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Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Chapter 34 Caring for the Child with Cancer Susan Ward Shelton Hisley Cancer Cancer is a group of diseases in which there is out-ofcontrol 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 Tumor Benign Slow, limited, noninvasive growth (not cancerous) Malignant Progressive virulent growth (cancerous) 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 Clinical trials—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. 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 Common Childhood Cancers 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 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 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 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 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) 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 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 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 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 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 Bone Tumors 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 Ewing’s Sarcoma Two separate types of tumors Ewing’s sarcoma family of tumors Peripheral primitive neuroectodermal tumor (PPNET) 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. Lymphomas 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. 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) Other Cancers 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 Nursing Care of the Child with Cancer 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 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 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) 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 Radiation Nursing care Measures that address the radiation side effects Nausea Alopecia Fatigue and malaise Low WBC Skin desquamation Mucous membrane inflammation and irritation 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 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 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 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) 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) 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 Medical Emergencies 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 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 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) 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