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Chapter 34

Chapter 34. Caring for the Child with Cancer. Cancer. Cancer is a group of diseases in which there is out-of-control growth and spread of abnormal cells (anaplasia).

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Chapter 34

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  1. Chapter 34 Caring for the Child with Cancer

  2. Cancer • Cancer is a group of diseases in which there is out-of-control growth and spread of abnormal cells (anaplasia). • Anaplasic cells resist normal growth controls. This abnormal cellular growth is also known as neoplasm and is caused by one or a combination of three factors • External stimuli or environment • Viruses that alter the immune system • Chromosomal and gene abnormalities

  3. Tumor • Benign • Slow, limited, noninvasive growth (not cancerous) • Malignant • Progressive virulent growth (cancerous)

  4. Terms Associated with the Cancer Patient • Roadmap—protocol or treatment plan that is “mapped out” to guide staff and families • Protocol—complete explanation of a treatment plan • Clinicaltrials—medical research studies designed to answer scientific questions and to find new ways to treat cancer • Remission—the partial or complete disappearance of signs and symptoms of disease. • Extravasation—leakage of potentially damaging medications into tissues • Induction—chemotherapy given to achieve remission • Consolidation—chemotherapy given after induction to control microscopic disease • Maintenance—chemotherapy given on a long term basis to maintain remission • Palliative care—treatment given to relieve rather than cure symptoms caused by cancer.

  5. Differences Between Childhood and Adult Cancers • Childhood cancers • Arise from primitive embryonic tissue (environmental link) • Cure rate is better • Cancers affect stem cells • More aggressive and faster growing • Respond more readily to chemotherapy and radiation • Treated at major cancer centers in the United States • More resilient • Tolerate more aggressive therapy • Less other physiological problems

  6. Common Childhood Cancers

  7. Leukemia • Leukemia (based on cell line affected and level of cellular differentiation) • Acute leukemia (progresses rapidly and affects immature and undifferentiated cells) • Chronic leukemia (progresses less rapidly, allowing for the production of more mature and differentiated cells) • Three classifications—ALL, AML, and CML

  8. Acute Lymphocytic Leukemia (ALL) • Signs and symptoms • Fever, fatigue, lethargy, anemia, pale skin, anorexia, and bone or joint pain • Increased WBC • Nursing care (treatment phases) • Remission through induction • Consolidation • Maintenance

  9. Acute Myelogenous Leukemia (AML) • Signs and symptoms • Symptoms resembling the flu, anemia, pallor, fatigue, bone pain, fever, headache or dizziness, petechiae, easy bruising, nosebleeds, or bleeding gums • Increased WBC • Nursing care • Administer multi-agent chemotherapy • Discuss hematopoietic stem cell transplant • Matched-sibling bone marrow or stem cell transplantation after remission

  10. Chronic Myelogenous Leukemia (CML) • Signs and symptoms • Fever, fatigue, weight loss, anorexia, increased WBC, and splenomegaly • Nursing care • Administer hydroxyurea (Droxia, Hydrea) • Administer interferon-α • Administer combination chemotherapy • Allogenic bone marrow or stem cell transplantation

  11. Solid Tumors (named for the type of cells of which they are composed) • Type of cells • Sarcoma (connective or supporting tissues) • Carcinoma (glandular and epithelial cells) • Lymphomas (lymphoid glands)

  12. Brain Tumors • Two types • Supratentorial (anterior 2/3 of brain) • Intratentorial (posterior 1/3 of brain) • Signs and Symptoms • Depends on the tumor location, tumor type, and the age of the child • Obstruction of CSF drainage leading to ICP • Nursing care • Tumor is staged; surgical resection, radiation therapy, chemotherapy, or a combination • Postoperative care; IV steroids and anticonvulsants • Conduct neurological assessment and airway and fluid management, prevent infection, manage pain, ensure adequate nutrition, and promote normal growth and development • Ensure good communication, emotional support, and accurate information

  13. Neuroblastoma • Signs and symptoms • Wide variety depending on site of primary tumor • Upon palpation, tumor crosses midline; hard painless mass in neck or abdomen • Nursing care • Determined by the stage of the disease and the age of the child • Surgery resection preformed followed by chemotherapy (radiation or bone marrow transplant may be used) • Conduct nursing assessment for infection and stable condition • Alleviate pain • Offer support, accurate information, and education

  14. Wilm’s Tumor (Nephroblastoma) • Signs and symptoms • Painless abdominal mass in one or both kidneys (seldom crosses midline) • Nursing care • Obtain health history and nursing assessment • Explain laboratory and diagnostic tests • Administer chemotherapy and give postradiation care • Postoperative care • Assess function of remaining kidney • Ensure high-calorie, high-protein diet • Give dietary supplements

  15. Rhabdomyosarcoma • Signs and symptoms • Depends on location of primary tumor and metastasis (head and neck, nasopharynx, genitourinary, extremities, skeletal or smooth muscle, perianal regions) • Nursing care • Understand that treatment is based on the primary tumor and disease stage • Surgical resection • Give chemotherapy and address radiation side effects

  16. Retinoblastoma • Signs and symptoms • Leukocoria; strabismus; red, painful eyes (blindness is a late sign) • Nursing care • Preoperative—reassure parents and educate about what to expect postoperatively • Postoperative—teach parents about eye socket irrigation and antibiotic ointment • Teach parents about home care of the eye • Offer support and encourage follow-up care

  17. Bone Tumors

  18. Osteosarcoma • Signs and symptoms • Pain and swelling • Limp • Dull aching pain • Palpation at site, tenderness, swelling, warmth, and erythema • Nursing care • Administer chemotherapy • Surgery—amputation versus limb sparing

  19. Ewing’s Sarcoma • Two separate types of tumors • Ewing’s sarcoma family of tumors • Peripheral primitive neuroectodermal tumor (PPNET)

  20. Ewing’s Sarcoma • Signs and symptoms • Pain or tenderness and swelling at the site of the tumor (chest wall tumor causes respiratory distress) • Nursing care • Administer multi-agent chemotherapy • Surgical resection • If radiation treatment is performed, address radiation side effects.

  21. Lymphomas

  22. Hodgkin’s Disease (HD) • Signs and symptoms • Painless, firm, cervical, or supraclavicular lymphadenopathy • Nursing care • Administer chemotherapy • If radiation treatment is performed, address radiation side effects.

  23. Non-Hodgkin’s Lymphoma (NHL) • Signs and symptoms • Pain or swelling (abdomen, chest, and head/neck) • Nursing care • Administer aggressive multi-agent chemotherapy • Administer intrathecal chemotherapy (for CNS prophylaxis)

  24. Other Cancers

  25. Liver Cancer • Two primary types • Hepatoblastoma • Hepatocellular carcinoma • Signs and symptoms • First sign is a mass in the abdomen (upper right side) • Abdominal fullness, pain, vomiting, diarrhea, fever, abnormal weight loss, jaundice, or general itching • Nursing care • Chemotherapy may be needed first to shrink the size of the tumor • Surgical removal of the tumor

  26. Nursing Care of the Child with Cancer

  27. Several Areas of Nursing Care • Maintain nutrition • Prevent infection • Administer chemotherapy • Addressing radiation side effects • Understand the use of surgery and related nursing diagnosis • Control pain • Provide psychosocial support • Manage negative and long-term effects of cancer treatments • Understand psychological impact of pediatric cancer

  28. Nutrition • Nursing care • Maintain good nutrition (Box 34-2) • Help parents with proper nutrition • Assess poor nutrition • Assess side effects of chemotherapy related to nutrition • Maintain immune system • Try simple care measures first (enteral feedings or TPN may be the only option) • Communicate to parents that their child may be able to eat independently again

  29. Infection • Nursing care • See Nursing Care Plan (Child with Acute Lymphocytic Leukemia) • Monitor for systemic and localized signs of infection every 2–4 hours • Take temperature every 4 hours • Report a single temperature greater than 101.2°F (38.5°C) in a 24-hour period or 100.4°F (38.0°C) three times in a 24-hour period • Provide meticulous skin care and use good hand washing (instruct visitors) • Use universal precautions and designated isolation precautions • Monitor and report lab values • Teach family about the principles of prophylactic antibiotics and signs and symptoms of infection (See Family Teaching Guidelines: Signs and Symptoms of Infection)

  30. Chemotherapy • Administer chemotherapy using a variety of drugs • See Table 34-2: Chemotherapeutic Agents and Common Cancer Drugs • See Table 34-3: Venous Access Devices

  31. Radiation • Nursing care • Measures that address the radiation side effects • Nausea • Alopecia • Fatigue and malaise • Low WBC • Skin desquamation • Mucous membrane inflammation and irritation

  32. Surgery • Nursing care • Understand that surgery is used as an adjunct to both chemotherapy and radiation • Important role in the diagnosis of a tumor via biopsy • The insertion of central venous catheters

  33. Pain Control • Nursing care • Administer pain medications combined with adequate rest and sleep, massage, heat, distraction, and social support • Use topical anesthetics • Remember ethnocultural considerations

  34. Psychological Support • Nursing care • Provide holistic nursing care • Encourage 24-hour stay • Involve the child-life specialist • Be present or simply listen • Provide family with community resources, reliable Internet sources, or information about support groups

  35. Negative Effects of Chemotherapy • Nausea and vomiting (administer antiemetics) • Alopecia (address body image) • Extravasation (prevent accidental leakage of drugs) • Mucositis (keep oral cavity clean) • Diarrhea (skin care, diet, and medication) • Constipation (diet, activity, and medication)

  36. Negative Effects of Chemotherapy • Anemia (s/s, diet, vitamin, RBC transfusion, administer hematopoietic growth factors) • Thrombocytopenia (platelet transfusion) • Neutropenia (assess fever, blood cultures, and administer antibiotics)

  37. Long-Term Effects of Chemotherapy • High-tone hearing loss • Loss of speech • Impaired depth perception • Increased response time • Lung problems (SOB) • Kidney problems (bleeding) • Musculoskeletal defects • Functional and/or mobility deficits • Hormonal abnormalities • Sterility • Growth retardation, cognitive impairment, and/or learning disabilities • Diabetes insipidus • Peripheral neuropathy

  38. Medical Emergencies

  39. Hemorrhagic Cystitis • Signs and symptoms • Bloody or painful urination • Nursing care • Ensure hydration • Test urine for blood, pH, and specific gravity (see procedure 34-1) • If urine is positive for presence of blood, notify physician immediately • Monitor intake and output • Obtain daily BUN and creatinine • Administer MESNA

  40. Tumor Lysis Syndrome • Signs and symptoms • Lethargy, nausea and vomiting, oliguria, flank pain, pruritus, tetany, and altered level of consciousness • Renal failure can also occur • Nursing care • Keep the urine alkalinized • Maintain a low-phosphate diet • Administer allopurinol (Aloprim) • Maintain adequate hydration • Monitor electrolytes • Obtain BUN and creatinine • Understand that sometimes dialysis or exchange transfusions are necessary

  41. Septic Shock • Signs and symptoms • Confusion; fever; tachypnea; decreased urinary output; and cold, clammy skin • Note: Decreased blood pressure is a late sign • Laboratory studies reveal acidosis and sometimes renal failure • Nursing care • A neutropenic child is given antibiotics; take vital signs every 10 to 15 minutes during the antibiotic administration to recognize signs of septic shock • Administer large amounts of an isotonic fluid (normal saline) • Check peripheral pulses and capillary refill to monitor perfusion • Perform ABCs and other emergent care measures (see Critical Nursing Action: Nursing Care for Septic Shock)

  42. The Psychological Impact of Pediatric Cancer • Signs and symptoms • Shock, denial, confusion, fear, blame, and loss of control • Nursing care • Suggest support • Communicate adequate rest and nutrition for parents • Be honest • Use a multidisciplinary approach • Tailor information to developmental stage • Keep lines of communication open • Provide for spiritual care • Help child and family express feelings

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