NURSING DIAGNOSIS RELATED TO THE ADVERSE EFFECTS OF RADIOTHERAPY

Radiotherapy is frequently used in cancer treatment, but it often causes several adverse effects, both immediate and late ones. Objective: To construct nursing diagnoses related to the adverse effects of radiotherapy. Methodology: This is a descriptive, exploratory study, consisting of three stages: literature review on the adverse effects of radiotherapy using textbooks on oncology, and fully available articles from Lilacs and Bdenf databases; selection of empirical indicators, and construction of the nursing diagnoses, according to the ICNP® 2011. Results: 97 diagnoses were constructed considering five different adverse effects (xerostomia, radiodermatitis, trismus, mucositis, and osteoradionecrosis). Conclusion: The previously elaborated diagnoses will be able to guide adequate interventions, allowing for individualized care, and contributing for the effective establishment of the nursing consultation at the Radiotherapy sector.


INTRODUCTION
The World Health Organization (WHO) estimates nearly 27 million new cases of cancer by the year 2030.The greatest effect of such increase will happen in low-and middle-income countries.In Brazil, the estimates for the years 2012 and 2013 were approximately 518,510 new cases of cancer, reinforcing the magnitude of this disease as a public health issue in the country.In Espírito Santo, the occurrence of about 10,740 new cases was estimated for that same period. 1ancer treatment can be local (surgery, radiotherapy) or systemic (chemotherapy).They are used together in the treatment of malignant neoplasms, the only variable being the importance of each one and the order of their indication. 2Radiotherapy is one of the major therapeutic modalities for the treatment of neoplasms.It is a localized treatment, which uses ionizing radiation produced by devices or emitted by natural radioisotopes.It is mostly performed out of hospital. 3t is believed that 50% of patients with cancer will need radiotherapy.However, despite being an effective treatment, it brings some acute and chronic manifestations, known as adverse effects, with the main ones being: skin reactions (radiodermitis, erythema), nausea, mucositis, xerostomia, fatigue, anorexia, diarrhea and disphagya. 2Prevention and control of these effects are critical, because they may limit the treatment, lead to the need for temporary or permanent withdrawal, decrease the patient's motivation to continue with the treatment planning, thus compromising local tumor control rates and survival. 4herefore, the nursing team must act to minimize these effects and serve as a link, working on specific care, on patient and family education.The nursing consultation in the radiotherapy department deserves special attention because it is the most specific activity performed by nurses in the sector.The patient seeks the nursing consultation in order to obtain information for the practice of self-care and to face care.Thereby, the nursing consultation customizes nursing care in the radiotherapy department. 5n order to organize and systematize nursing care, the nursing process or nursing consultation, a methodological tool, is used.It is organized into five interrelated, interdependent and recurring steps, namely: data collection (or history), diagnosis, planning, implementation and evaluation. 6he use of classification systems or taxonomies related to the nursing process provides benefits, such as planning security, implementation and evaluation of nursing work, improved communication and quality of documentation, visibility of nursing actions and development of electronic records and service organization. 7vertheless, the existence of various classification systems to describe nursing practice led the International Council of Nurses (ICN) to the conclusion that nursing needed an international classification system for practice, considering a suggestion made by WHO. 8 In this sense, the ICN developed the International Classification for Nursing Practice (ICNP®) in an international project.Among the existing classifications, the ICNP® is the only internationally validated classification and was approved in late 2008 for inclusion in the WHO Family of International Classifications, becoming the standard terminology that represents the domain of practice and unifies nursing in a worldwide level. 9he ICN emphasizes that, in order to fulfill its objectives, ICNP® should be incorporated into the daily activities of nurses in the health and educational institutions, in order to keep up with the changing demands of the profession, which makes it a major challenge for professionals, who should adopt strategies to promote this practice. 8,9iven the above, and considering the importance of the nursing consultation in radiotherapy, the aim of this study was to construct nursing diagnoses related to the adverse effects of radiotherapy.

METHODS
This was a descriptive-exploratory study, consisting of three stages: literature review on the adverse effects of radiotherapy using textbooks on Clinical Oncology, manuals by the Ministry of Health and scientific articles from Latin American and Caribbean Health Sciences Literature (LI-LACS) nursing databases (Bdenf).The following descriptors were used: radiotherapy and adverse effects.Inclusion criteria were: fully available articles in the databases searched, in Portuguese, English and Spanish.The final sample consisted of 12 articles and two books.
It is important to mention that the current articles did not provide the definitions and descriptions of the clinical characteristics of radiotherapy complications, therefore it was necessary to use references, such as textbooks and older articles, which defined the complications, enabling the identification of empirical indicators needed to construct the diagnoses.
Considering the identification and definition of the adverse effects, the empirical indicators were selected.In the hierarchy of nursing knowledge, empirical indicators are the criteria and/or experimental conditions used to observe or to measure the concepts of a theory. 10In this study, empirical indicators were considered as clinical manifestations, signs and symptoms of basic human needs affected due to the adverse effects of radiotherapy.
With regard to osteoradionecrosis, the following indicators were identified: bone necrosis, bone pain, bone edema, bone fracture, loss and suppuration of the bone structure.
Based on the empirical indicators, the respective axes of focus, judgment and location were identified in order to enable the construction of nursing diagnoses, as shown in Table 2.
Table 3 presents the diagnoses based on the adverse effects related to radiotherapy.Ninety-seven nursing diagnoses were constructed according to the ICNP® terms.For the adverse effect mucositis, 24 diagnoses were constructed.In the case of radiodermitis, 12 were constructed; and for trismus, 25 diagnoses.Regarding xerostomia, 17 diagnoses were constructed; in relation to osteoradionecrosis, 19 nursing diagnoses.
Mucositis is an inflammatory reaction of the oral mucosa characterized by erythema and edema of the mucosa, commonly followed by ulceration and peeling, which continues until the therapy is complete.It can result in ulceration, dysphagia, loss of taste, and difficulty eating.5]20 Radiation, when in doses between 40 and 65 Gy, promotes degenerative inflammatory reaction, especially of the serous acinar cells of the salivary glands, leading to decreased salivary flow which, together with the patient's anxiety and depression, triggers xerostomia.It comprises the state in which salivary flow is less than 0.3 mL/min, leading to change of tasting, dysphagia, loss of appetite and weight, adversely affecting the quality of life of the patient, because liquefaction and lubrication of food does not occur, and, associated with mucosal irritation, makes swallowing painful. 12,18sed on the empirical indicators, the researchers developed the nursing diagnoses using terms from the Seven-Axis Model of ICNP® version 2011 and the literature of the area, as recommended by the ICN.For diagnoses, one should necessarily include a term from the focus axis and a term from the judgment axis; if necessary, terms of the other axes should be included (location, means, client, time). 11

RESULTS AND DISCUSSION
Considering the literature review, it was found that radiotherapy is a treatment widely used for malignant neoplasms 5 , however, short, medium and long-term adverse effects are important limiting factors of treatment, because they have consequences in the quality of life of the patients, and therefore this population demands multidisciplinary follow-up. 123][14][15][16][17][18][19][20][21] Five effects were identified, namely: mucositis, radiodermitis, trismus, xerostomia and osteoradionecrosis.Such effects were defined, which allowed for the description of empirical indicators, i.e., signs and symptoms that affect patients' basic human needs.
For the adverse effect, mucositis, six empirical indicators were identified (inflammation, edema, erythema, pain, ulceration and hemorrhage in the oral mucosa).
For radiodermitis, three indicators were identified: dermis inflammation, skin erythema and risk for dermatitis.
Regarding trismus, five manifestations were observed: edema of masticatory muscles, pain in masticatory muscle, difficulty in speech, impaired oral hygiene and difficulty eating.
For xerostomia, four empirical indicators were identified: dry oral cavity, difficulty chewing, difficulty swallowing, and impaired articulation.

Mucositis
Inflammation of the mucous lining13.Inflammation of the oral mucosa, which is manifested as edema, erythema, ulceration, hemorrhage and pain. 2,14,15 Iammation of the oral mucosa; oral edema of oral mucosa; erythema of oral mucosa; pain in oral mucosa; ulceration of the oral mucosa and hemorrhage in the oral mucosa

Radiodermitis
Destruction of the basal cell layer of the epidermis (loss of permeability) with exposure of the dermis (inflammatory process) and manifests as erythema, which may or may not evolve to dermatitis. 15,18rmis inflammation; skin erythema; risk for dermatitis

Trismus
The masticatory muscles, while inside the radiation field, present edema, cellular destruction and fibrosis.[21] Pain in masticatory muscle; edema of masticatory muscles; difficulty in speech; impaired oral hygiene; difficulty eating Xerostomia Dry oral cavity resulting from decreased salivary gland function.13-15,20 Xerostomia causes difficulty chewing, swallowing and articulation, not affecting the physiological aspects of food transportation, but the sensory process and comfort during eating. 4,12  oral cavity; difficulty chewing; difficulty swallowing; and impaired articulation.

Osteoradionecrosis
Osteoradionecrosis is the ischemic bone necrosis due to radiation, resulting in pain and possible substantial loss of bone structure.20,21It can also result in edema, suppuration and pathological fractures. 15,16 e necrosis; bone pain; bone edema; bone fracture; loss and suppuration of the bone structure.
Radiodermitis can also occur after radiation exposure and is characterized by initial erythema, progressive edema, hyperpigmentation, dry or moist desquamation and ulceration, depending on the dose of radiation. 2,21It happens due to destruction of the basal cell layer of the epidermis (loss of permeability), exposing the dermis (inflammatory process).It manifests as erythema, which may or may not evolve into dermatitis. 14,16

Mucositis
Light inflammation of the oral mucosa; moderate inflammation of the oral mucosa; severe inflammation of the oral mucosa; risk for inflammation of the oral mucosa; light erythema of oral mucosa; moderate erythema of oral mucosa; severe erythema of oral mucosa; risk for erythema of oral mucosa; light pain in oral mucosa; moderate pain in oral mucosa; severe pain in oral mucosa; risk for pain in oral mucosa; light edema of oral mucosa; moderate edema of oral mucosa; severe edema of oral mucosa; risk for edema of oral mucosa; light ulceration ofthe oral mucosa; moderate ulcer in the oral mucosa; severe ulcer of the oral mucosa; risk for ulcer in the oral mucosa; light hemorrhage in the oral mucous membrane; moderate hemorrhage in the oral mucous membrane; severe hemorrhage in the oral mucous membrane; risk for hemorrhage in the oral mucous membrane.

Radiodermitis
Light skin inflammation; moderate skin inflammation; severe skin inflammation; risk for skin inflammation; Light heat erythema on the skin; moderate heat erythema on the skin; heat erythema on the skin; risk for heat erythema; light skin eczema; moderate skin eczema; severe skin eczema; risk for skin eczema.

Trismus
Light edema of masticatory muscle; moderate edema of masticatory muscle; severe edema of masticatory muscle; risk for edema of masticatory muscle; light pain in masticatory muscle; moderate pain in masticatory muscle; severe pain in masticatory muscle; risk for pain in masticatory muscle; light moderate dysarthria; severe dysarthria; risk for dysarthria; light discomfort in the oral cavity; moderate discomfort in the oral cavity; severe discomfort in the oral cavity; risk for discomfort in the oral cavity; effective oral hygiene; ineffective oral hygiene; risk for ineffective oral hygiene; effective self-care; ineffective self-care; risk for ineffective self-care; effective eating; ineffective eating; risk for ineffective eating.

Xerostomia
Light dry oral mucous membrane; moderate dry oral mucous membrane; severe dry oral mucous membrane; risk for dry oral mucous membrane; effective swallowing; impaired swallowing; risk for impaired swallowing; effective chewing; impaired chewing; risk for impaired swallowing; impaired effective tasting; impaired tasting; risk for impaired tasting; light maxillary articulation contracture; moderate maxillary articulation contracture; severe maxillary articulation contracture; risk for maxillary articulation contracture.Finally, the nursing process is an essential instrument for the organization of clinical practice and the ICNP® uses practical methods for the construction of diagnoses and selection of interventions that facilitate nursing care systematization. 25

CONCLUSION
It can be concluded that radiotherapy is a widely used treatment modality in cancer treatment, but often leads to both immediate and late adverse effects, five of which were evidenced in this study: mucositis, radiodermitis, trismus, xerostomia and osteoradionecrosis.Considering these adverse effects, 97 nursing diagnoses were constructed.
This finding strengthens the understanding of the importance of nursing diagnosis construction in the care process, since the correct identification of a diagnosis is essential to guide appropriate interventions and thus allows for the provision of individualized care, guided by the actual patient's demands.
Thereby, previously constructed diagnoses related to the side effects can guide nurses' clinical reasoning in the planning of nursing interventions, contributing to the effective implementation of the nursing consultation in the radiotherapy department.Their development reinforces the importance of using a uniform language by nurses in order to facilitate communication and improve care.The ICNP®, a methodological tool, international adopted for nursing practice, allowed for language standardization.The 2011 version includes terms of nursing practice, with its language being simple and easy to understand, which favored the construction of the diagnoses.
This study is expected to motivate professionals to study the ICNP® and subsequently develop validation studies of these diagnoses, contributing for the improvement of this nursing classification.
Osteoradionecrosis is one of the most serious complications of radiotherapy, with a more pronounced effect in the elderly.Ionizing radiation makes vascular channels narrower, which decreases blood flow.Thereby, the pathogenesis of osteoradionecrosis depends on the degree of impairment of vascularization, as well as the decrease of viable osteocytes and osteoblasts in the bone affected.Signs and symptoms include edema, soft tissue erythema, exposure of necrotic bone, trismus, ulceration, pain, intra and extraoral suppuration, paresthesia and pathological fracture. 17,21adiation-induced trismus, which occurs three to six months after completion of treatment, has significant impact on the quality of life of patients, because it hinders the mandibular mobility, compromises oral hygiene, speech and nutrition, and impairs rehabilitation.The masticatory muscles, while inside the radiation field, present edema, cellular destruction and fibrosis. 12,19,20 nsidering these results, the use of nursing diagnosis may favor the autonomy of nurses, serving as a reference for the development of nursing interventions, enabling nurses' exercise of critical thinking and clinical judgment.
Moreover, authors state that the nursing process guides the way nurses think dynamically, in order to make appropriate decisions about what the care needs are (diagnoses), what outcomes are to be achieved (outcomes) and about the best care to meet those needs related to the desirable outcomes (interventions). 6,7t is important to mention that the application of the nursing process improves the quality of nursing records, favoring the evaluation of care and directing the actions of assistance.The respect to the individuality of the patient is considered.It should be noted that individualized care articulates a favorable relationship with the multidisciplinary team, patient and family, favoring the humanization of care. 22 study concluded that nurses believe in the importance of the nursing process, state that it improves the quality of care, promotes independence and enables the unification of language.However, it was found that most nurses had no knowledge about the process, because 70% could not name a nursing diagnosis and also did not use them in care, and 56% did not perform any of phases. 23urses want to practice all phases of the nursing process, planning, investigating, diagnosing and evaluating interventions.However, they cannot find the path due to a series of factors that separate theory from practice.Thus, the process is said to be implemented, but what is seen is a partial way of working, with the performance of one or other stage. 24n this sense, it is observed that nurses recognize the nursing process as a tool for care planning that assists in structuring and organizing the service, because it orders the actions implemented by the team and written actions.

Table 1 -
Description of the adverse effects and empirical indicators related to radiotherapy.Vitória, Espírito Santo.Mar-Jun/2012

Table 3 -
Adverse effects and nursing diagnoses according to the ICNP® 2011.Vitória, Espírito Santo.Mar-Jun/2012 Light bone pain; moderate bone pain; severe bone pain; risk for bone pain; light bone edema; moderate bone edema; severe bone edema; risk for bone edema; partial bone fracture; total bone fracture; risk for bone fracture; light bone necrosis; moderate bone necrosis; severe bone necrosis; risk for bone necrosis; light loss of bone structure; moderate loss of bone structure; severe loss of bone structure; risk for loss of bone structure.