Maternal-Child Nursing CareMaternal-Child Nursing CareOptimizing Outcomes for Mothers, Children, & FamiliesOptimizing Outcomes for Mothers, Children, & Families

Susan WardSusan WardShelton HisleyShelton Hisley

Chapter 34

Caring for the Child with Cancer

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

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