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Leading cause of death from disease
in children
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Almost all childhood cancers involve
blood or blood-forming tissues
Leukemia
Brain Tumors
Lymphomas
Neuroblastoma
Wilms
Rhabdomyosarcoma
Retinoblastoma
Othes
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Brain tumors – second leading cause of death from
childhood cancer.
◦ Most are cerebellar and brain stem tumors
Lymphomas
◦ Non-Hodgkins lymphomas—one-third present with a
mass in the neck or mediastinal area. Also have
dyspnea, wheezing, abdominal mass or pain and
lymphadenopathy.
◦ Hodgkin’s disease – arises in single lymph node with
painless nodal enlargement, followed by extension to
adjacent nodes and into spleen, liver, lungs, bone
marrow.
Neuroblastoma – malignant tumor arising from
sympathetic NS ganglion cells outside the cranium and
and can arise from anywhere along the sympathetic
nervous system chain. Can also occur in retroperitoneal
area, pelvis, neck.
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Wilms Tumor – solid tumor of kidney.
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Rhabdomyosarcoma—malignant tumor of the
striated muscle cells.
◦ occur in muscles around eye, head, neck,
extremities, GU system.
Retinoblastoma – intraocular malignancy of the
retina of eye. Usually unilateral. If bilateral ,
hereditary. First sign is white pupil.
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Others – osteogenic sarcoma/ Ewings sarcoma –
tumor of bones of the trunk. Often seen in
adolescence growth spurt. Found in distal femur,
proximal tibia.
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Intrauterine carcinogens
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Immune defects
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Physical carcinogens
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Viruses
Genetics
◦ Discovered gene for
leukemia on
chromosome 22
C = continual unexplained weight loss
H = headaches with vomiting (early morning)
I = increased swelling of pain in joints
L = lump or mass
D = development of whitish appearance in pupil
R = recurrent or persistent fevers, night sweats
E = excessive bruising or bleeding
N = noticeable paleness or tiredness
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Biopsy
Blood Tests
◦ CBC
◦ Uric Acid
Bone Marrow Aspiration
PET, SPECT
MRI, CT, ultrasound
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Radiation therapy
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Chemotherapy
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Surgery
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Bone Marrow and Stem cell transplantation
Changes the DNA component of
a cell nucleus
The cell cannot replicate which
Inhibits further cell division and growth
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Radiation sickness- anorexia, nausea, vomiting
◦ Treated with antiemetics (Zofran or Anzimet). Cool
cloth to forehead, provide distraction, accurate
I&O.
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Fatigue
◦ allow for naps an rest periods (coordinate care),
encourage parent to cuddle in bed with child,
pillow, blankets, favorite toys
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Skin reactions –erythema, tenderness
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Bone marrow suppression – anemia, neutropenia
thrombocytopenia
◦ May be on reverse isolation
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Mucositis- inflammation of mucus
membranes mainly the mouth
◦ Offer soft foods, and cold foods.
◦ Frequent mouth care. Lidocaine oral to swish in
mouth (older child)
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Long term – depends on part of body receiving
radiation
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There are several categories of antineoplastic drugs
used in treating childhood cancers.
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Scheduled at set times and days and by different
predetermined routes.
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May remain in hospital for few days at first, then
later report on specific day for therapy.
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Children and Parents must be taught about what to
do and not to do during therapy.
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Chemotherapy
◦ Bone marrow
suppression
◦ Alopecia
◦ Malaise/fatigue
◦ Nausea
◦ Vomiting
◦ Anorexia
◦ Stomatitis
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Radiation side effects
◦ Skin reactions
◦ Fatigue
◦ Bone marrow
suppression
◦ Nausea
◦ Vomiting
◦ Anorexia
◦ Mucositis
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Bone Marrow Suppression – neutropenia,
anemia, thrombocytopenia
◦ Place in reverse isolation, keep anyone exposed to
a virus away from patient.
◦ Monitor temperature
◦ Should not receive live-virus vaccines
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Bleeding Tendency
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Apply pressure to puncture site
No contact sports
Check urine and stool for blood
Give stool softeners. WHY?
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Malaise and fatigue
◦ Encourage video games, movies, etc
◦ Allow visits from friends
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Nausea, vomiting, diarrhea, anorexia
◦ Give anti-emetics
◦ Small frequent meals
◦ Monitor for dehydration
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Altered mucous membranes
◦ Stomatitis
◦ Rectal ulcerations
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Renal involvement
◦ Uric acid levels rise as a result of breakdown of cells.
The renal tubules causing renal failure.
◦ If kidney affected/damaged- chemo drugs will not be
excreted as usual and may limit drugs given.
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Body Image changes
◦ Alopecia
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Pain Management
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Know OSHA guidelines for administering antineoplastic
agents
Confirm all measurements and calculations
Double-check ordered dosages
Obtain complete blood count within 48 hours of
chemotherapy administration
Note white blood cell and platelet levels before
chemotherapy begins
Know side effects of chemotherapeutic agents and
ways to alleviate these effects
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Ensure patency of IV tubing by checking for blood
return
Ensure needle placement for implantable infusion
device
Give vesicants (agents that can cause tissue necrosis)
only through a fresh IV site
Have emergency drugs available
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Curative
◦ Remove the tumor and cancerous tissue
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Palliative
◦ Relieve complications due to the cancer
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The goal of therapy is to administer a
lethal dose of chemotherapy and radiation
therapy that will kill the cancer and then
re-supply the body with bone marrow and
stem cells to reconstitute immunologic
function.
Healthy bone marrow or stem cells are
infused into the bloodstream and migrate
to the marrow space to replenish the
patient’s immunologic function and help
kill remaining cancer cells.
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Syngeneic
◦ bone marrow comes from identical twin
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Allogeneic
◦ bone marrow comes from matched sibling (one in
four chances) or someone who is histocompatible.
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Autologous
◦ own bone marrow. May be harvested at time of
remission in preparation for relapse or when bone
marrow is free of malignant cells. Also being used
so toxic doses of chemotherapy and radiation can
be administered and the bone marrow rescued.
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First --All potential donors are typed for HLA (human
leukocyte antigen) compatibility.
Collection of bone marrow is a surgical procedure.
◦ The donor undergoes anesthesia for aspiration of the
bone marrow
◦ The bone marrow is then processed and frozen
◦ When patient ready - it is infused into the recipient.
1. Graft-Versus-Host Disease (GVHD) – potentially lethal
immunologic response of donor T cells against the
tissue of the recipient.
◦ Signs and symptoms – rash, malaise, high fever,
diarrhea, liver and spleen enlargement.
◦ Because there is no cure, prevention is essential.
Careful tissue typing, irradiation of blood products
which helps to inactivate mature T lymphocytes.
2. Rejection of the transplant
CNS – cognitive disorders, seizures, headaches,
coordination problems
 Bone – asymmetric growth of bones, easy fractures,
scoliosis, kyphosis
 CV – cardiomyopathy (pericardial thickening) ,
pericardial damage
 Respiratory – pneumonitis, pulmonary fibrosis
 GI – enteritis, bleeding, hepatic fibrosis
 Urinary – hemorrhagic cystitis, reflux
 Endocrine – decrease in growth, thyroid and gonadal
dysfunction
 Reproductive – decrease sperm
 Dental - caries
 Secondary malignancies
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What is the most common form of childhood
cancer?
a. leukemia
b. brain tumors
c. lymphoma
d. osteosarcoma
A malignancy of the blood forming
tissues/ bone marrow in which normal bone
marrow is replaced by
malignant immature WBC’s
Most common type of leukemia-- 80% of
leukemias in children
The malignant cell involved is the lymphoblast,
which is an immature lymphocyte from stem cell.
Highest incidence in children 2-6 yrs of age
(white)
Survival rates have improved substantially but are
dependent on several factors such as age
diagnosis made, initial WBC, and presence of
invasion into other organs.
90-95% go into initial remission, 70% survive at
least 5 yrs
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Most common of this type is acute myelogenous
leukemia (AML)(20%)
overproliferation of myeloblasts- blast stage is
immature
stem cell=myeloblast= basophils, eosinophils,
neutophils
overproliferation limits production of RBC's &
platelets
usually seen in older children- adolescence- adult
S&S, diagnosis similar to ALL
Remission more difficult than in those with ALL
25% 5 year survival rate-depends on type cell, extent
involved, age
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The WBC's are produced so rapidly that
immature cells (blast cells) are released
into the circulation.
These blast cells are nonfunctional, can't
fight infection, and are formed continuously
without respect to the body's needs
The blasts cells then invade other organs
and interfere with metabolism / function.
The production of red blood cells and
platelets decreases leading to anemia and
thrombocytopenia.
Bone marrow Depression results in:
1. Decrease in mature WBC’s - fever
2. Decrease RBC’s, Anemia- pallor, lethargy, anorexia
3. Decreased Platelets/ thrombocytopenia
4. Increase cell metabolism which deprives cells of
nutrients
5. Enlargement of organs infiltrated with blast cells
results in:
◦ Bone pain
◦ Spleenomegaly. Hepatomegaly, Nephromegaly
◦ Lymphadenopathy
◦ CNS infiltration – increased ICP
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History and Physical
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Blood Work
◦ Platelet count, Hgb and Hct low
◦ Blast cells appear (where they normally don’t)
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Bone Marrow Aspiration
◦ Used to identify the type of WBC involved,
therefore, type of leukemia
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X-rays of long bones
◦ Show lesions caused by invasion of abnormal cells
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Lumbar Puncture – blast cells in the CSF
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A combination of antineoplastic drugs are given for
about a month
A different combination is given for about 2-3 years
Advantages of using a combination of drugs:
◦ Decrease resistance to one drug
◦ Lessening of severe side effects of massive doses of
one drug
◦ Breakdown of the tumor cell cycle at multiple sites
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1. Remission induction- most intense treatment.
Large doses of antineoplastic drug administered in
an effort to destroy as many proliferating cells as
possible. Lasts 4-6 wks. About 95% respond.
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2. Consolidation- method of destroying leukemic
cells in the CNS- for children who have CNS
involvement or are high risk. Given Intrathecal.
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3. Remission maintenance- drugs given at specific
intervals. If remain in remission for 3 yrs, treatment is
discontinued. Approx 80% of children who sustain
remission for 2-3 yrs continue to remain in remission
and appear to be cured.
Prevent infection (neutropenia, anemia)
Pain Relief
Nausea and vomiting
Mouth discomfort-mucositis / stomatitis
Fatigue
Alopecia
Prevent blood loss-platelet low- nose bleed most
common kind of bleed
 Support child and family
 Assist with referrals to social services, home health
agency, chaplain
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Community Resource
◦ Candlelighters Childhood Cancer Foundation® (CCCF) is a
national non-profit membership organization whose mission
is to educate, support, serve, and advocate for families of
children with cancer, survivors of childhood cancer, and the
professionals who care for them.
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 http://www.candlelighters.org/
American Cancer Society
Make a wish Foundation
Leukemia Society
Church and Schools
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Intracellular contents are dumped into the
extracellular fluid as cells are lysed, or killed
Intracellular electrolytes overload the kidneys and,
if the condition is not monitored and treated,
cause kidney failure
Most common in children with leukemias with very
high WBCs and in children with non-Hodgkin’s
lymphomas, especially when extensive disease is
present
Elsevier items and derived items © 2009, 2005
An embryonic tumor
of the kidney.
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Cause is unknown
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Originates from immature renoblast cells
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Tumor is vascular
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Palpable abdominal mass
◦ Firm and smooth
**The abdomen should not be palpated once the
diagnosis is made. Avoid palpating the tumor mass
during assessment because of the risk of rupturing the
protective capsule. Excessive manipulation can cause
seeding of the tumor and spread of cancerous cells
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Abdominal distention
Fever
Fatigue
Late signs
◦ Anemia
◦ Hematuria, dysuria
◦ Hypertension
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Abdominal ultrasound
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CT, MRI
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Biopsy
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Nephrectomy and removal of lymph nodes
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Post-op chemotherapy and / or radiation
therapy
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CT every 6 months for 3 years
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Chest x-ray every 3 months for 3 years
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Pre-op
◦ Sign on bed ”Do Not Palpate Abdomen”
◦ Child / Parent teaching
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Post-op
◦ Monitor kidney function, Strict I & O
◦ Monitor vital signs—B/P and temperature
◦ Monitor GI function– assess bowel sounds and stool
production
◦ NG tube to drainage. Measure abdominal girth.
Caring for a child who
is dying can be one of
the hardest tasks in nursing
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Children under 3
◦ Have no understanding of own impending death
◦ May perceive family anxiety, sadness
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Preschool to 5 years
◦ More afraid of separation from parents than of
thought of dying. Greatest fear is separation.
◦ Envision death as temporary, and have little of adults’
fear of it
◦ Think of it as a long sleep, not a final process.
Nightmares increase.
◦ May feel pain / illness is a punishment for misdeeds
or thoughts
◦ May ask questions about death
◦ In long term illness – may simulate adult response
with depression, withdrawal, fearfulness, anxiety
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School Age 5-9
◦ Begin to understand that death is permanent
◦ May think it is something that only happens to
adults
◦ Become aware of what is happening to them
when their disorder has a fatal prognosis.
◦ Concerns center around fear of pain, fear of
being left alone and leaving parents and friends.
◦ May associate death with sleep and may be
afraid to go to sleep without someone near them.
◦ May associate death with darkness—want light
left on in room
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Adolescent, older school age
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By age 10 have an adults concept of death, realizing
that it is inevitable, universal, and irreversible. Have
more understanding than adults realize.
Understand that death is the cessation of life.
Emotional outbursts may reflect anger
View death as fearsome and fascinating (increase in
adolescent suicide).
May feel immune to death and deny symptoms for
longer than usual because they believe it is
impossible that anything serious could happen to
them.
Some adolescents consider themselves alienated
from their peers and unable to communicate with their
parents for emotional support feeling alone in their
struggle.
Elicit child's understanding of death before
discussing
2. Encourage children to express feelings in own way
through play, drawings, or verbalization to promote
free expression.
3. Provide a safe, acceptable outlet for expressions of
feelings
4. Structure care of child to allow child choices and
participation in process within constraints of physical
condition
5. Help child maintain independence and control;
normal ADL as much as possible (set realistic goals)
6. Realize that they will go through the stages of dying:
denial, bargaining, anger, depression, acceptance
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1.
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3.
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Spend time with family to listen, answer questions, and
provide information. Discuss issues with parents before
discussing with child.
Provide opportunities for family to express their
emotions and deal with their feelings. Parental
reactions: continuum of grief process and usually
depend on previous experiences with loss,
intellectualization.
Reactions may depend on relationship with child and
circumstances of illness or injury
Reactions depend on degree of guilt felt by parents-help
them sort out
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Assist parents in expressing fears, concerns, grief to
enable them to appropriately support child
Assist parents to understand sibling' possible
reactions to terminally ill child
 Guilt- believing they caused the problem or illness
 Jealousy- wanting equal attention from parents
 Anger- feelings of being left behind
Support, enhance parent-child communication,
enhance parents' ability to support child
Refer to parent, family support groups- not alone,
help focus, open communication, provide
information
 Nurse needs to care for self.
 Care of the caregiver is imperative if the nurse is to
provide physical and psychosocial care for families at
such a difficult time.
 Caring for dying children and their families can be
stressful and emotionally demanding.
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Clinical manifestations
Treatment sequence
 How does this treatment differ from
osteosarcoma?
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Why is metastases more of a concern
with this cancer?
 Clinical
manifestations-
 Treatment
sequence-
 Chemotherapeutic
agents (VAC)
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Clinical manifestations
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Treatment sequence
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Why is the sequence of treatment
important?
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Pre-operative nursing goals for the child diagnosed with
cancer◦ Disturbed sensory perception
◦ Anticipatory grieving
◦ Risk for infection
Post-operative nursing goals◦ Risk for infection
◦ Impaired skin integrity
◦ Impaired adjustment- disturbed body image
◦ Pain
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What is the rationale for treating some cancers with
chemotherapy prior to removal of the tumor?
What specific teaching should the nurse include as
priority regarding chemotherapy?
What lab values does the nurse monitor carefully in the
client undergoing chemotherapy?
 Prioritize
psychosocial needs of the
child/family diagnosed with cancer
 Develop
nursing interventions to
assist with stressors that influence
the child/family’s response to the
diagnosis and treatment of cancer.