recommendations for nurses in the management of patients receiving radioiodine

7/29/2019 RECOMMENDATIONS FOR NURSES IN THE MANAGEMENT OF PATIENTS RECEIVING RADIOIODINE

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Date Issued: March 2008

Review Date: March 2011 Page 0

NZNO Cancer Nurses Section

RECOMMENDATIONS FOR NURSES IN THEMANAGEMENT OF PATIENTS RECEIVING RADIOIODINE

THERAPY


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CONTENTS PAGE

INTRODUCTION 2Radio-biology 3131- Iodine (131-I) 3

PRINCIPLES OF RADIATION SAFETY 5

AIMS OF THE GUIDELINES 6Optimisation of protection 6Individual dose and risk limitations 7

SAFE PRACTICE 8

INFORMED CONSENT 8

NURSING COMPETENCE 9

NURSING ASSESSMENT 10

NURSING MANAGEMENT 10Checklist for high dose administration as an inpatient 11Pre-admission 11Prior to treatmentAdministration of Iodine 131 11Patient care while in isolation 12Discharge 12Checklist for low dose administration as an outpatient 13Pre-admissionAdministration 13Staff monitoring and safety management 14

MANAGEMENT OF RADIOIODINE SPILL 15Immediate action 15Decontamination procedures 16Documentation 16Emergency care 17Emergency spill kit 17

META-IODO-BENZYL-GUANIDINE (MIBG) IV THERAPY 18Nursing information 18

EXAMPLE OF PATIENT INFORMATION 19

EXAMPLE OF 131- IODINE THERAPY CHECKLIST 20

EXAMPLE OF RADIOIODINE AUDIT-INPATIENT 21

BIBLIOGRAPHY 22

ACKNOWLEDGEMENTS 22


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INTRODUCTION

Human beings have always been exposed to a small but finite level of radiation, primarily from naturally

occurring radioactive materials eg Potassium-40, and from cosmic radiation reaching earth from origins in outer

space. The level of radiation from these sources varies from place to place on the surface of the earth and is

termed natural background radiation.

Radiation exposure above background can arise from sources such as medical diagnostic radiation both from x

ray sources and radionuclides (radioisotopes). Certain occupational groups are subject to radiation above

background levels in their work. Included in this group are those that come into contact with patients undergoing

therapy with radionuclide sources and those who work in x ray departments. Radiation exposure from

necessary medical procedures are not however included in the determination of the occupational radiation

exposure status of the individual. (It is also interesting to note that modern air travel at high altitude, results in a

small increase in radiation exposure to air crew and members of the public).

When using radionuclides for therapeutic purposes, consideration must be given to the potential for radiation

exposure (however small) to nursing staff in the hospital environment as well as other people in the home

environment.

The radionuclide 131-I, as Sodium Iodide (NaI), is used in cases of thyroid disease for its ability to concentrate in

the thyroid gland and destroy thyroid tissue. It is administered as a liquid by a trained physicist on prescription

from a licensed medical practitioner.

The radio isotope circulates in the blood stream with concentration in thyroid tissue. Excretion is via the kidneys

and thus the urine is highly radioactive. Generally however all body excretions e.g. sweat, vomit and saliva

must be considered as radioactive.

Radioactive decay of the 131-I results in the emission of both beta particles and gamma rays. Beta particles

travel only a few millimetres in soft tissue before expending all their energy. Gamma rays produced by radio-

isotopes distribute their energy throughout the body, and significant amounts can pass through the body without

a reduction in intensity. These gamma rays therefore present a potential hazard for persons near to the

patient.

In addition to the radiation that penetrates through the body, a large proportion of the radioactive iodine is

excreted in the urine over the first 48 hours. Much smaller amounts are present in saliva and perspiration, as

noted above. Consequently, avoiding contact with body fluids whenever possible is important, as is the

checking of items in the patients room for contamination prior to disposal.

By 72 hours, the risk of contamination from body fluids is minimal.

During the first 12 hours any vomiting will result in loss of 131-I in the vomitus.


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RADIO-BIOLOGY

131-Iodine, 90-Yttrium, 89-Stontium and 111-Indium are radioactive materials used to treat patients.

They are termed unsealed sources as they are in liquid form and are given to patients orally or by

injection. Thus they become part of the patients biological system. This is different to the sealed

sources (for example 137-Caesium used in gynaecological work, which are inserted for a particular time

and then removed).

The unsealed sources pose very different radiological protection problems, not only for staff, but family,

and the general public. Contamination of body fluids is frequently a problem.

Generally, the radionuclides suitable for unsealed source therapy have a relatively short half-life when

compared with sealed sources. However, they are significantly longer than the Technetium used in

diagnostic scans in Nuclear Medicine.

The amount of radioactive material is Becquerel (Bq). Generally Mega (106)or Giga (10

9) is used as a

prefix.

Radioactive materials emit a number of different types of radiation. Beta and Gamma are the most

common.

Beta particles only travel a short distance in tissue whereas Gamma radiation is much more penetrating.

The unsealed source therapy is carried out using radioactive materials that emits Beta particles. The

radioactive material finds its way biologically to the target or is injected into the target. The radiation

does not have to travel far to carry out the treatment and it is the Beta particles they emit which cause

the required biological effect.

In the case of 131-Iodine the therapeutic Beta particles are accompanied by Gamma radiation which is

the main problem for radiation protection.

For therapeutic effect, concentration in the target organ or lesion is a must. Ideally this should happen

quickly, and results in more radiation dose delivered to the target than to other organs.

Achieving this can be by manipulating the chemical form of the radiopharmaceutical and then utilising

the bodys physiological processes, or by physically placing the radionuclide in the target volume.

Post administration, the absorbed dose rate reaches a peak at the time of maximum concentration in the

target and then decreases subject to physical radioactive decay and biological excretion.

131-IODINE (131-I)

Picture courtesy of www.cancerhelp.org.uk


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131- I

Physical half life of 8.4 days

The main Beta particle has a maximum energy of 0.606 MeV

The particles have a maximum range in tissue of 3mm

Also emits Gamma radiation, the main energy being 0.364 MeV

The Beta particles contribute to 90% of the therapeutic dose

131- I is by far the most important and widely used unsealed source. In the chemical form of Sodium

Iodide, it is given orally for treatment of both benign and malignant thyroid conditions.

Activities given to patients range from 300MBq for treatment of thyrotoxicosis to 10GBq for treatment of

metastatic disease post-ablation of the thyroid in cancer of the thyroid.

Side effects of treatment include sore throat, tiredness, and breathlessness. Rare: swelling of salivary glands

(caused by iodine not radioactivity).

Radiation protection is a major consideration when using 131-I therapy. The patient becomes a source of

relatively high energy Gamma radiation, and also significant amounts of the radionuclide are excreted in the

urine. However, all body excretions, for example blood, perspiration, vomit, saliva, sperm, vaginal secretions,

tears must be considered as being potentially radioactive. When using 131-I, radiation safety of members of the

immediate family and the general public is a concern. If patients are hospitalised, protection of ward staff and

other patients is very important.

Patients who receive in excess of 1GBq are hospitalised in a side room and access is restricted. Radiation dose

rates are measured around the patient until a level is reached when the patient may go home. This is usually

equivalent to 1GBq level.

Post discharge, other restrictions are in place. The length of time depends on initial activity and clinical status

(rate of excretion etc). These restrictions govern physical segregation in the household, in particular, avoiding

young children and women who are pregnant, avoiding public places and transport, and when the patient can

return to work. In the latter case, someone who works outdoors for example on a farm, may return to work

sooner than someone who worked alongside other people, for example a restaurant or playschool.

Contraindications to therapy include a decreased life expectancy, incontinence, and an inability to self care when

in isolation.


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Occasionally patients who receive an activity less than 1GBq are hospitalised for other medical reasons or social

reasons. They are accommodated in a shielded treatment room and access is restricted. The level of radiation

around the patient is obviously markedly less than in the cases of treatment with GBq activities. Consequently,

the restrictions in place are not at the same level. A separate sheet at the end of the instructions for staff

working with inpatients applies. The patient will have received instructions regarding safety of others at home

and the community. The decision to discharge a patient is the responsibility of the clinician.

*****************

Recap:

Low dose iodine is given to reduce the over activity of the thyroid gland to low levels so it can be managed by

thyroid replacement therapy. Regular blood tests will monitor the progress and medication dosages will be

amended until a maintenance dose is determined.

High dose or ablative iodine therapy is used in the management of well or moderately differentiated thyroid

cancers, the aim being to stop any of the remaining thyroid tissue from functioning, which includes the

management of metatastic disease.

Thyroid replacement therapy will be required forever. The isotope circulates in the blood stream with

concentration in thyroid tissue. Excretion is via the kidneys, making urine highly radioactive. However, all body

excretions should be regarded as radioactive.

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PRINCIPLES OF RADIATION SAFETY

Best practice occurs when nurses involved in the care of patients receiving radioiodine therapy understand theprinciples of risk management.

Radiation protection is based on the following three principles:

JUSTIFICATION OF PRACTICE No practice shall be adopted unless its introduction produces a positive netbenefit to the exposed individuals or to society. It shall take into account the benefits, the relative merits ofalternative modalities and the risks entailed in the administration of radiation.

OPTIMISATION OF PROTECTION In relation to a particular practice, the magnitude ofindividual doses, the number of people exposed, and the likelihood of incurring exposure shall be kept as lowas reasonably achievable (ALARA). This procedure should be subject to dose and risk constraints onindividuals.

INDIVIDUAL DOSE AND RISK LIMITATIONS - The risk either from a dose or potential dose to a class ofindividuals shall not exceed the limits set by the regulations and Safe Code of Practice for that class.


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AIMS OF THE GUIDELINES

The purpose of these clinical practice guidelines is to enhance nurses knowledge of radioiodine therapy.The evidence supports specific nursing considerations for patients receiving radioiodine therapy.

The aims are to:

promote a high standard of care for patients receiving therapeutic levels of radioiodine.

prevent or minimise radiation exposure for health professionals and the public.

The recommendations in this document are based on the Code of Safe Practice for the use of Unsealed

Radioactive Materials in Medical Diagnosis, Therapy, and Research as published by the National Radiation

Laboratory, Ministry of Health, New Zealand (1994).

The planning and implementation of care, based on knowledge of the physical properties of radiation and the

application of the principles of distance, time and shielding, are complicated by the need for sensitivity,

communication and confidence by all staff.

Because of the safety considerations nursing care requires reduced patient contact and this may necessitate

frequent rotation of nursing staff. This lack of continuity coupled with the imposed isolation can lead to a sense of

abandonment. However, the nurse who knows and understands the principles of this therapy will convey

confidence that will offer emotional support and reassurance to the patient and family during the therapy.

Collaborative practice will further promote the goals of safe and appropriate care.

OPTIMISATION OF PROTECTION

External radiation hazards are minimised by incorporating the following principles into all aspects of

management including the storage, administration, patient care and waste management:

Shielding. High atomic number materials reduce the intensity of Gamma radiation. Examples are

concrete in the walls in designated room, and fixed and mobile lead shields. Mobile lead shields are

provided in case staff have to attend to the patient. All radioactive material is transported in lead

containers.

Distance. Inverse square law applies. If the volume of a radiation source is small then doubling the

distance from it reduces the radiation dose rate by a factor of 4. Minimising time spent close to source is

very important.


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Time. Because the radioactive material is part of the patients biological system, the radiation cannot be

switched off, nor can the source be returned to the safe position. Any reduction in the time of exposure

results in a corresponding reduction in radiation dose. All procedures involving radioactive material must

be carried out as quickly as possible. Nursing the patient in the room must be kept to a minimum.

Accessing the room to deliver medication must be done behind the mobile lead shield. Nurses are towear their monitoring film badge when caring for patients on treatment.

Internal radiation hazards most commonly result from the following during the preparation of the radio-iodine

Ingestion

Strict hygiene rules must be observed. Mouth pipetting is not permitted.

Inhalation

Through broken skin. Any cuts or broken skin on the hands should be covered with a waterproof

dressing and disposable gloves worn.

Whenever unsealed radioactive materials are handled and there is a possibility of spillage or splashing,

disposable gloves, a laboratory coat or gown and protective glasses must be worn.

INDIVIDUAL DOSE AND RISK LIMITATIONS.

Limits for persons exposed to radiation as a normal condition of employment:

an effective dose of 20 mSv per year averaged over any five year period and 50 mSv in

any one year

an equivalent dose of 500 mSv to the skin at the nominal depth of 7mg/cm

2

,regardless of the total area exposed, in any one year.

an equivalent dose of 150 mSv to the lens of either eye in any one year

an equivalent dose of 500 mSv to the hands and feet in any one year

for women who declare themselves pregnant, an equivalent dose of 2 mSv at the surface of the

abdomen over the remainder of the pregnancy and the intake of any radioactive materials shall not

exceed one-twentieth of the annual limit on intake.

Designated areas for the administration of and subsequent care of inpatients should be designed to minimise

risks. It is recommended that the following considerations are implemented:

The distance between radiation sources and areas of high occupancy be maximised

A designated room should be available for the administration of radiopharmaceuticals as in a nuclear

imaging unit, with signs indicating that treatment is in progress. Radiation physics staff will calculate

what shielding is necessary.

Other patients and visitors and hospital cleaners are not permitted to enter the room.


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Inpatients must have a single room with ensuite, with the bed being as remote as

possible from other hospital beds in the neighbouring rooms. Patients stay in isolation, and have to be

able to self care. They are not permitted to walk around outside the room.

Patients should be advised that it is preferable they wear either hospital clothing, or if they have their

own clothing, something that be can left at the hospital for the entire stay.

Depending on the wall construction some extra shielding may be required. The flooring should be smooth, continuous and non- absorbent. The walls and furniture should be

covered with a non-absorbent surface for ease of decontamination.

Linen and rubbish could be contaminated. Containers must be provided in the room for

temporary storage of linen and rubbish. Meal trays remain in the room. No item must leave the room

until cleared by radiation physics staff.

Wear gloves when in the vicinity of the patient.

An emergency spill kit must be readily accessible. (see page 17).

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SAFE PRACTICE

Management staff in health care establishments are responsible for ensuring that personnel who are

designated to nurse patients receiving radioactive sources are provided with training that includes

theoretical and competence assessment, and for ensuring that personnel have attained sufficient

knowledge prior to undertaking this aspect of care.

INFORMED CONSENT

The treating physician is responsible for obtaining informed consent for therapy. This must be obtained

in a written form prior to commencement of treatment.

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NURSING COMPETENCE

Best practice is achieved by the establishment of training courses for nurses and development assessment

criteria. All nursing staff involved in managing patients receiving radioiodine must be trained and proficient in the

following aspects of management:

Understand the principles of radiation ablation therapy, radiation isotope as a treatment modality and its

action.

Can take a comprehensive nursing assessment, including baseline observations.

Is able to educate patient and family on the procedure, going through patient information leaflet,

checking informed consent has been acquired, reinforcing obligations agreed to by the patient, assisting

patient and families to express concerns and to clarify uncertainties prior to treatment.

Points to discuss with patients and families: Areas for discussion include:

o the patients goals

o the goals of therapy

o the 131-I treatment plan and the associated risks and side effects.

o patient and nursing responsibilities

o associated nursing interventions

o discharge planning

Can correctly use protective equipment and materials:

Has firm knowledge of management of waste, including handling of patients excreta.

Is able to recognise potential occupational hazards, and using methods to minimise these.

Spill management

Emergency procedures

Understand potential side effects and toxicities related to therapy for both patient and nurse, for

example the patient has potential to vomit.

Does the patient know how to contact hospital or physician if required?

Is there adequate support at home?

Is a Community nurse required to follow up post discharge?


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NURSING ASSESSMENT

In order to promote patient, staff and public safety a comprehensive nursing assessment is completed. The

physicians assess the patient as to their suitability to meet the precautions necessary. When considering the

nursing interventions, should the patient be potentially unsuitable for this therapy and all it entails, the nurse

must raise any concerns with the physician.

Risk Factors to be Considered:

1. CognitionCareful assessment needs to be given to identify cognitive or intellectual impairment. The patientsability to comprehend and observe the precautions outlined for distance isolation and for dealing withbody fluids is crucial.

2. Patient UnderstandingAssessing the patients understanding and learning of the processes involved prior to the therapy isessential. The physicist will be able to enhance the patients understanding of radiation safety.If the patient requires translation services, these need to be made available for this learning process. It is

crucial that the patients understanding of the process prior to the administration of 131-Iodine issecured.3. Ability to self-care

Patients for 131-I therapy should be independent in ADLs. Any patient who requires nursing careshould be assessed as to the degree of nursing input necessary. Patients who require more than 15minutes of close nursing attention per duty may not be suitable for 131-I.

4. ContinencePatients who exhibit the potential for incontinence of urine present an unacceptable risk to nursing staff,and should not receive 131-I unless in the nurses opinion, continence can be assured by regulartoileting.

5. Potential for vomitingAny patient who has a significant risk of vomiting within the first 12 hours despite antiemetics must havethe therapy delayed until their condition stabilises and the risk of vomiting is reduced.

NURSING MANAGEMENTROOM PREPARATION

This must be completed before the administration of the iodine and preferably before the patient arrives. This will

allow more personal time to spend with the patient. Advise ward staff of restrictions.

Ensure that:

The room is clean, and any equipment (telephone, television) is functional. Remove any fabric chairs.

Call bell working, emergency equipment in room is available and working. Radiation symbol signage outside of room.

Linen skip is in the room. Rubbish bins are in place, labelled rubbish and food scraps. Safety signs are

placed on rubbish bins so they are not removed prior to clearance

Visitor restriction sign on outside door of room

Water jug, vomit cartons and tissues are in room

Hospital clothing, linen and towels are provided

Spill kit in place outside of room


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CHECKLIST FOR HIGH DOSE ADMINISTRATION AS AN INPATIENTPRE ADMISSION

Written consent for the procedure must be obtained by the prescribing consultant.

Isolation procedures and visitor restrictions must be outlined and a commitment from the patient to abide

by these, to be obtained either verbally or incorporated in signed consent form.

Check that patient knows when to stop thyroxine, or similar medications containing iodine as advised bymedical staff. Fish and shellfish contain iodine. These items must not be consumed within two hours of

treatment.

Advise the patient that in the event of contamination any items they bring into hospital may need to go

into storage for an indeterminate time.

Advise patient to bring in reading material etc. to occupy themselves keeping, the above statement in

mind. Letters may be written but must be cleared for radioactivity before posting. However, instruct

patient not to lick the stamps.

Instruct patient that on the day of admission to have a light breakfast of tea and toast and then nothing to

eat or drink for two hours pre treatment to maximise uptake and minimise the risk of vomiting. Assess and determine patient needs while in isolation, for example, dressing changes for wounds or

tracheostomy care. Consider whether patient can manage their own dressing change. There must be

discussion with the physicist regarding nursing intervention in the case where patient needs help, as to

appropriateness prior to treatment. If help is required, and agreed to by physician and nurse, ensure

staff rotate in caring for patient.

Assess need for other medications.

Routine admission procedures must be completed prior to the administration of the iodine. This includes

blood tests and x-rays.

If there is a possibility of pregnancy, a pregnancy test is mandatory and treatment must be delayed until

results are available.

PRIOR TO TREATMENT

Complete nursing assessment and record any dietary requirements, baseline observations.

Check consent has been signed.

Check that the patient identity bracelet is on patients wrist.

Check patient has been nil by mouth for two hours prior to administration of radioiodine.

Recommend wearing of hospital clothing.

Administer antiemetic medication.

Remind patient of visitor restrictions.

Notify physicist when nursing assessment is complete.

ADMINISTRATION OF 131-I

Iodine 131 is available in liquid and capsular forms or as an injection. It is the responsibility of a Registered

Radiation Therapist or Physicist to administer. The identity of patient must be confirmed and consent for

treatment signed. Protective clothing and gloves must be worn at all times. Protect patients clothing.


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1. Remove patients dentures, or dental plates.

2. Patients must drink the isotope through a straw, taking care not to spill it. The patient holds the straw, or

the staff may use forceps to steady the straw . A non-touch technique should be used if medication is

in capsular form.

3. Dentures may now be replaced.

4. The patient requires a follow-up appointment with consultant.

ADVICE FOR VISITORS: RESTRICTIONSPreferably for the first 24 hours-- No visitors.After 24 hours, a maximum of an hour each dayNo pregnant women or children under 16 years of ageVisitors must keep a distance of two metres from patientNo personal contact, for example, hugging and kissingVisitors must not handle any of the linen, food utensils or toiletriesVisitors must not share food or drinks with patient

PATIENT CARE WHILE IN ISOLATION

Observe for incidents of nausea and / or vomiting

Over the subsequent days, observe for signs of tenderness or swelling of the thyroid area. Report to

medical staff as early intervention will prevent any degree of dysphagia or shortness of breath.

Patients should be physically able to attend to own cares. Any assistance required will need to comply

with maintaining minimal physical contact by staff.

Check each duty that patient has plenty of fluids and that meals are acceptable. Ensure linen

requirements are meet.

Isolation is always difficult for the patient to endure and they require a great deal of encouragement and

support from staff. Reassure patients that nurses are always available when needed. Ensure patient of

ringing bell, or telephoning for nursing staff if any concerns arise. The door to the room may be left open.

Does patient want daily newspaper delivered?

As isolation progresses patients often become increasingly anxious to leave hospital, therefore it is

important that an inappropriate discharge date is not given to avoid confusion and disappointment.

DISCHARGE

The time of discharge is determined by the level of radiation remaining on the patient therefore only an

estimated date can be given to the patient prior to the therapy. First ablative therapy averages 4 to 5 days.

Subsequent treatments may only require 2-3 days

Patients undergoing ablation must have a body count with a calibrated radiation detector to determine when they

can leave hospital. Discharge limits are according to the NRL Code of Practice C3.

Discharge information and instruction should be given to patients:


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PATIENT DISCHARGE INSTRUCTIONS

These restrictions apply for up to one week following your discharge

Refrain from holding and cuddling children and pregnant women or being to close to them, less

than two metres, for more than a few minutes at a time

Avoid sleeping in the same bedroom as a spouse / partner

Avoid visiting places of entertainment or going to work

Use your own set of crockery and cutlery, or use disposables

Refrain from food preparation

Restrict use of public transport

Flush the toilet twice after use and wash hands thoroughly

On discharge you should have a prescription for thyroxine, an appointment for a whole body scan

and an appointment to see the consultant for review.

CHECKLIST FOR ADMINISTRATION AS AN OUTPATIENTPRE ADMISSION.

Patient to be notified that following therapy they will be radioactive for up to one week following

treatment.

Close contact with children and pregnant women must be avoided. If employment involves contact with

either, or the patient is employed in the catering/food industry, arrangements for leave need to be made.

To maximise uptake and to reduce the likelihood of vomiting the patient should have nothing to eat or

drink for 2 hours before their appointment

If there is a possibility of pregnancy, a pregnancy test is mandatory and treatment must be delayed until

results are available

ADMINISTRATIONThis is the responsibility of a Registered Radiation Therapist or Physicist. The identity of patient must be

confirmed and consent for treatment signed. Protective clothing and gloves must be worn at all times by

staff. Protect patients clothing. Any blood samples/x-rays required must be taken prior to treatment starting.

1. Remove patients dentures, or dental plates.

2. Patients must drink the isotope through a straw, taking care not to spill it. The patient holds the straw (or

staff member may use forceps to steady the straw). A non-touch technique should be used if medication

is in capsular form.

3. Dentures may now be replaced.

4. The patient requires a follow-up appointment with consultant.


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DISCHARGE INSTRUCTIONS TO THE PATIENT.

The radiation dose you have received is low.

In order to maximise the benefit of treatment we recommend that you do not eat or drink for two hours

after the treatment.

If you are sick within 2-3 hours, vomit into a toilet or an area where human or domestic animal access is

unlikely soon after you have been there.

Notify your consultant as you may need another dose.

In order to reduce the risk of exposure to others the following is recommended .

Flush the toilet twice after use and wash your hands thoroughly.

For one week after the drink avoid close contact, (i.e. more than two metres), with young children and

pregnant women for more than short intervals.

For one week after the drink avoid greeting people by kissing or shaking hands, and from preparation of

food, It is advisable to have your own personal set of cutlery and crockery during this time.

STAFF MONITORING AND SAFETY MANAGEMENT.(This may vary, refer to local policy)

If staff need to enter the room:

Pregnant staff must be exempt from caring for patients on treatment

Staff must wear radiation film badge.

Wear gown and gloves.

If patient requires any help, for example making the bed, nurse must only remain in the room for no

more than 15 minutes per 24 hours. If practical, have patient sit 2 metres away while chores are

attended to. Any dressing cares should have been addressed prior to treatment starting.

Avoid direct contact with patient where possible.

Do not remove any soiled linen or rubbish from the room.

If patient should vomit, spill procedure must be followed.

Avoid any unnecessary accumulation of equipment, for example, consider removing food from meal tray

before entering room. If meal tray is taken into room it will need to stay in the room.

Discourage family and visitors from congregating outside the room.

Allay feelings of loneliness or isolation by regular communication, conversation from the door.


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MANAGEMENT OF RADIOIODINE SPILL

THE RADIATION SAFETY OFFICER OR LICENSEE MUST BE NOTIFIED IMMEDIATELY

Spill management must be adhered to, to minimise the spread of contamination to staff, patient and thegeneral public, and surrounding environment.

IMMEDIATE ACTION CORDON AREA OFF

If spill involves patient (vomiting)

Reassure patient.

Get patient to do as much as possible ie. change and clean themselves and put soiled clothing, linen in

plastic bag in skip..

If able, cover the spill with absorbent material.

Leave patient sitting quietly in the room until the Radiation Safety officer and/or clean up crew arrive.

Protective clothing must be worn, and overshoes before entering room.

If spill involves staff

If spill is liquid and hands are protected (gloved), right the container and cover the spill with absorbent

material.

If spill on clothes, all contaminated clothing must be removed and placed in plastic bag.

Limit/ prohibit entry to the spill area until the clean up crew arrive.

Remain in the room until cleared by physicist. Wear overshoes to prevent spread of contamination.

Complete incident report as per local policy after clean-up is complete.


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DECONTAMINATION PROCEDURES.

Decontamination of personnel

DO NOT SHOWER unless the Radiation Safety Officer gives approval.

Wash affected area only using soap and water. Avoid contamination of eyes and mouth, and any

breaks in the skin surface.

Non-contaminated person to check using radiation detector. Repeat above two steps until no further reduction in concentrate is achieved.

Decontamination of area

Ensure that staff are wearing protective clothing and overshoes.

Cover spill with absorbent paper.

Ensure radioactive warning signs are in place.

Wash area with detergent and water.

Monitor area with a radiation detector, for example, Geiger counter. Repeat washing until no further

reduction in concentrate is achieved.

If short half - life isotope is involved, then spill may be isolated for a few days if appropriate.

Place contaminated gloves, paper etc. in waterproof bag and store until levels of radioactivity comply

with those levels set by the Code of Safe Practice.

DOCUMENTATION.

Complete an incident form as per local policy. Include the following:

Date and time of incident.

Location.

Personnel involved.

Description of incident.

Action taken

A copy may be required by the Radiation Safety Officer for forwarding to the National Radiation

Laboratory.


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EMERGENCY CARE

If calling a code, it is imperative that the physicist is also notified.

Wear gown and gloves before entering room

Adhere to care of body fluids guidelines

For respiratory resuscitation use Laerdal bag to ventilate patient

Change working staff to within 2 metres of the patient every 15 minutes. If any person has to remain

with the patient for more than 15 minutes, that person must work from behind the mobile lead shield.

Maximum time within 2 metres of the patient without a lead shield is 15 minutes per person

Organise equipment so that procedures such as drawing up drugs are done 2 metres from the patient.

Do not remove any equipment or allow any staff member who has attended the patient to leave

until checked by the physicist.

EMERGENCY SPILL KIT

The National Radiation Laboratory states that every dispensing laboratory and therapy room shall haveready access to an emergency kit located in a well marked place

The kit should contain

radiation survey meter (Geiger counter)warning signs to prevent entryprotective clothinggowns or overalls (2)impermeable gloves (4 pairs)disposable overshoes ( 2 pairs)mild soap or chelating detergent

decontaminating agent

spongeiodide tablets and phosphate carrier solutions, ifappropriatesurface decontamination equipmentbucket and scrubbing brushtowelsabsorbent pads

forceps or tongslead potplastic bagssealing tape


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META- IODO- BENZYL-GUANIDINE (MIBG)

IV THERAPYNURSING INFORMATION

MIBG, also known as iodine l 131 metabenzylguanidine is a radioactive substance that is used in imaging tests

and cancer therapy. It is a type of radiopharmaceutical and is used on the treatment of neuroendocrine tumours,

that is, cancers formed from the same sorts of tissue as found in the adrenal glands such as

phaeochromocytoma. (www.cancer.gov).

Phaeochromocytoma is a rare condition where the body produces too much adrenaline/noradrenaline, or both,

caused by a tumour in the adrenal medulla. Because of the increased quantity of hormone, a person is at risk of

dangerously high levels of blood pressure or brain haemorrhage. If the phaeochromocytoma is outside the

adrenals, the aim is to surgically remove it. However if this is unsuccessful or impossible to achieve, then MIBG

is often the treatment of choice. MIBG works by target and being taken up by the overactive hormone secreting

cells. (NHS Tayside Nuclear Medicine Unit).

Before injection, the MIBG is attached to the radioiodine, which is radioactive. The need is to target cancer cells,

and not the thyroid gland. Medication to block the thyroid is given prior to treatment. Most of the iodine is taken

up by the cancer, and the rest passes out of the body in urine. Patients have 4 episodes of treatment, at 6-8

week intervals. The starting dose is 4GBq, with increasing amounts as tolerated. The patient may be in hospital

for about one week (7-10 days in some cases) each episode.

THE SAME PRECAUTIONS FOR 131-I THERAPY MUST BE ADHERED TO

The patient is under the care of the Oncology and the Nuclear medicine teams. The prescribing physician is

responsible for obtaining informed consent, peripheral cannulation and injection of the drug.

POINTS OF DIFFERENCE

Additional Side effects:

Labile blood pressure. Because MIBG can cause labile blood pressure, it is essential that blood pressure is

monitored during admission. Ideally a self-monitoring sphygmomanometer for patients will be made available.

Education around the importance of blood pressure checks, and teaching the patient how to take their own blood

pressure is required.

Acute bone marrow suppression (25% of patients) post treatment episodes. Patients are at risk of infection.

Psychological support. Assess patients feelings of isolation, loneliness. Patients may bring in DVDs, Laptop,and radio to help pass the time.

SAFETY

Nursing Staff: 10 minutes exposure per duty

No more than 30 minutes within one month. This is a 1/3 of maximum allowable.


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EXAMPLE OF PATIENT INFORMATION

Welcome to Your hospital stay will be approximately 2-4 days.

You have been assigned a single room, with ensuite so that others will not be affected with radioactive iodine during your

stay. Once you have settled in the room, the nurse will repeat information given to you by the Radiation Physicist on your

obligations while on treatment. The nurse will take recordings of your vital signs (temperature, pulse, blood pressure).

Please take this opportunity to discuss with the nurse any concerns you may have, and discuss any further medications that

you may require.

Very few side effects occur as a result of taking radioiodine, but nausea has been experienced by some, and you may feel

queasy. To prevent any vomiting, the nurse will provide you with an anti-sickness drug to be taken before receiving

radioiodine. Further anti-sickness drugs will be provided also at your request if nausea continues.

The physicist will then bring your radioiodine in a special container. It is about 10mls of clear, tasteless fluid. Using a straw,

swallow this, followed by two small amounts of water. Dentures or dental plates must be removed before taking radioiodine.

Your body contains radioactivity therefore contact with others is restricted. Signs indicating treatment is in progress will be

placed outside your room

Once you have taken radioiodine YOU MUST REMAIN INSIDE YOUR ROOM.

Shower: When you wish, all towels and soiled linen remains in linen skips inside your room.

Toilet: Your urine is radioactive. Please flush toilet twice after use.

House-Keeping: Please keep room tidy, with bed made. All rubbish remains in rubbish bin inside your room.

Meals: There are no dietary restrictions exceptavoiding fish/seafood prior to iodine drink and for 2 hours after. Meal trays

will be placed on a table outside the door to your room. Discard leftovers into bin marked Food Scraps. Plastic cutlery and

disposable cups and plates are discarded into rubbish bin.

Leftover liquids may be discarded down the sink.

A water jug will be in your room. Please use the tap in your room to refill.

Food or fluids brought in by you must also remain in your room.

Entertainment: Please bring items which will help pass the time, for example, books, radio, laptop, DVDs, writing material,

magazines. Some rooms may have a television. You may check.

Nursing Care: a nurse is assigned to you for each shift, while you are on treatment. Please ring bell to summon your nurse

if you have any requests, enquiries. The nurse will talk to you at the door. Please remain a distance of 2 metres away from

the door when conversing.

MAIN POINTS

Remain in your room. The door can be left open if required.

Keep all items in your room until you are discharged.

Keep a distance of 2 metres between yourself and staff

Visitors must observe the restriction signs and remain at the doorSharing food or drinks with visitors IS NOT PERMITTED

The nursing staff wish you well, and endeavour to make your stay with us comfortable and restful.


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EXAMPLE OF 131 IODINE THERAPY:CHECKLIST

PREPARING ROOM White linen skip in bathroom

2 x rubbish bins with plastic rubbish bags, labelled rubbish and food scraps

2 x vomit cartons

Tissues in brown paper bag

Disposable cutlery knife, fork, spoon

Disposable cups

Towels, face cloths, ensure soap is in dispenser

1 x full jug of water

Extra blankets

1 x rubbish bin with plastic bag placed in bathroom

OUTSIDE PATIENTS ROOM

2 x Long sleeved yellow disposable gowns

1 x box gloves

Plastic spill sheet

Mobile shield

Warning signs

NURSING REQUIREMENTS

Nurse is wearing radiation film badge

Patient is orientated to ward and treatmentPatient Information sheet is discussed with patient

Record baseline observations

Administer antiemetic medication

Notify the physicist that patient has arrived, settled and has taken antiemetic

DISCHARGE

Physicist clears patient for discharge

Room and contents left undisturbed after patient has left. Signs remain in place

Physicist will remove contaminated linen and rubbish

Physicist must declare when room is free of radiation precautions

All articles left in room may now be discarded in the usual manner. Bed can now be

remade, and room cleaned

(Based on checklist designed by Natalie Mason)


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EXAMPLE OF RADIOIODINE THERAPY AUDIT INPATIENT

CRITERIA

Nurse is wearing regulation radiation film badge

Patients room has been prepared as per protocol:

Clearly marked bins for rubbish and food scraps, bin for bathroom, linen skip,fresh lien and towels, disposable cutlery and cups, vomit cartons, tissues, paper

bag, extra blankets, water jug, vomit cartons

Patient is informed of how to contact nurse for any requests, queries such as call

bell, telephone contact number

Outside room: Spill kit, Gloves, spill sheet, yellow disposable gowns, overshoes

On admission patient is assessed, orientated to environment, information and

obligations regarding treatment are reinforced, for example not leaving the room

Assessment includes recording baseline observations

Assess for nausea. Patient is given antiemetic, and is instructed to notify nurse if

nausea persists during treatment

Physicist is notified of patients arrival. Physicist will bring radioiodine

Ensure warning signs are clearly displayed outside patients room.

Ensure mobile shield is in place outside door.

Patient are discharged only after physicist review

Room and contents must be left undisturbed until cleared by physicist

Once cleared, all other articles may be discarded and room cleaned and set up

for next admission

(Based on audit designed by Natalie Mason)

Questions:

How often should nursing staff change their film badge?

Staff can safely stand at the patients door during treatment. What is the recommended distance between patient

and nurse?

Where do you locate the physicist, or on-call physicist locator numbers?

What process would you undertake if the patient should vomit or become incontinent during the treatment?

Explain the process of managing a patient during and emergency, for example Cardiac Arrest/ Respiratory

Arrest or Respiratory event (anaphylaxis)?

What is the maximum time a nurse can spend in the patients room within 2 metres of the patient, without the

lead shield present in an emergency situation?


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BIBLIOGRAPHY

British Code of Practice for the protection of persons against Ionising Radiation arising from medical and dentaluse.

International Commission on Radiation Protection, (1977). The handling, storage, use and disposal of unsealedradionuclides in hospitals and medical research establishments.

Pergamon Press for the ICRP. ICRP publication no.25

National Radiation Laboratory (1994). Code of safe practice for the use of unsealed radioactive materials inmedical diagnosis, therapy and research. (NRL C3). National Radiation LaboratoryMinistry of Health. PO Box 25-099 Christchurch, New Zealand.

N.B The legislation under which the above code was written is;New Zealand Radiation Protection Act 1965New Zealand Radiation Protection Regulations 1982

Useful Resources

www.cancer.govNHS, Tayside, Nuclear Medicines Unit. www.dundee.ac.ukThe Royal Marsden Hospital Manual of Clinical Nursing Procedures (2004). 6

thed. Blackwell Publishing:

Oxford.

Acknowledgements

Thanks to previous members of the Cancer Nurses National Committee

Thanks to: Jenny Baylis, Jacqui Bowden Tucker, Joan Carter, Trish Clark, Lynda Dagg, Noelle Farrell, Maureen

Morris, Catherine Smith, NZNO Cancer Nurses Section National Committee 2007-2008Anne Brinkman, Professional Nurse Advisor, NZNOKath Honeybone, Charge Nurse, Auckland City HospitalNatalie Mason, Senior Staff Nurse, Auckland City HospitalMichael Rutland, Consultant, Nuclear Medicine, Auckland City HospitalAllan Stewart, Physicist, Auckland City Hospital

recommendations for nurses in the management of patients receiving radioiodine

Documents