Caring for the Child with Cancer

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Chapter 34

• Caring for the Child with Cancer

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Cancer

• Cancer is a group of diseases in which there is
  out-of-control 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

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Tumor

• Benign
• Slow, limited, noninvasive growth (not cancerous)
• Malignant
• Progressive virulent growth (cancerous)

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Terms Associated with the Cancer Patient

• Roadmapprotocol or treatment plan that is
  mapped out to guide staff and families
• Protocolcomplete explanation of a treatment plan
  
• Clinical trialsmedical research studies designed
  to answer scientific questions and to find new
  ways to treat cancer
• Remissionthe partial or complete disappearance
  of signs and symptoms of disease.
• Extravasationleakage of potentially damaging
  medications into tissues
• Inductionchemotherapy given to achieve remission
• Consolidationchemotherapy given after induction
  to control microscopic disease
• Maintenancechemotherapy given on a long term
  basis to maintain remission
• Palliative caretreatment given to relieve rather
  than cure symptoms caused by cancer.

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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

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Common Childhood Cancers
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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 classificationsALL, AML, and CML

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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

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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

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Chronic Myelogenous Leukemia (CML)

• Signs and symptoms
• Fever, fatigue, weight loss, anorexia, increased
  WBC, and splenomegaly
• Nursing care
• Administer hydroxyurea (Droxia, Hydrea)
• Administer interferon-a
• Administer combination chemotherapy
• Allogenic bone marrow or stem cell transplantation

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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)

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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

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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

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Wilms 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

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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

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Retinoblastoma

• Signs and symptoms
• Leukocoria strabismus red, painful eyes
  (blindness is a late sign)
• Nursing care
• Preoperativereassure parents and educate about
  what to expect postoperatively
• Postoperativeteach parents about eye socket
  irrigation and antibiotic ointment
• Teach parents about home care of the eye
• Offer support and encourage follow-up care

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Bone Tumors
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Osteosarcoma

• Signs and symptoms
• Pain and swelling
• Limp
• Dull aching pain
• Palpation at site, tenderness, swelling, warmth,
  and erythema
• Nursing care
• Administer chemotherapy
• Surgeryamputation versus limb sparing

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Ewings Sarcoma

• Two separate types of tumors
• Ewings sarcoma family of tumors
• Peripheral primitive neuroectodermal tumor (PPNET)

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Ewings 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.

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Lymphomas
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Hodgkins Disease (HD)

• Signs and symptoms
• Painless, firm, cervical, or supraclavicular
  lymphadenopathy
• Nursing care
• Administer chemotherapy
• If radiation treatment is performed, address
  radiation side effects.

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Non-Hodgkins 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)

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Other Cancers
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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

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Nursing Care of the Child with Cancer
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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

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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

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Infection

• Nursing care
• See Nursing Care Plan (Child with Acute
  Lymphocytic Leukemia)
• Monitor for systemic and localized signs of
  infection every 24 hours
• Take temperature every 4 hours
• Report a single temperature greater than 101.2F
  (38.5C) in a 24-hour period or 100.4F (38.0C)
  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)

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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

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Radiation

• Nursing care
• Measures that address the radiation side effects
• Nausea
• Alopecia
• Fatigue and malaise
• Low WBC
• Skin desquamation
• Mucous membrane inflammation and irritation

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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

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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

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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

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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)

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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)

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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

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Medical Emergencies
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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

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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

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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)

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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