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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