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NURSING CARE OF THE CHILD WITH CANCER

Vera Brock RNC, DSN NURS 1102 Spring 2009

Cancer
Occur most frequently in rapidly growing tissues Neoplasms are any new or abnormal growthresearch suggests that abnormal cells loses the abilty to kknow when to stop growing, so it just keeps growing) Benign do not demonstrate anaplasia (Inappropriate cells for the organ that it is in) or metastasis Malignant have specific properties of anaplasia and metastasis Cancer is an alteration in cell function

Cancer
S&S: fatigue, bone pain, persistent lymphadenopathy, lack of appetite, HA, malaise, and changes in balance, gait or personality Others: mass, purpura, pallor, weight loss, squint or change in the eye, vomiting, recurrent or persistent fever Covert symptomssymptoms that are unspecific (pretty much symptoms that can be caused by other things) Overt symptomsreal specific symptoms to that specific cancer. (retinoblastomaspecific white color in eye, w/ eye drooping and squinting)

Diagnostic Tests
CBC increased production of immature cells, and overproduction of others Something is going to weird or wrong w/ differential. Basic chemistry profile liver enzymes will be reacting, renal and electrolytes LP (lumbar Puncture to see if there is CNS involvement), Bone marrow aspiration, CT and MRI Biopsy for TNM (once tumor is found they biopsy it to look at the markers T=tumor, L=lymph node, M= metastasis)

Therapies (what can correct this?)

Chemotherapy Radiation therapy Surgicallocalized and encapsulated?, if it is, removal is a good possibility; if not there is a risk for metastasisafter removed, then the decision will be made whether or not to do radiation or chemo Bone marrow transplantation

Chemotherapy
Antineoplastic agents (really bad drug in hopes that it will slow down the growth/ stop the growth of the tumor) Given IV, must be a patent line (not infiltrated). If infiltrates, may cause cell lysis and tissue sloughing; may need central venous access if drug is ran into an infiltrated IV line, then the drug will go all the way into the tissue to where the infiltration has occurred b/c the drug will cause all the tissue to die and fall off (blistering agents)may necrose to the bone. Anaphylaxis can occur: needs at the bedside B/P equipment, ambu bag, and Epinephrine

Chemotherapy
Will usually see N&V, hair loss, and anorexia To control N&V, give antiemetic (30 minutes to 1 hour before) and around the clock during the next 24-48 hours after infusion is complete. Ex: Zofran IV (has SE constipation, N&V, diarrhea), Kytril, Anzement Risk for secondary infection and fever, bleeding and anemias

Chemotherapy
Alteration in nutrition and oral mucosa anorexia and taste changes (bad on taste buds). Meal time should be pleasant and enjoyable. Allow the child to anything they want and later try to provide nutritious snacks. (JUST GET THE CHILD TO EAT, DOES NOT MATTER WHAT IT IS) (traylet sit open before you give it to child, pour 2 packets of sugar all over foodeven if they are diabetic b/c the child can be given more insulin to correct it)after the child gets over N&V (about a wk) then good can be given Bland, soft or light dietmash potatoes, no sugar or salt, everything tastes more bitter than usual in kids Use of soft sponge or soft toothbrush, rinse mouth with hydrogen peroxide and water, avoid viscous lidocaine (makes child lose gag reflex and can make a child <5 yrs old have seizures) and rectal temperatures (b/c if child has blisters in mouth, the blisters probably runn all the way thru GI tract, and thermometer can cause rectal perforation) Should do mouth care 30min before meal time so that food will taste better Loss of hair is not as big of deal anymore but dew rags and wigs can be used do not use an all polyester wig b/c it causes head to be hot and then hair cannot grow back After chemo and hair is starting to grow back (curly hair may become straight after chemo and after several haircuts the hair may turn back to normal).

Radiation Therapy
Use of unstable isotopes that release varying levels of energy to cause breaks in the DNA molecule and thereby destroy cells (radiologists job to figure out what kind and how much to administer over the period time) (bubble for breast cancer 2/day for 10 days) Common course once daily for 4 to 5 days/week for a period of 2-6 weeks Do not take the marks off Highly sensitive tumors: Hodgkins disease, Wilms tumor, retinoblastoma,

rhabdomyosarcoma (not common to see) Side effects: anorexia, N&V, extreme fatigue

Nursing Management for Radiation Therapy

Prior to treatment: indelible ink marks are applied (dont take marks off) After treatment: monitor CBC, WBC, platelet count. Observe for skin integrity

Bone Marrow Transplant

Aspirate from iliac crests or spines, in newborns from anterior tibia Conscious sedation (more traumatic for donor than for recipient)b/c it goes thru skin and into bone and the recipient gets it into the vein Human leukocyte antigen (HLA) matching AND ABO compatibility is the most important thing Give IV - monitor for cardiac dysfunction and pulmonary emboli; N&V, fever, and chills Tylenol, Valium and Benadryl; observe for anaphylasis (epinephrine) Strict Isolation (no flowers or raw fruit due to bugs b/c immune system is severely compromised)

Hematopoietic Stem Cell Transplantation

Stem cells harvested from bone marrow, peripheral blood, or the umbilical vein of the placenta are given to the patient via IV transfusion depends on how young the stem cells are b/c it is due to how specialized the cells are (b/c of this bone marrow is preferred for older children) some families will procreate another child so that the child w/ leukemia can use its stem cells cord blood is used for this reason. Conscious sedation Human leukocyte antigen (HLA) matching and ABO compatibility Post-procedure same as Bone Marrow Transplant

Brain Tumors (malignant)

Related to anatomic location, size and age of the child First thing that a parent may see is that the child is missing developmental milestones, or child may stop doing well in school or may get strabismus In infants it is difficult to see ICP until the tumor is large. very hard to check about tumor activity due to the anterior fontanelle that stretches to accommodate the tumor Most common types: medulloblastoma, cerebral astrocytoma, brainstem gliomahow big the tumor is going to determine other neurological deficits that are going on hard to remove b/c the tumor has finger/ tentacles that are around brain. S&S: classic HA and vomiting early in the morning (wake kid up and then sit them up quickly so the kid needs to make a slow progression into the sitting position) Most of these children WILL die. DX: CT, MRI, PET scan, neurologic testing TX: surgery (debulk the tumor take largest part of tumor and all the tentacles that be gotten to but the tumor will grow back faster), the child will have to have chemo and radiation essentially this process is extending the life of the child so that the family can get ready

for the child to die. Preop: radiation to shrink tumor Postop: position on nonoperative side, monitor V/S, check pupils, assess LOC, eye and facial edema from ICP apply cold compresses, seizure precautions, check dressings (the dressing should not be bloody or if so only mildly), observe fever

Neuroblastoma
Originates from embryonic neurocrest cells that normally give rise to the adrenal medulla and the sympathetic ganglia. (in abdomengenerally painless w/ intermittent fever activity and can press on aorta and cause cardiac symptoms(decompisation) S&S: usually in abdomen, firm, nontender, smooth mass in the flank area, weight loss, irritability, fatigue, and fever DX: radionuclide scan, 24 hour urine for catecholamines and VMA, CT, bone marrow aspiration TX: surgery to debulk the tumor and chemo (Vincristine, Cisplatin) PROGNOSIS IS BAD.

Wilms Tumor (Nephroblastoma)

Intraabdominal tumor S&S: asymptomatic, firm mobile mass confined to one side and deep within the flank (parent usually finds this tumor during a bath). DO NOT PALPATE every time this tumor is messed w/ there is a high risk of un-encapsulating this tumor- once uncapsulated it is very bad DX: abdominal x-rays, US, CT, MRI and blood studies TX: nephrectomy then radiation and Chemo; if inoperable; Vincristine and Dactinomycin Prognosis: Excellent if encapsulated, can recur in lungs as lung cancer b/c it comes back due to metastasisif un-encapsulated, all that can be done is serious chemo

Osteosarcoma or Osteogenic Sarcoma

Bone cancer in the long bones (distal femur), grows rapidly, highly malignant and metastasizes early (usually occurs in teenage boys)usually metastatic by the time it is found If tumor is localized and small at the time of diagnosis then the child has a good prognosis b/c they can remove the bone and put in a prosthesis If not localized than amputation is suggested May metastasize to lungs S&S: pain and swelling at the tumor site, palpable mass, limping, and limited ROM DX: CT, bone scans, tumor biopsy, x-ray TX: single bone removal, amputation These children and parents need your honestythe child usually knows that something really bad is happening but be honest on how you answer their questions of death unless the parent has specifically asked you not to say anything then tell kid to ask mom Phantom painoccurs b/c of amputation (VERY REAL) Anger and depression common This child will be very angry and will usually lash out (mainly at the nurseHow will you handle it?).

Ewings Sarcoma
Malignant small cell tumor, arising in the marrow spaces of the bone, metastasis usually to lungs and bones (possible to survive this now, although it is very often that it mets to lungs) S&S: pain, soft tissue swelling at the tumor site and fever (often in girls at beginning of puberty) TX: radiation and chemo, surgery high dose radiation and what is left is a shriveled limb Amputation is another option, either way the child loses function of the limb guided imagery has been shown to help w/ the phantom pain.

Leukemia
Unrestricted proliferation of immature WBCs. This robs the healthy WBCs nutrition. Bone marrow hypertrophies and then atrophies leading to anemia, bleeding disorders, and immunosuppression (differential: bands will be way high) (lots of different leukemias) Acute lymphocytic leukemia (ALL) and Acute myelogenous leukemia (AML)

ALL
Most common, in children 2 to 5 years (in kids <14 y.o) S&S: chronic cold, anemia, fatigue, weakness, pallor, lethargy, lymphadenopathy, hepatospenomegaly, bruising without reason (!!!!!), joint pain, petechiae, nosebleeds and gum bleeding- more overt symptoms (ITP may be thought of due to the bruising, but there is usually some reason for the bruising in ITP, ther is no reason for the bruising in ALL) (respiratory inf. 2mos agoand does not seem to be getting well; allergies?- no, then flags should go up)should always be tested for Mono first DX: CBC neutropenia, thrombocytopenia, decreased Hgb and Hct, + bone marrow aspiration, LP may show CNS involvement

ALL
Very good chance of going into remission the first time Chemo will stop the system/purge it and then it will be kick started back up. Treatment: chemotherapeutic agents Induction phase complete remission or absence of leukemia cells Consolidation phase preventing leukemia cells from invading or growing in the CNS Maintenance phase maintain remission

ALL
Nursing consideration: gentle assessments, close monitoring of renal function, I&O, weights, bone marrow suppression, protective isolation, mouth care, and observation of changes in neurologic functioning (be very careful when doing percussion b/c everytime you hit , you are causing bruising, palpate very lightly) pay strict attention to urinary system if the child goes into remission, chemo may need to be done periodically to maintain remission b/c if the child exacerbates again, she only has a 60-75% chance of going into remission again.

AML
Common in adolescents (only has a 50% of going into the first remission and only a 10-15% of going into a 2nd remission) Death usually from overwhelming infection (staph or URI) Same Tx as ALL but the child will have very strong chemo.

Lymphomas
Hodgkins and non-Hodgkins lymphoma (arises from lymphoid tissue) (nodularlymph nodes in clavicular area will be firm and nontender) NHL usually younger than 14 years old with early stage disease survival is 90%. Late stage disease survival 65-75%. (widespread thru-out the lymph tissue in the body) HL usually adolescence, 15-19 years old with survival excellent with localized nodal disease, survival after 2 years is cured. (not widespreadusually nodular that can be taken out) Neoplastic disease that arise from lymphoid and hemopoietic system

Hodgkins Disease
S&S: painless enlargement of the cervical or supraclavicular lymph nodes with a firm, movable mass; low-grade fever, night sweats, weight loss, cough, abd discomfort, anorexia, nausea and pruritus Labs: CT, MRI, lymph node biopsy, bone marrow aspiration and staging TX: combination of chemo and radiation

Non-Hodgkins Disease
Diffuse, un- or poorly differentiated, dissemination early, mediastinal involvement and invasion of meninges It eventually will affect the mediastinum and causes a obstruction and causes cardiac dyrhythmias and effects resp. system and then you die. DX: CT and biopsy TX: combination of chemo and radiation

Rhabdomyosarcoma (rare)
Malignant soft tissue tumor of striated muscle Most common in the orbit of the eye and poorly defined(bad) Hard painless mass with poorly defined margins, rhinorrhea, otalgia, swelling, ptosis, discoloration (lesion on outside of the orbit but the cancer is in the muscle of the eye) DX: CT, bone marrow aspiration, biopsy the area of the eye that has lesion and the muscle TX: radiation and chemo; surgical (excise it)if large the lesion will be radiated first and then surgery will done try to save the eye but eventually the eye will be taken out piece by piece.

Retinoblastoma
Congenital intraocular malignancy of the retina Leukokoria or cats eye reflex w/ a white spot on the pupil, fixed strabismus, red painful eye with glaucoma, blindness (if a picture is taken and instead of red reflex there will be white reflex- this is usually the case) DX: ophthalmologist exam

TX: external beam radiation therapy; best chemotherapy with cyclosporine therapy, laster therapy and cryosurgery; or enucleation (take the eye out) (you cannot biopsy the retina, and if the correct area is not biopsied than a false negative will show up)