Download Document 3 – Module 3

Assessments of the Child with Cancer:
Author: Ayda G. Nambayan, DSN, RN, St. Jude Children’s Research Hospital
Content Reviewed by: Lisa South, RN, DSN, UA School of Nursing, University of Alabama at
Birmingham
Cure4Kids Release Date: 16 December 2005
Approximately 85% of pediatric cancers have a strong family association and about 15% occur
sporadically. Cancer in children is hard to recognize, so parents and caregivers should be alert
for unusual symptoms (A – 1) that persist.
Often, the early signs of a malignancy in children mimic other, more common childhood
illnesses; and this can delay correct diagnosis and treatment. The signs and symptoms of
pediatric cancer often depend on the patient’s age, the type of tumor, tumor location, and the
extent of the disease. Generally, a high index of suspicion is the greatest tool in diagnosing
malignant diseases in children.
Nurses and other health care workers must use good communication and interviewing skills in
order to elicit appropriate information about the child’s symptoms. Such information might
suggest the possible malignancy and also identify helpful cues to the needs of the child and the
parents. The nurse should start with the chief complaint (A – 2), review the child’s medical and
social history, pertinent family history, and organ systems.
Symptoms Suggestive of Childhood Cancers:
Symptoms
Possible Type of Cancer
A – 3 Pallor, fatigue, malaise
A – 4 Bleeding, bruising,
petecchia
A – 5 Weight loss, night
sweats
Swelling or Edema of the
face and neck
Pancytopenia
A – 6 Lymphadenopathy
Bone Pain and fevers
Leukemia, lymphoma,
neuroblastoma, Wilms
Tumor
Leukemia, neuroblastoma
Hodgkin lymphoma
Neuroblastoma
Wilms Tumor
Non-Hodgkin Lymphoma,
Leukemia, mediastinal
mass
Leukemia, Neuroblastoma
Hodgkin, non-Hodgkin
Lymphoma
Leukemia, Ewing sarcoma
Possible Non-Malignant
Condition
Iron deficiency anemia
Coagulopathy, idiopathic
thrombocytopenia
Viral infections, TB
Superior Vena Cava Occlusion
Infection, Aplastic Anemia
Infection
Osteomyelitis; normal growth
Assessments of the Child with Cancer:
A – 7 Limping
Vaginal Bleeding
Chronic drainage from the ear
A – 8 Cat’s eye reflex (white
eye reflex)
A – 9 Abdominal mass
Abdominal pain
Bone tumors, leukemia,
neuroblastoma
Yolk sac tumor,
rhabdomyosarcoma
Rhabdomyosarcoma,
histiocytosis
Retinoblastoma
pains, trauma
Osteomyelitis, trauma
Trauma, normal menstruation
Otitis media, otitis externa
Coat’s disease, severe uveitis
Wilms tumor,
neuroblastoma,
hepatoblastoma
Brain tumors
NHL/T Cell
Viral illness, constipation
Glomerulonephritis
A – 10 Assymetry
(extremities, face)
Neuroblastoma
Wilms tumor
Wilms tumor, Bone
tumors, CNS tumors with
palsy
A – 11 Presence of a tumor or
growth
A – 12 Precocious puberty;
virilization
Bone tumors, myosarcoma
lymphoma
Adrenocortical carcinoma
brain tumors
Benign tumors
Headache, morning vomiting
Difficulty breathing,
wheezing, adventitious breath
sounds
Hypertension
Migraine headaches
Flu, upper respiratory tract
infections, asthma
Stroke secondary to Sickle Cell,
premature hypertension and
brain injury
Congenital CNS abnormalities
hydrocephalus
Medical History
Prenatal, neonatal, growth, and development patterns
Presence or history of genetic disorders (e.g., history of immunodeficiency or metabolic
diseases, Down Syndrome, aniridia, Beckwith Weideman syndrome, Hypo-epispadius)
Immunizations and past illnesses
Social History:
Parent information and caregiver – age, marital status and occupation
Siblings’ ages and relationship with ill child
Financial status including health insurance
Family housing situation
Available community and social resources
Family History:
History of cancer in family members (Note age and diagnosis)
Health status of grandparents, parents and siblings
RED FLAGS: Pediatric cancers and/or familial cancer syndromes
Module 3- Document 3
Page 2 of 14
Assessments of the Child with Cancer:
NOTE: Construct and document a family pedigree, especially if there are several family
members with cancer
Tips:
During review of each body system, elicit or follow through symptoms that the
parent/caregiver/patient has not recognized or considered irrelevant.
Example:
Cat’s Eye reflex - always present in photo of patient
Frequent falling and bruising
Frequent cold symptoms
Persistent muscle and bone pains – often thought of as “growing pains”
Remember the age-related adjustments (A – 13) that need to be considered when doing
assessments and physical examination in children.
Psychosocial Assessments:
The reality of being sick and the possibility of a cancer diagnosis is often very stressful to the
patients and the family. Parents often express concern, especially if the child is unable to
communicate their anxieties and needs. Children should be encouraged to verbalize their
concerns rather than have others to speak for them: Verbalizations and open discussions often
lessen anxiety. Children often respond best to telling stories or drawing pictures in order to play
out their feelings. If this is the case, then these activities should be encouraged. Also,
collaboration with Child Life often produces the best results in assessments and care.
Nutritional Assessments:
Nutrition assessments should be included in the routine assessment of children with cancer. A
registered dietician should be consulted after a diagnosis of cancer has been made and a
treatment regimen has been established. Nutritional assessment should also include the resources
(financial, home health care) available to the patient and the ability of the family to manage the
nutritional requirements of the treatment modalities. Also, the nurse should assess
potential cultural and ethical issues related to nutritional support.
The nurse should also anticipate potential treatment side effects that could directly impact patient
nutrition, such as mucositis, nausea, and vomiting. By anticipating the occurrence of the
symptoms, the nurse can help the patient to be prepared and may even alleviate the intensity of
the symptoms and their nutritional consequences.
Ongoing measurement of nutritional status and energy requirements should be done during
therapy and should include anthropometric studies, body mass index and the resting energy
expenditure (REE) A – 14.
Module 3- Document 3
Page 3 of 14
Assessments of the Child with Cancer:
Helpful Weblinks:
American Medical Association, Chicago, IL
This site contains a family history tool and a Pediatric Clinical Genetic Questionnaire that could serve as a
comprehensive assessment and physical examination form.
http://www.ama-assn.org/ama/pub/category/2380.html
Ped-Onc Resource Center, Colorado
This site contains additional information on signs and symptoms associated with childhood malignancy.
http://www.acor.org/ped-onc/diseases/diseases.html
National Cancer Institute, Bethesda, MD
Surveillance Epidemiology and End Results (SEER) on Childhood Cancers
This site contains childhood cancer incidence and survival in the US
http://seer.cancer.gov/publications/childhood/
http://www.cancer.gov/cancertopics/types/childhoodcancers
American Cancer Society
http://www.cancer.org/docroot/CRI/content/CRI_2_4_3X_Can_childhood_cancers_be_detected_early_7.asp
St. Jude Children's Research Hospital, Memphis, TN
Patients and Parents
http://www.stjude.org/patientsandparents
Harris-Benedict Calculator
http://www.bmi-calculator.net/bmr-calculator/harris-benedict-equation/
Related www.Cure4Kids.org seminars:
Seminar #146 Family and Patient Coping Mechanisms
Frances L. Greeson, MSW
http://www.cure4kids.org/seminar/146
Seminar #250 Child Growth and Development
Angie Koenecker, CCLS and Clare Grode-Gardner, CCLS
http://www.cure4kids.org/seminar/250
Seminar #456 Childhood Cancer - Don't Miss the Signs
Scott Howard, MD, MS
http://www.cure4kids.org/seminar/456
Module 3- Document 3
Page 4 of 14
Assessments of the Child with Cancer:
Appendix:
A – 1 Symptoms that may indicate the presence of a malignancy in children
Unusual mass or swelling especially of the abdomen
Unexplained paleness and fatigue
Loss of energy (limited time at play)
Persistent localized pain or swelling
Prolonged unexplained fever or illness, especially with bone pain
Frequent headaches, especially in the morning, often with vomiting
Sudden eye or vision changes
Excessive rapid weight loss
Swelling of the face and neck
Cat’s eye reflex
Limping
Lymphadenopathy
Vaginal bleeding in a premenstrual child, or prolonged bleeding between or with periods,
excessive bleeding during periods.
Go Back
A – 2 Chief Complaint (Reason for Seeking Medical Help)
Duration of the complaint or the illness, i.e. – date symptoms appeared. Ask patient, “When
was the last time you were completely well,” since the patient might be confusing symptom
appearance with the first time he or she was concerned about those symptoms.
Order of occurrence of the symptoms
Character/quality of symptoms (consistent/intermittent, duration, pattern, timing)
Diagnosis made by previous health care provider who treated the patient
Home remedies and alternative or complimentary therapies tried
Patient response to the treatment
Effect on other systems and activities or body functions (e.g. eating)
Caregivers’ description of the illness/complaint
Go Back
A – 13 Some general pointers: (Age-related adjustments)
1.
2.
3.
4.
5.
6.
7.
Make the child as comfortable as possible
Respect privacy, especially with adolescents
Integrate play – involve the child in the examination process
Allow young patients to manipulate equipment
Foster a trusting nurse-patient-parent relationship
Consider culturally/ethnically-related variations
Position yourself on their level-eye level
Go Back
Module 3- Document 3
Page 5 of 14
Assessments of the Child with Cancer:
A – 14 Resting Energy Expenditure (REE)
Represents the number of calories required by the body in a 24-hour non-active period. REE
increases during normal activity and with psychological (e.g., examination, life changes, new
school) and physiological (illness, growth) stressors. The Harris –Benedict equation (formula) is
one way to calculate caloric requirements. This formula takes into account the person’s gender,
age, height, and weight.
To start calculation, determine the BMR using the BMR formula (below). Then, use the BMR
results to calculate caloric requirements.
English BMR Formula
Women: BMR = 655 + ( 4.35 x weight in pounds ) + ( 4.7 x height in inches ) - ( 4.7 x age in years )
Men: BMR = 66 + ( 6.23 x weight in pounds ) + ( 12.7 x height in inches ) - ( 6.8 x age in year )
Metric BMR Formula
Women: BMR = 655 + ( 9.6 x weight in kilos ) + ( 1.8 x height in cm ) - ( 4.7 x age in years )
Men: BMR = 66 + ( 13.7 x weight in kilos ) + ( 5 x height in cm ) - ( 6.8 x age in years )
Harris Benedict Formula
To determine your total daily calorie needs, multiply your BMR by the appropriate activity factor, as
follows:
1. If you are sedentary (little or no exercise) : Calorie-Calculation = BMR x 1.2
2. If you are lightly active (light exercise/sports 1-3 days/week) : Calorie-Calculation = BMR x 1.375
3. If you are moderately active (moderate exercise/sports 3-5 days/week) : Calorie-Calculation =
BMR x 1.55
4. If you are very active (hard exercise/sports 6-7 days a week) : Calorie-Calculation = BMR x 1.725
5. If you are extra active (very hard exercise/sports & physical job or 2x training) : CalorieCalculation = BMR x 1.9
BMI Calculator
http://www.bmi-calculator.net/bmr-calculator/harris-benedict-equation/
Example: Caloric requirement for a 7 year old girl who is 45 pounds and 3 feet and 2
inches tall.
BMR = 655 + (4.35 x 45) + (4.7 x 38 inches) – (4.7 x 7)
= 655 + (195.75) + (178.6 ) – (32.9)
= 996.45
Caloric needs: (using moderately active lifestyle)
996.45 x 1.55 = 1544.50 calories/day
Go Back
Module 3- Document 3
Page 6 of 14
Assessments of the Child with Cancer:
Assessment Pictures
A – 3 Pallor
Mohammed Khattab, MD
Children’s Hospital, Rabat Morocco
Fatigue, Malaise
Mae Dolendo, MD
Davao Medical Center, Phillippines
Go Back
A – 4 Bleeding, Bruising, petecchia
Ecchymosis of the eye (Neuroblastoma)
Mohammed Khattab, MD
Rabat, Morocco
Blueberry Muffin Syndrome – Neuroblastoma
Carlos Rodriguez-Galindo, MD
St. Jude Children's Research Hospital
Go Back
Module 3- Document 3
Page 7 of 14
Assessments of the Child with Cancer:
A – 5 Weight loss, Cachexia
Constance Chaduka, RN
Zimbabwe
Go Back
A – 6 Lymphadenopathy
Laila Hessissen, MD
Morocco
Mohammed Khattab, MD
Rabat, Morocco
Go Back
Module 3- Document 3
Page 8 of 14
Assessments of the Child with Cancer:
A - 7 Limping
Gourinda Hassan, MD
Morrocco
Go Back
A – 8 Cat eye reflex
Carlos Rodriguez-Galindo, MD
St. Jude Children's Research Hospital
Go Back
Module 3- Document 3
Page 9 of 14
Assessments of the Child with Cancer:
A – 9 Abdominal Mass\Abdominal Distention
Mohammed Khattab, MD
Rabat, Morocco
Go Back
Module 3- Document 3
Page 10 of 14
Assessments of the Child with Cancer:
A – 10 Assymetry –
Mohammed Khattab, MD
Rabat, Morocco
Carlos Rodriguez-Galindo, MD
St. Jude Children's Research Hospital
Kanya Hanoki, MD
Nara Medical University, Japan
Go Back
Module 3- Document 3
Page 11 of 14
Assessments of the Child with Cancer:
A – 11 Presence of a tumor or growth
Mohammed Khattab, MD
Rabat. Morocco
Valeriy Boleslav Livandovsky
Vinnitsa Children’s Regional Hospital,
Ukraine
Go Back
Kanya Hanoki, MD
Nara Medical University
Japan
Go Back
Module 3- Document 3
Page 12 of 14
Assessments of the Child with Cancer:
A – 12 Precocious Virilization/Puberty
Galo Veintemilla, MD
Argentina
Go Back
Module 3- Document 3
Page 13 of 14
Assessments of the Child with Cancer:
Acknowledgments:
Author: Ayda G. Nambayan, DSN, RN, St. Jude Children’s Research Hospital
Content Reviewed by: Lisa South, RN, DSN, UA School of Nursing, University of Alabama at
Birmingham
Edited by: Marc Kusinitz, St. Jude Children’s Research Hospital
Cure4Kids Released date: 16 December 2005
Cure4Kids.org
International Outreach Program
St. Jude Children's Research Hospital
332 N. Lauderdale St.
Memphis, TN 38105-2794
You may duplicate and redistribute this content in its entirety for educational purposes provided that the
content is made available free of charge. This content may not be modified or sold. You can assist us in
the development of additional free educational materials by sending us information about how and when
you show this content and how many people view it. Send all comments and questions to
[email protected].
© St. Jude Children's Research Hospital, 2005
Last printed 05/07/2017 3:46:00 PM
Last Updated 16 December 2005; AS
X:\HO\IO Edu Grp\Projects\NURSING COURSE\NCEnglish\Edited\Module 3\M3 Final revisions\NEM03D03V09.doc
Module 3- Document 3
Page 14 of 14