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Home , Brachytherapy, Nuclear medicine, Radiation therapy

Medical Care Program Southern Region

Radiation Safety for Nurses

Rev. 2/01

RADIATION SAFETY FOR NURSES

HOW TO USE THIS HANDOUT

This handout is in two parts, and you should use each part differently.

The first part, Radiation Safety Review contains essential information for all nurses whose duties may involve radiation and/or radiation sources. Please read all of this section as soon as possible.

The second part, Radiation Safety Procedures, contains specific radiation safety rules for the nursing care of patients undergoing each of the major procedures involving radiation and/or radiation sources. Please read the section on each procedure before providing patient care connected with that procedure. If you are already providing care in connection with a procedure, read the appropriate section immediately, to review the safety rules for nurses.

Page numbers for these procedures are:

Diagnostic X-Ray: page 5

Diagnostic Nuclear : page 6

Radioiodine : page 6

Radiophosphorus Therapy: page 7

Brachytherapy: page 7

Radiation Emergencies: page 8

Rev. 4/02 Kaiser Permanente Radiation Safety Training Nursing Page 1 Radiation Safety Review

INTRODUCTION X-Rays As an experienced professional in your field, you X-Rays are produced by several types of equipment. may already be familiar with radiation safety; but no The types of x-ray equipment that you encounter matter how much you know, you need to review the depend on your specialty. In general though, nurses key points, for two reasons: most often see mobile radiographic and C-arm fluo- • State regulations and Kaiser Permanente poli- roscopy units. cies both require an annual review of radiation safety procedures in your professional spe- Diagnostic cialty. Diagnostic radionuclides are radioactive materials • Under the pressures of time and work load, used in departments. They include even experienced nurses can become some- -99m, -67, -201, and oth- ers. Overall, the risk presented by diagnostic radio- what lax about routinely taking proper safety nuclides is minimal. precautions. Therapeutic Radionuclides For people who consistently practice radiation safety, Therapeutic radionuclides are unsealed radioactive the risk is truly negligible. But for people who are materials administered in therapeutic doses to pa- uninformed, forgetful, or just careless, the risk in- tients orally or by injection. They include: creases. So no matter how experienced you are with • Radioiodine (I-131), usually administered radiation, take some time to refresh your memory by orally to treat and reading this review. . • Radiophosphorus (P-32), which is admini- SOURCES OF RADIATION stered by injection to treat certain types of In medical facilities, the five most common sources cancer. of are: • X-Ray producing equipment, usually found in Therapeutic radionuclides present potential radia- the department, and in , emer- tion hazards. But if proper safety practices are gency, and patient care areas, as well as in followed carefully, the risk here is also minimal. specialized areas such as the cardiac catheteri- zation lab. Sources • Diagnostic radionuclides, usually found in the Brachytherapy procedures use sealed sources con- nuclear medicine department and in patient taining radioactive material in therapeutic quantities care areas. to treat certain types of cancer. These sources are • Therapeutic radionuclides, usually found in inserted into patients’ bodies, in areas such as the the nuclear medicine department, and in pa- , , and naso-. The most com- tient care areas where therapeutic nuclear monly used radioactive materials include: medicine patients are cared for. • Radioactive cesium (Cs-137). • Brachytherapy sources, usually found in the • Radioactive (Ir-192). same areas as therapeutic radionuclides. • Radioactive (I-125). • equipment, usually found in the radiation therapy department. Although brachytherapy sources containing radio- active materials are sealed, they do present potential Now let’s look more closely at each source of radiation hazards. Here again, the risks are greatly ionizing radiation. reduced by following sound safety practices. Kaiser Permanente Radiation Safety Training Rev. 4/02 Page 2 Nursing Radiation Therapy Equipment Radioactive contamination can produce significant lev- Radiation therapy equipment uses ionizing radia- els of localized . tion to treat certain forms of cancer and other abnor- mal tissues. This equipment focuses high-energy Sources that DO NOT Produce Ionizing radiation from outside the body, on carefully se- Radiation lected tissues. It is usually administered in therapeu- Remember that the hazards we are discussing are tic doses. The linear accelerator and (Co-60) produced by ionizing radiation. Occasionally, people teletherapy units are examples of radiation therapy think there may be a radiation hazard in other situ- equipment. ations where there is actually none, because there is no ionizing radiation. RADIATION HAZARDS The potential hazard from radiation is exposure to Selected examples of things that do not produce ionizing rays or particles. Radiation exposure can ionizing radiation include x-ray machines that are occur in three types of situations: not actually making an exposure, patients who have • When you are near an x-ray machine that is had x-rays or external beam radiation therapy treat- actually making an exposure. In this situation, ments, nuclear medicine imaging equipment, iodine x-rays scatter and can expose an unshielded contrast material used in patients for x-ray imaging, body. ultrasound equipment, and ovens. • When you are near or in contact with a patient undergoing brachytherapy or State and Kaiser Permanente Standards therapy. In this situation, radiation is emitted Five thousand mrem per year is the maximum expo- from the patient’s body, and/or from objects sure permitted by state regulations for workers con- that have been contaminated by radioactive sidered to be “occupationally exposed.” (Occupa- material. tionally exposed workers are people such as x-ray • When you or your clothing have been con- and nuclear medicine technologists who routinely taminated by radioactive material. and regularly work with and around radiation and radioactive materials.) Radioactive Contamination Normally, potential radiation hazards are evident, because they are associated with specific areas, Kaiser Permanente’s own standards are more con- equipment, and procedures. But radioactive con- servative than the state’s. We set standards to tamination is not. By definition, radioactive con- achieve radiation exposure levels “As Low As Rea- tamination is the presence of radioactive materials sonably Achievable” (ALARA). For example, our anywhere they don’t belong — that is, anywhere maximum permissible exposure per year for occu- they are not appropriately identified, contained, and pationally exposed workers is 1,000 mrem — only controlled. one-fifth of the limits allowed by state regulations. Here is a summary of state and Kaiser Permanente Contamination is especially hazardous because it radiation exposure standards for occupationally ex- can be present without your knowing it. With posed workers: people, contamination may be external (contact with the skin) or it may be internal, due to ingestion, Maximum Permissible Whole Body Dose , or absorption of radioactive material. Period State Standard Kaiser Standard This can happen with , but is Month (no standard) 150 mrem unlikely in brachytherapy, because sealed brachyth- Year 5,000 mrem 1,000 mrem erapy sources are not likely to leak or break.

Rev. 4/02 Kaiser Permanente Radiation Safety Training Nursing Page 3 Keep in mind that these are maximum allowable doses • Do not handle material labeled as radioac- for occupationally exposed workers. The amount actu- tive unless you are trained and authorized to do ally received is normally much less. For all workers who so. are not considered to be occupationally exposed, the maximum extra exposure is 100 mrem per year — the Reduce Your Exposure Time same as for the general public. The key to reducing your exposure time is planning. Make sure in advance that you have everything you What this means to you depends on your particular need so that you can complete necessary procedures job responsibilities: near a radiation source as quickly as possible. • If you do not routinely and regularly work with or near radiation sources, you are “non-occu- Increase Your Distance From Radiation pationally exposed.” In this case, you will Radiation levels vary inversely with the square of probably receive no extra radiation whatever. the distance from their source — that is, levels • If you work with patients receiving therapeu- decrease sharply with distance. The farther away you place yourself, the less radiation you are ex- tic doses of radioactivity, you may receive posed to. around 50 extra mrem per year. (You are still not “occupationally exposed”). Shield Yourself from Radiation Shielding will also reduce the level of radiation. Pregnant Personnel Shielding is very effective with x-rays. Wear a lead Kaiser Permanente policies discourage pregnant apron, where provided. If your hands may be in the personnel from caring for patients receiving thera- x-ray beam, wear lead gloves unless doing so would peutic radiation (except for external beam radiation compromise patient care. Use lead shields when therapy), and from holding patients receiving x- available. rays. If you should become pregnant, be sure to inform your supervisor promptly. In diagnostic nuclear medicine and radionuclide therapy, a lead apron is not effective. An appropriate RADIATION SAFETY PRECAUTIONS bedside shield is effective in some situations (such To minimize exposure, you need to take five routine as brachytherapy), and should be used wherever precautions: provided. • Recognize radiation sources. • Reduce your exposure time. Avoid Radioactive Contamination • Increase your distance from radiation. In general, try to avoid radioactive contamination by • Shield yourself from radiation. taking the precautions you would use with infec- • Avoid radioactive contamination. tious agents: • Wear gloves, a gown, and shoe covers if indi- Recognize Radiation Sources cated. Radiation sources are marked by the international • Avoid contact with objects or areas that may radiation hazard symbol: a purple trefoil on a bright be contaminated. yellow background. When you see this sign: • Don’t eat, drink, or smoke in areas where • Make sure you are aware of the source of the radioactive materials are in use. hazard. • Don’t apply cosmetics or groom your hair • Be sure that you are authorized to be in the while in the area. • Wash your hands when leaving the area. posted area (and if not, do not enter it). • Read and follow all signs and instructions. • Take appropriate precautions to reduce expo- And remember: Don’t handle radioactive materials sure and avoid contamination. unless you are trained and authorized to do so.

Kaiser Permanente Radiation Safety Training Rev. 4/02 Page 4 Nursing RADIATION Section 11-03 Though you are unlikely to receive more than moderate • Damaged Sealed Sources: Section 35-55 amounts of radiation in performance of your duties, you • Emergency assistance: Section 35-56 may be issued a personnel monitor or (badge) • Eye and thyroid protection: Section 11-05 in some situations, to ensure compliance with all limits set • Major spills of radioactive material: by regulation and good practice. (You will be assigned Section 35-53 a dosimeter only if your job responsibilities require it. If • Minor spills of radioactive material: you have any question about whether or not you should Section 35-51 receive a dosimeter, see your supervisor.) • Nursing care of patients receiving brachyther- apy: Section 42-05 If you wear a badge, it is essential that you use it • Nursing care of patients receiving radioactive properly. To do this: chromic phosphate in the pleural or perito- • Always wear it when required. neal space: Section 42-03 • Always wear it in the proper place. Where you • Nursing care of patients receiving radioactive place your badge depends on your particular chromic phosphorus intravenously in thera- work. If you are issued a badge, you will be peutic amounts: Section 42-04 shown where to place it. • Nursing care of patients receiving radioactive • Never wear someone else’s badge, or lend your badge to anyone. iodine therapy: Section 42-02 • Never take the badge home. • Nursing care of patients receiving radioactive • Store the badge at work in a designated area material for diagnostic procedures: free from stray radiation, heat, and moisture. Section 42-01 These things can damage the film packet. • Personnel policy: Section 11-01 • Never open the dosimeter packet. • Pregnant Personnel: Section 11-04 • Return the badge promptly at the end of each • Radioactive patient waste disposal: month, for processing. Section 33-05 • Keep track of your badge readings. They indicate the amount of radiation you have THE AREA RADIATION SAFETY OFFICER received. You have a right to see these read- (ARSO) ings. The Area Radiation Safety Officer (usually called the “ARSO”) is the person who is responsible for THE REGIONAL RADIATION SAFETY radiation safety throughout the facilities in your MANUAL area. The Regional Radiation Safety Manual is the au- thoritative reference for radiation safety policies and In most cases, you should discuss any questions or procedures. This guide, which is based on that concerns you might have with your supervisor. manual, contains the basic procedures you will need, However, there are situations in which you can presented in quick reference form. contact your ARSO directly. If there is an emergency and you cannot contact your If you want more in-depth information about proce- ARSO, you can contact the physicist-on-call during dures and nursing duties of particular interest to you, normal working hours by phoning the Medical you will find this additional information in the Regional Department. After normal hours, use the pager proce- Radiation Safety Manual. Here are the principal dure for contacting . You will find it in manual sections that may be of interest to nurses: section 35-56 of the Regional Radiation Safety • Bioassay procedures: Quantification of Iodine- Manual. 131 present in thyroid tissue: Rev. 4/02 Kaiser Permanente Radiation Safety Training Nursing Page 5 Your Area Radiation Safety Officer is: • Monitoring all radiation-related activities for safety. (fill in information below) • Providing training such as this.

Name : ______And finally, remember that we know how radiation works, we know how to handle it with complete Dept.: ______safety, and we know how to use its great potential for the benefit of our patients. Telephone: ______DIAGNOSTIC X-RAY Key Concepts IN CONCLUSION • The first key to safety is distance. Stay out of the Kaiser Permanente is working actively to protect you. area, if possible — but at least six feet away. Our comprehensive radiation safety program includes: • The second key to safety is shielding. Wear a • Setting safety standards that are more conserva- lead apron if you are participating in an x-ray tive than state requirements.

Radiation Safety Procedures for Nurses

procedure. or leave the room if possible. 7. If movable shielding is available, use it. Safety Procedures 8. When working with mobile units, stand be- 1. Do not enter a surgery, recovery room, or hind the remote control console when making emergency room during x-ray exposures un- exposures (if practical). less you are needed there, and are wearing an 9. If you have been assigned a badge, wear it at apron. collar level outside the lead apron. 2. If holding or restraining a patient, wear a lead 10. In the Neonatal Intensive Care Unit, the risk of apron. Wear lead gloves if your hands may be radiation exposure to nurses is low (without in the beam (for example, when you must hold protective shielding) and very low (with shield- the film cassette in position). The beam path ing). The hazard to adjacent neonates is mini- is indicated by the visible “locator” used mal. to position the equipment. This light, of course, is not an x-ray beam and does not contain any DIAGNOSTIC NUCLEAR MEDICINE ionizing radiation. Key Concepts 3. If your duties may require you to turn your • The overall hazard from radiation is very small back to the radiation source, wear a wrap- because of the low quantities and short half-lives around apron that will protect your sides and of the radioactive materials used. back. • Patient wastes, however, can pose a hazard if 4. If not holding the patient or required for nearby not dealt with appropriately. patients, leave the room until the x-ray procedure has been completed. Safety Procedures 5. If you must remain in the room for some 1. Radiation exposure is not significant. Minor reason, step back at least six feet from the contamination is possible from patient body wastes beam. and fluids. 6. During “cine” fluoroscopic exposures, step back Kaiser Permanente Radiation Safety Training Rev. 4/02 Page 6 Nursing 2. No personnel dosimeter (badge) or lead apron is visitors, etc. may not enter unless approved necessary. by the nurse in charge. 3. Provide patient care according to usual proce- 5. The patient may not leave the room. dures, and any instructions in the chart. B. Visitors: 4. When cleaning up patient wastes or body 1. No visitors during the first 24 hours. fluids that may be contaminated soon after a 2. No pregnant visitors or children under 18 nuclear medicine examination: at any time. a. Wear disposable latex gloves. 3. After 24 hours, other visitors may be per- b. Set any possibly contaminated materials mitted, according to the instructions pro- or objects aside to be surveyed and dis- vided by nuclear medicine personnel. posed of according to procedures provided 4. The patient must stay in bed throughout by nuclear medicine. the visit. c. Place possibly contaminated linen in a 5. Visitors must remain at least six feet away properly labeled bag and store according from the patient. to procedures provided by nuclear medi- 6. Visits must end within the “limits of stay” cine. time posted on the patient door and/or in d. Flush patient wastes and body fluids down the patient chart. the nearest toilet. Avoid splashing. Flush C. Patient care: twice to ensure complete disposal. Wash 1. Before providing care, read any special bedpans or urinals thoroughly before reus- instructions or restrictions posted on the ing. door or noted in the patient’s chart. e. Wash your hands with gloves on. 2. Do not provide care if you are pregnant or 5. Do not wear a lead apron. It does not provide think you might be. effective protection against radiation emitted 3. Do not remain in the room longer than the by diagnostic radionuclides. “limits of stay” time posted on the door and/or in the chart. THERAPEUTIC NUCLEAR MEDI- 4. Plan your activities before entering, so that CINE: RADIOIODINE THERAPY you can provide speedy, efficient care. Key Concepts D. Your personal protection: • Radioiodine (I-131) therapy involves the ad- 1. Wear your badge at waist level. ministration of unsealed sources of radiation, 2. Do not wear a lead apron. It will not usually orally, to treat hyperthyroid conditions provide effective protection, and it can and . hamper your movements. • The procedure offers the possibility of a cer- 3. Wear latex gloves, shoe covers, and gowns, tain amount of radiation hazard, unless proper if indicated in the nurses’ instructions. safety procedures are followed. Remove them before leaving the room and place them in the disposal containers pro- Safety Procedures vided. A. Access to the patient: 4. Before leaving the room, wash your hands 1. Patient must be in a private room with with gloves on, dispose of the gloves in the private bathroom. specially marked bag provided for contami- 2. The room door is to be posted with nurses’ nated trash, then wash your hands again. instructions and with a radiation or radio- 5. Do not eat, smoke, apply cosmetics, or groom active materials sign. your hair in the patient’s room. (Of course, 3. Do not enter the room or allow others to smoking is not permitted anywhere in a Kai- enter unless authorized and adequately ser Permanente building.) trained. E. Contaminated patient wastes: 4. Housekeeping, food service, maintenance, 1. Never try to clean up any patient vomitus Rev. 4/02 Kaiser Permanente Radiation Safety Training Nursing Page 7 or other body fluid spillage. Instead, cover NOTE: Because radiophosphorus therapy is performed with a towel or other absorbent material. very infrequently, nursing care procedures for this therapy 2. Call nuclear medicine personnel and/or are not included in this guide. the responsible immediately. F. If you think you may be contaminated: However, in the event that you do provide care for a 1. Move away from the source of contamina- radiophosphorus patient, it is essential that you tion, but do not leave the area. review the appropriate procedures and precautions. 2. Remove any clothing and accessories (such They are covered fully in the Regional Radiation as watches) that might be contaminated. Safety Manual, Sections 42-03 and 42-04. 3. Wash the suspected area thoroughly with large amounts of mild soap and water. (Do BRACHYTHERAPY not scrub hard enough to risk breaking Key Concepts your skin.) • Brachytherapy involves the application of 4. Have someone else telephone the nuclear sealed sources of radiation to the skin or into medicine department. body openings. It is used to treat various forms 5. Wait for instructions from the nuclear of cancer. medicine department. • The procedure offers the possibility of a cer- G. Room protection, survey, and release: tain amount of radiation hazard, unless proper 1. Areas and objects in the room that may safety procedures are followed. become contaminated should be covered Safety Procedures by nuclear medicine personnel with pro- A. Access to the patient: tective material (such as absorbent, dis- 1. Patient must be in a private room with posable cloths, “Chux”, and plastic bags private bathroom. and sheeting). 2. The room is to be posted with a radiation or 2. Do not remove any objects from the room radioactive materials sign. until they and the room have been sur- 3. Do not enter the room or allow others to veyed for contamination and released by enter unless authorized and adequately nuclear medicine personnel. trained. 3. Verify that this survey has been completed 4. Housekeeping, food service, maintenance, and radiation warning signs have been visitors, etc. may not enter unless approved removed before removing objects and re- by the nurse in charge. leasing the room. 5. The patient may not leave the room, and may be restricted to bed, as detailed in the THERAPEUTIC NUCLEAR nursing instructions. MEDICINE: RADIOPHOSPHORUS B. Visitors: THERAPY 1. No pregnant visitors or children under 18 Key Concepts at any time. • Radiophosphorus therapy involves the admini- 2. Other visitors are permitted, according to stration of unsealed radiation sources to treat the instructions provided by radiation therapy various forms of cancer. personnel. • In general, the risk of radiation exposure is 3. The patient must stay in bed throughout relatively low. the visit. (As noted above, the patient may be • Radiophosphorus may be administered intrave- confined to bed at all times.) nously or into the pleural or peritoneal spaces. 4. Visitors must remain at least six feet away • Details of safety procedures depend on the from the patient. method of administration. 5. Visits must not be longer than the “limits of stay” time posted on the patient door Safety Procedures Kaiser Permanente Radiation Safety Training Rev. 4/02 Page 8 Nursing and/or in the patient chart. RADIATION EMERGENCIES C. Patient care: Radioactive Material Spill 1. Before providing care, read any special • The basic objectives in dealing with radioac- instructions or restrictions noted in the tive spills are to prevent contamination of patient’s chart. others by restricting access to the spill area and 2. Do not provide care if you are pregnant or to summon expert help to clean up the spill and think you might be. check the area. 3. Do not remain in the room longer than the • After a spill, notify others in area, clear area of “limits of stay” time posted on the door non-contaminated people, restrict access to and/or in the chart. area, and call nuclear medicine. If spill is 4. Plan your activities before entering, so that major, do not clean it up, and, if nuclear you can provide speedy, efficient care. medicine cannot be reached, contact the ARSO D. Your personal protection: immediately. 1. Do not wear a lead apron. It will not • Never attempt to clean up the spill yourself provide effective protection. (except in the case of minor amounts of body 2. Use any other shielding barriers provided, wastes or fluids from patients containing diag- such as a bedside lead shield. nostic radionuclides). 3. Wear your badge at waist or collar level. When using a bedside shield, wear the badge Personnel Contamination at collar level. • The key concepts are to remain in the area of G. Room survey and release: contamination, restrict others from entering it, 1. Do not remove any objects from the room and obtaining expert help in decontamination. until they and the room have been sur- • If you may be contaminated: veyed and released by radiation therapy 1. Do not leave the contaminated area, but personnel. move as far away as you can from the 2. Verify that this survey has been completed source of contamination. before removing objects or releasing the 2. Remove all accessories (such as a wrist room. watch and jewelry), and any clothing that H. Dislodged radiation source: might be contaminated. 1. Description: A dislodged sealed source is 3. Wash thoroughly with generous amounts a capsule or needle that has been dislodged of warm water and mild soap. Do not scrub from its position in the patient. It is usually hard enough to risk abrading your skin. found in patient clothing or bed linen, or on 4. Have someone else contact nuclear medi- the floor. cine, and then wait for their instructions. 2. To secure a dislodged sealed source: a. Use long-handled forceps. Do not touch Code Blue Patient the source with your hands. • A degree of radiation hazard is present only b. Using the forceps, pick up the dis- with patients containing therapeutic amounts of lodged source and place it in the radia- radionuclides or brachytherapy sources. tion-shielded container left in the room by • The degree of hazard from radiation or radioac- radiation therapy personnel. tive contamination will vary, depending on the c. Call the radiation therapy physician procedure that the patient is undergoing at the immediately. time. In any case, the risk to you is less significant than the risk to the code blue patient. • Carry out code blue procedures in the usual manner.

Rev. 4/02 Kaiser Permanente Radiation Safety Training Nursing Page 9 • If you think you may have been contaminated, Death of Patient contact the nuclear medicine department. • A degree of radiation hazard is present only with patients containing therapeutic amounts Emergency Surgery of radionuclides or brachytherapy sources. • A degree of radiation hazard is present only • Without notification and proper precautions, with patients containing therapeutic amounts people, equipment, and facilities involved in of radionuclides or brachytherapy sources. post-mortem procedures could receive unex- • Without notification and proper precautions, pected exposure to radiation or contamination surgical staff, areas, and equipment could re- by radioactive materials. ceive unexpected exposure to radiation or con- • Restrict room access and do not allow the tamination from radioactive materials. body to be removed until authorized by • If possible, do not move the patient until you nuclear medicine or radiation therapy physi- have consulted the nuclear medicine or radia- cian. tion therapy physician.

Kaiser Permanente Radiation Safety Training Rev. 4/02