Pediatric Cancer
Pediatric Cancer
Pediatric Cancer
Childhood Cancers
“…communication
promotes understanding
and clarity;
with understanding, fear
diminishes;
in the absence of fear,
hope emerges; and in the
presence of hope, anything
is possible” (Stovall, 1995)
Childhood Cancer
C- continual unexplained weight loss, fatigue malaise
H- headaches with vomiting (early morning)
I- increased edema or pain in joints
L- lump or mass, persistent lymphadenopathy
D- development of whitish appearance in pupil of the eye
R- recurrent or persistent fevers, night sweats
E- excessive bruising or bleeding
N- noticeable pallor
Childhood Cancer & Treatment
Chemotherapy
Surgery
Radiation
Stem Cell Transplantation
Steroid Therapy
Biologic Agents
Complementary and Alternative Medical (CAM)
Chemotherapy: Antinoeplastic agents
Titrated to specific formula- closely correlated with
cardiac output and blood flow to kidneys and liver
Highly specialized nurses- The Association of Pediatric
Hematology/Oncology Nurses
Administration routes:
Oral
Intravenously (large bore catheter)
Intramuscularly
Subcutaneously
Intrathecally
Chemotherapy:
side effects/ nursing interventions
Bone Marrow GI and GU Integumentary
Suppression Changes
Neutropenia Nausea/vomiting Hair loss
Anemia Stomatitis Hyperpigmentation
Thrombocytopenia Anorexia of skin
Renal damage Hypersensitivity to
sunlight
Chemotherapy
Nursing Interventions:
Protection of the patient:
Isolation- what specific type?
Exposure to sun, chemicals, skin irritants
Nutritional needs:
Prevent nausea & vomiting
Types of foods to meet metabolic requirements
Temperatures/textures/acid-base
Fluid balance
Intake and output
Integumentary
Self image
Chemotherapy
Nursing Interventions:
When administering chemotherapy, the nurse should
observe for an anaphylactic reaction for 20 minutes
and stop the medication if one is suspected.
Chemotherapy is associated with both general and
specific adverse effects, therefore close monitoring for
them is important.
Assessing for signs of infusion infiltration and
irritation
?? ! !
NCLEX Question
Which of the following statements is correct about
the rate of cell growth in relation to chemotherapy?
A. Faster growing cells are less susceptible to
chemotherapy.
B. Non-dividing cells are more susceptible to
chemotherapy
C. Faster growing cells are more susceptible to
chemotherapy
D. Slower growing cells are more susceptible to
chemotherapy
Radiation Therapy
Purpose
Palliative- prevent growth, reduce tumor size, pain relief
Eradicate or kill a tumor
Side effects similar to chemotherapy: Sub-acute & Late
Somulence syndrome
Fever
Irritability
Ataxia
Anorexia
Dysphasia
?? ! !
NCLEX Question
Nausea and vomiting are common
adverse effects of radiation and
chemotherapy. When should a nurse
administer antiemetics?
A. 30 minutes before the initiation of
therapy.
B. With the administration of therapy.
C. Immediately after nausea begins.
D. When therapy is completed
Surgical treatment for cancer
Purpose
Confirm diagnosis
Debulking or resecting
Removal of tumor as adjunct to chemotherapy/radiation
Nursing Interventions
How does the nurse prepare the patient for surgery?
What interventions apply specifically to the family?
Hematopoietic Stem Cell and
Bone Marrow Transplantation :
Conditioning- eradicate disease with high-dose
chemo/radiation therapy
Infusion- implantation of stem cells or bone marrow
Increase in patient’s WBC, RBC, and platelets signal
success!
Complications
GI disturbances
Graft-Versus-Host Disease (GVHD)
Maintain patient on anti-rejection medications
Prednisone
Cyclosporine
Tacrolimus
Graft-Versus-Host Disease (GVHD)
Potentially lethal immunologic response of donor T cells
against the tissue of the recipient.
Prevention: Careful tissue typing, irradiation of blood
products to inactivate mature T lymphocytes.
Signs & Symptoms
rash, malaise, high fever, diarrhea, liver and spleen
enlargement
Treatment
Maintain patient on anti-rejection medications
Prednisone
Cyclosporine
Tacrolimus
Complementary /Alternative
Medical Therapies (CAM)
Risks-vs- benefits
Qualification of practitioner
Delay or interfere with conventional
treatment
Costs
Contraindications
?? ! !
NCLEX Question
Which of the following would be inappropriate
when administering chemotherapy to a child?
A. Monitoring the child for both general and
specific adverse effects
B. Observing the child for 10 minutes to note
for signs of anaphylaxis
C. Administering medication through a free-
flowing intravenous line
D. Assessing for signs of infusion infiltration
and irritation
Acute Lymphatic
Leukemia-
ALL
What signs and symptoms would lead to the
diagnosis of leukemia?
Fever
Pallor
Overt signs of bleeding
Lethargy or malaise
Anrexia
Large joint or bone pain
Petechiae, frank bleeding
Enlarged liver or spleen, changes in lymph nodes
Neurologic changes
Lab values for a diagnosis of
leukemia: examination of CBC with at
least 25% blasts confirm the diagnosis
Normal Leukemia
Leukocytes < 10,000 Leukocytes> 10,000
Platelets 20-100,000
Hemoglobin 7-11
Further diagnostic findings:
Bone marrow aspiration- iliac crest (why this
site?)
How does the nurse prepare the
child/family for this procedure?
What are the nurse responsibilities for this
procedure?
Treatment and Plan of Care: (p 1274-1280)
Chemotherapy: three phases
Induction phase
Consolidation
Delayed intensification
Remission and maintenance
Nursing Care for a Child Undergoing
Chemotherapy: review
Myelosupression- protect from injury
Infection/sepsis (neutropenia)- protect
from infection
Renal damage
GI disturbances
Metabolic emergencies
Intrathecal Medication
Chemotherapy instilled
into spinal canal
Assess and monitor for
placement of
intrathecal catheter
and assess neuro
checks
Treatment of Tumor Causing
Cancers
Cranial Radiation
Head and neck tumors are more
sensitive to radiation than
chemotherapy.
When would chemotherapy become
an adjunct to radiation therapy?
Tumor Lysis Syndrome:
What causes tumor lysis syndrome?
What are signs and symptoms of
this complications
What nursing interventions apply to
treatment?
Other Cancers of
Childhood
Clinical manifestations of Neuroblastoma
Smooth, hard, non-tender along sympathetic
nervous system
Frequent location is abdomen
Neck and facial edema from vena cava
syndrome
Increased ICP
Limp if metastasis to bone
Pancytopenia
Nursing Management
Assess by observation and inspection (not
palpation)
Document bowel and bladder function
Record height & weight, observe gait
Chemotherapy, radiation, surgery
Teach parents S&S of infection. Why?
?? ! !
NCLEX Question
Which of the following laboratory values is
expected for a client just diagnosed with
chronic lymphocytic leukemia?
A. Elevated sedimentation rate
B. Uncontrolled proliferation of
granulocytes
C. Thrombocytopenia and increased
lymphocytes
D. Elevated aspartate aminotransferase and
alanine aminotransferase levels
?? ! !
NCLEX Question
Which of the following foods
should a client with leukemia
avoid?
A. White bread
B. Carrot sticks
C. Stewed apples
D. Medium rare steak
?? ! !
NCLEX Question
A client with leukemia has
neutropenia. Which of the
following functions must be
frequently assessed?
A. Blood pressure
B. Bowel sounds
C. Heart sounds
D. Breath sounds
?? ! !
NCLEX Question
What are the three most important prognostic
factors in determining long-term survival for
children with acute leukemia?
A. Histologic type of disease, initial platelet
count, and type of treatment
B. Type of treatment and client’s sex
C. Histologic type of disease, initial WBC
count, and client’s age at diagnosis
D. Progression of illness, WBC at the time of
diagnosis, and client’s age at the time of
diagnosis.
?? ! !
NCLEX Question
Which of the following complications are
three main consequences of leukemia?
A. Bone deformities, spherocytosis, and
infection.
B. Anemia, infection, and bleeding
tendencies
C. Lymphocytopoiesis, growth delays, and
hirsutism
D. Polycythemia, decreased clotting time,
and infection
?? ! !
NCLEX Question
A child is seen in the pediatrician’s office
for complaints of bone and joint pain.
Which of the following other assessment
findings may suggest leukemia?
A. Abdominal pain
B. Increased activity level
C. Increased appetite
D. Petechiae
?? ! !
NCLEX Question
Which of the following immunizations
should not be given to a 4-month-old
sibling of a client with leukemia?
A. Diphtheria and tetanus and pertussis
(DPT) vaccine.
B. Hepatitis B vaccine
C. Haemophilus influenzae type b
vaccines (Hib)
D. Oral poliovirus vaccine (OPV)
?? ! !
NCLEX Question
Which of the following tests in
performed on a client with leukemia
before initiation of therapy to evaluate
the child’s ability to metabolize
chemotherapeutic agents?
A. Lumbar puncture
B. Liver function studies
C. Complete blood count (CBC)
D. Peripheral blood smear
?? ! !
NCLEX Question
Which of the following is the reason to
perform a spinal tap on a client newly
diagnosed with leukemia?
A. To rule out meningitis
B. To decrease intracranial pressure
C. To aid in classification of the leukemia
D. To assess for central nervous system
infiltration
Osteosarcoma
Osteosarcoma- most common
primary bone malignancy in children
Goal of treatment- remove tumor and prevent spread of
disease
Biopsy Chemo Surgery Chemo
(radiation=palliative pain control)
Promote self esteem
Side effects of chemotherapy
Amputation of extremity
Separation from friends and family
Ewing Sarcoma- second most common bone
tumor associated with children
Pain, soft tissue swelling
Anorexia, fever, malaise with metastasis
Diagnosis same as osteosarcoma
Management
Chemo
Surgery (decrease tumor bulk)
Radiation
Rhabdomyosarcoma
Pathophysiology and Manifestations
Most common soft tissue malignancy
Divided by young (<10 yrs) and older
(adolescents) in location
60% have positive prognosis
Soft to hard, nontender mass (depends
on location)
In pelvic tumors, may disrupt organ
function
Diagnosis and Treatment
CT, BM aspiration and biopsy
Renal function and liver function tests
Treated with chemo, surgery and
radiation
Nephroblastoma- Wilm’s Tumor
Soft renal tumor - one or both kidneys
Metastasis or seeding spread by palpation
Nephrectomy treatment of Wilm’s tumor
Nephroblastoma- Wilm’s Tumor
The most common sign of Wilms’ tumor is
a painless, palpable abdominal mass,
sometimes accompanied by an increase in
abdominal girth.
Microscopic hematuria may be present.
Nursing treatment of Wilms’ tumor:
Pain management
Frequent reposition
Noninvasive and pharmacologic pain interventions
Prevent circulatory overload
Weigh daily
I&O, urine for specific gravity
Prevent infection
Hand washing
Protective isolation
Homecare needs
?? ! !
NCLEX Question
A child is diagnosed with Wilms’
tumor. During assessment, the
nurse in charge expects to detect:
A. Gross hematuria
B. Dysuria
C. Nausea and vomiting
D. An abdominal mass
?? ! !
NCLEX Question
David, age 15 months, is recovering
from surgery to remove Wilms’
tumor. Which findings best indicates
that the child is free from pain?
A. Decreased appetite
B. Increased heart rate
C. Decreased urine output
D. Increased interest in play
Retinoblastoma
Retinoblastoma- rare malignant tumor of the
neural retina
“cat’s eye” reflex seen as a white light in the
pupil is the most common “leukocoria”
May have strabismus of involved eye
Red painful eye is late symptom
Staging based on extent of disease
Nursing care of the child/family with a
malignant disease: (p905-915)
Initial focus on support of family members
Nurses facilitate the educational process to allay
fears of unknown
Encourage family members to verbalize fears and
questions
Postoperative care if indicated
Community resources (through the discharge
planner, case worker)
Death and Dying:
Understanding of death according to developmental age:
< 3 years- no understanding/concept of death
3-5 years- afraid of separation from parents
5-9 years- understand death is permanent, irreversible
and sad. Concerns for fear of pain, being left alone and
leaving parents and friends.
Age 10> have adult’s concept of death
Nursing Care and Grief
Child- encourage child to express
feelings, allow choices, help maintain
independence