changes in how well the body uses food for energy, weight loss, loss of muscle­s/s­tre­ngth, meds that cause drowsi­ness. problems getting enough sleep, being less active, other medical conditions

Risk Factors
1. Age/pe­rfo­rmance status
2. Type/site of tx. (volume, dose, normal tissue damage)
3. Pre-tx fatigue, commute to tx.
4. Blood counts

Patients most affected by fatigue 
1. Lung patients- breathing, coughing, infection, if tumor close to medias­tinum then i­ssues with swallo­wing  
2. Head and Neck patients - weight loss from not eating enough because everyt­hing  hurts 
3. Concurrent chemo patients - both the radiation and chemo effects together are the  most difficult to deal with 
4. Brain patients - sleep issues 

Why it's important
↓ QOL for patient, ↓ self-care ability, ↓ ability to recover, ↑ feeling of ill health

Managing Fatigue
1. Warn patients so they are prepared and educated
2. Allow patients to talk about it
3. Recommend exercise if possible
4. Stress management techniques
5. Psycho­logical counseling
6. Sleep

Skin Reactions

Most likely to occur in the following rad tx. areas:
1. Breast
2. Head and Neck
3. Perineal
4. Where skin folds rub together

Tend to peak towards EOT, usually worsen after tx. completed
Most reactions heal within 4 weeks after EOT

Main Layers of Skin
1. Epidermis (super­ficial)
- Most sensitive to rad
- Basal layer rapidly divides; when cells of this layer die off, repopu­lation of epidermis is disrupted so degree to which basal layer is affected = degree of skin reaction
2. Dermis (deep)

RTOG used to assess skin reactions (scoring is 0-4)
Adv: accurate estimate of area of skin affected and of severity of skin reaction

Risk Factors- Moist areas of the body, skin folds, nutrition, age, ethnicity, overall skin condition, dose, energy, fracti­ona­tion, bolus

Clinical Presen­tation- red, inflamed, sometimes shiny, skin feels   hot/it­chy­/un­com­for­table
Expected at 1.5 Gy and higher, usually after 20-25 Gy
Skin Care Recomm­end­ations- Gentle washing with mild soap, pat skin dry, loose cotton   clothing, no moistu­riz­er/­per­fum­e/d­eod­ora­nt/­mak­eup­/ra­zor­s/sun in the area   of treatment, hydroc­ort­isone, aloe vera without alcohol, benadryl cream 

Dry Desqua­mation
Clinical Presen­tation - dry and flaky skin, usually itchy 
Expected at 40+ Gy
Skin Care Recomm­end­ations- Gentle washing with mild soap, pat skin dry, loose   cotton clothing, avoid friction, topical steroids usually help 

Moist Desqua­mation
Clinical Presen­tation- bliste­r/v­esicle formation, serous drainage, pain,   exposure of dermal layer 
Expected at 50+ Gy
Skin Care Recomm­end­ations- silver sulfad­iazine cream (antib­act­erial), hydrogel 

Nutrition (NOT DONE YET)

Anorexia- lack/loss of appetite for food
1. Fatigue
2. Dry mouth, esopha­gities, nausea, vomiting
3. Presence of pain/i­nfe­ction
4. Presence of stress, anxiety, depression
5. Change in lifestyle patterns

Advice to patients
1. Eat small meals at frequent intervals
2. Adjust their protei­n/c­alorie intake
3. Avoid drinking fluids with meals so they do not feel full faster
4. Remove unpleasant smells
5. Use nutrit­ional supple­ments

Early satiety- inability to eat a full meal or feeling full after only a small amount of food

Late Tumor Burden-
Larger tumor burden = more difficult to restore energy
Esopha­gitis - inflam­mation of the esophagus

Marasmus- severe undern­our­ishment (usually occurs in children)

Cachexia- wasting away of the body due to severe chronic illness

Dysphagia- difficulty swallowing

Clinically Signif­icant Weight Loss

Factors Affecting Nutrit­ional Status
1. Pre Existing condit­ion(s) - diabetes, liver/­renal disease, poor housing
2. Surgery Related Factors - chewin­g/s­wal­lowing for H&N, early satiety for stomach
3. Cancer Related Factors - weight loss, anorexia, early satiety, altered body image

Side Effects
General Therapist Recomm­end­ations
1. Drink plenty of fluids
2. Avoid raw fruits­/ve­ggies
3. Reduce alcohol consum­ption
4. Avoid tobacco products
5. Avoid extremely hot/cold foods

Tolerance Doses 5/5

TD 5/5 (Gy)
2 - 3
Bone Marrow
Growing Cartilage
Whole Lung
Whole Kidney
Whole Liver
Salivary Glands
Whole Intestine
Whole Heart
Whole Brain
20 cm Spinal Cord
1/3 Lung
1/3 Liver
1/2 Intestine
1/2 Kidney
5 -10 cm Spinal Cord
Whole Stomach
Whole Lymph Node
Optic Chiasm
Whole Esophagus
100 cm2 Skin
1/3 Stomach
1/3 Brain
1/3 Heart
1/3 Esophagus
10 cm2 Adult Bone
50 cm2 Oral Cavity & Pharynx
Mature Cartilage
Adult Muscle
2/3 Bladder
10 cm Ureters
1/3 Bladder
10cm2 Large Arteries and Veins