Cancer and EOL Flashcards
What is cancer?
Cells that grow out of control (develop abnormal sizes and shapes) and develop own blood supply
How does cancer cells affect other cells? Where do cancer cells usually metastasize in children?
Destroy other cells by being parasitic and stealing their nutrients and blood supply
Adrenals, liver, brain, bones and lungs
What are the most common cancers in children?
Brain (CNS tumors)
Leukemia
What is the cause of cancer?
Multifactorial with genetics and epigenetics
Epigenetics: Exposure to an environmental factor can trigger a genetic predisposition
What are things that can put you at risk for developing cancer?
Genetics
Radiation
Exposure to power lines
Cigarette smoke
Viruses (Epstein bar)
Certain chemical drugs
What underlying health disease can increase the risk for developing cancer?
Genetic predisposition: Down syndrome (15x greater risk for leukemia)
Immune deficiency: Wiskott-Aldrich syndrome, post transplant lymphoproliferative disease, chronic immunosuppression meds after organ transplant
Viral infection: Epstein-Barr liked to lymphoma and leukemia
What are the 3 layers that form embryonic tissue? What is embryonic tissue?
Endoderm, mesoderm. ectoderm
Source of stem cells
What is the endoderm?
Inner layer of embryonic disc
Forming lining of digestive tract and derivatives
What is the mesoderm?
Middle layer of embryonic disc
Forms tissues like muscles, bones, and blood vessels
What is the ectoderm?
Outer layer of embryonic disc
Forms skin and neuroectoderm
Why are these tissues associated with the embryonic disc at risk? What does this cause ?
They are very rapidly diving cells –? prime location for cell dysplasia and cancer cells to develop in the embryo
D/t this they are born with cancer and it is not regconized until it reaches a critical point such as a palpated mass or causing s/s
What is a cancer that occurs d/t embryonic tissue?
Solid tumor cancer
What is unique about the pediatric tumors?
Tend to occur in primitive or embryonic tissues
Characterized by rapid growth
Responsive to chemotherapy because cells are still rapidly diving as a kid
Likely to have metastasis at diagnosis
Rarely associated with exposure/lifestyle choices (more genetic predisposition)
What is unique about the adult tumors?
Occurs in developed tissues
Often more slowly growing
Frequently loss responsive to chemo
More common to have local/regional disease
Commonly associated with exposures/lifestyle
What are some cancers that are primitive/embryonal tissues?
Whilms tumor (kidney)
Neuroblastoma (adrenal gland)
Brain tumor
What is our first goal regarding treating children that have cancer?
Allows them to be kids first. Provide and promote a sense of normalcy
What are major fears in an infant and what stage?
Trust/sensorimotor
Separation
Strangers
What are interventions for infant stage? (6)
Provide consistent caretaker
Comfort hold
Play with child
Routine
Bed is safe space
Minimize separation from parents and caregivers
What are majors fears of toddlers and what stage are they in?
Loss of control
Strangers
Pain
Autonomy/preoperational
What are the interventions for the toddler stage? (5)
Choices when appropriate
Routines
Allow for regression but make sure to still set limits
Safe bed/zones such as room
Security objects/blankets/toys
How is loss of control typically expressed in to toddler?
Regression
What are major fears or preschoolers? What stage are they in?
Body injury
Mutilation
Darkness
Being left alone
Initiative/preoperational
How does magical thinking impact a preschoolers view on their illness?
Believe that their illness is a punishment for something they have done
What are interventions in the preschool stage? (5)
Provide simple, concrete explanations
Avoid trigger words
Advance preparations - all equipment ready to go
Post procedures band aids and wraps to make them know their body is put back together and help with fear of body mutilation
Use pictures, models, and medical play
Expressive play
What are major fears of school age? What stage are they in?
Loss of control
Stalling - avoid pain
Afraid to disappoint others or show fear
Industry/concrete operational
What are interventions for the school age stage? (8)
Provide concrete choices to increase sense of control
Give them an age appropriate task to help them feel accomplished
Use pictures and models for explanations
Simple and honest answers (no lying even about death)
First/then statements
Allow child to express fears/emotions
Play and school support
Allow them to ask questions
What are major fears of an adolescent? What stage are they in?
Loss of privacy
Altered body image
Death
Separation form peers/FOMO
Intimacy/identity and formal operations
What interventions can be used in the adolescent stage? (7)
Allow them to be integral decision maker
Give information sensitively and privately
Allows as many choices and control as possible
Give them all the information about treatment, risk/benefits/consequences
Engage with peers as much as possible
Peer groups: journaling, memorializing, planning funeral
Allow them to talk about death
What is the concept about death in early childhood?
No concept
React to emotions but do not know what death is
Can sense when something is sad or if parents are sad/worried
Might be able to say death but doesn’t know what it means
What is the concept about death in school age?
Begin to appreciate death
Develops concept that death is permanent
Knows that they will not see the person that died ever again
OK to use work dead
What is the concept about death in adolescents?
Know death is permanent
Explore spirituality/religous beliefs (especially if facing their own death)
Depression (sometimes will hide these for the family)
Protective of family emotions - more honest with others about their fears b/c don’t want to upset/scare family
Which age groups have a more egocentric view on death? What does this mean?
Older school and adolescence
Worried about how their family will carry on without them once they are gone
More worried about those around them
Where do sole organ neoplasms and blood neoplasms arise from in children? What types?
Arise from embryonic tissue
Solid: Brain, neuroblastoma, Wilms, osteosarcoma
Blood: leukemia
What is the most common brain tumor in children? When do you commonly see these?
Medullaoblastoma
5-10 years
What are the s/s of medulloblastoma? (7)
HA
N/V
Dizziness
Visual disturbances
Sensory deficits
Seizures
Truncal ataxia
How is a medulloblastoma diagnosed? How is it treated?
Diagnosed via MRI
Treatment includes surgery, radiation, and chemotherapy
Why can medullablastomas cause hydrocephalus?
Tumor can compress on the 4th ventricle and cause hydrocephalus
What are presenting s/s of increased ICP? (11)
Poor feeding
Bulging fontanels
Rapidly increasing head circumference
Loss of milestones
Irritability and change in behavior
Poor coordination/clumsiness
Change in school performance/activites
Vision changes
Seizures
Morning HA
Vomiting
What is a neuroblastoma? When do they arise from?
Abdominal tumor
Arises from immature nerve cells “blasts” in the adrenal gland
When is a neuroblastoma diagnosed? Does it metastasize? What is the survival rate?
Present at birth but typically diagnosed at <5 when the abdominal mass is big enough to be noticeable
1-2 years old is typical diagnosis
Metastasizes usually to the brain and impairs QOL
80% survival rate
What are the presenting s/s of a neuroblastoma? (7)
HTN d/t aldosterone and rennin released by the adrenal glands (where it arises)
Anemia
Fatigue
Abdominal mass (can cross midline and invade other organs)
Pain
Constipation
Decreased appetite
What is Wilms tumor (nephroblastoma)? Where does it arise?
Most common solid tumor in children
Tumor in the kidneys
Arises from the immature nephroblasts in the kidneys
What is the peak age for Wilms tumor? What is the prognosis?
Peak in 2-3 years old
Excellant survival especially if isolated to one kidney. Survival rate decrease if it is in both kidneys
How does Wilms tumor present? What does it present similar to?
Unilateral mass that does not cross midline
Often asymptomatic
Only 1/4 present with hematuria. constipation, decrease appetite
Can present similar to neuroblastoma
On assessment what should you never do with Wilms tumor? Why?
DO NOT palpate the abdomen
Can cause the tumor to break off and travel throughout the blood
Post signs on the door near bed not to palpate the abdomen
Where does osteosarcoma arise from? When does it peak?
Arises in osteoblasts at birth
Peaks in adolescence d/t puberty
What does osteosarcoma most commonly affect? Does it metastasize? What is a complcation?
Long bones such as legs are most commonly affected
Frequently metastasizes and reoccurs
Amputation - w/ adolescence affects body image, hanging out with friends, sports
What is the treatment for solid tumor cancers?
Chemo through mediport
Radiation (curative or palliative)
Surgery (curative or palliative)
Child life
What are the side effects of radiation? (6)
Fatigue
Anorexia
N/V
Erythema and skin breakdown at radiated site
Altered bone growth in children less than 3 and could lead to short stature
Focal neuro/developmental/cognitive deficits
How do you diagnose acute lymphoblastic leukemia (ALL)? When does it present?
Bone marrow biopsy
Lumbar puncture (look for CNS metastasis)
Presents early preschool or early school age
What increases the risk of ALL? What is the prognosis?
Trisomy 21 (downs syndrome)
5 year survival rate is 80% but with downs syndrome 60-65%
What is the most common reason for seeking care that leads to the diagnosis of cancer?
Persistent fever that won’t go away with intervention
What occurs in the bones d/t ALL? What does this cause?
Over production of immature WBC and they start pushing out mature WBC –> bone marrow suppression
What occurs in the bones d/t ALL? What does this cause?
Over production of immature WBC and they start pushing out mature WBC –> bone marrow suppression
Leads to anemia, thrombocytopenia, neutropenia, bone pain (overcrowded bones)
What does anemia put the patient at risk for? How do you manage this?
Decrease perfusion
Fatigue
Poor oxygenation and impaired gas exchange
Cluster care, allow for rest, hydration, oxygen, blood transfusions, erythropoietin, NG tube, high calorie formula, eat as tolerated by mouth
What does thrombocytopenia put the patient at risk for? How do you manage this?
bleeding
Padding, soft oral care
What does neutropenia put the patient at risk for?
infections
What is the sepsis management for a patient with cancer?
Broad spectrum antibiotic in 30-60 minutes after cultures drawn
Bolus 20ml/kg over 5 minutes (reassess between each, can give up to 3 boluses)
If bolus doesn’t improve BP and perfusion –> vasoactive agents
If vasoactive agents do not improve it –> steroid to boost WBC production
How do we know if our patient with sepsis is improving?
Perfusion parameters have impaired
Increase LOC
Procalcitonin, inflammatory markers, lactate (LDH) improve
Kidney fx improved
What is neutropenia? When does it peak?
ANC<500 (900)
Peaks in 2-3 weeks post chemo
What is the cause of neutropenia? What are major concerns r/t it?
Cancer cells in bone marrow
Chemo
Radiation
Concerned about infection and sepsis
What is a neutropenic fever? Is it an emergency? What are the risk factors?
Neutropenia + fever (38-38.3)
Life-threatening so treat as emergency
Risk factorS: immunocompromised and central venous access
What is a neutropenic fever? Is it an emergency? What are the risk factors?
Neutropenia + fever (38-38.3)
Life-threatening so treat as emergency
Risk factorS: immunocompromised and central venous access
What are neutropenic precautions?
No plants, flowers, fresh fruits
Keep door closed
Dust free equipment and environment
Disinfect all equipment and most will have their own in room
When transporting patient must wear N95
What is the induction phase of chemo for leukemia?
Wipes out bone marrow
Reduce remission within 1 month
What is the consolidation phase of chemo for leukemia?
Maintain remission
Prevent metastasis (intrathecal chemo - methotrexate given to prevent CNS/brain metastasis)
LP to look for metastasis
What is the maintenance phase of chemo for leukemia? Outpatient or inpatient?
30 months for girls
36 months for boys
Outpatient
What are adverse reactions to chemo? When do they occur?
Immune medicated response that looks similar to transfusion reaction
Occur within minutes to day post chemo
What are the s/s of a chemo reaction? (7)
Hives
Urticarial
Flushing
Angioedema
SOB
Hemolytic anema
Throat feels tight
How do you treat a chemo reaction?
Stop the infusion
Come up with game plan for next infusion such as premeditate with Tylenol, glucocorticoid, high dose Benadryl and slow the infusion
What is a complication that can occur with the first dose of chemo? What electrolyte is released?
Toxic storm
Cancer cells destroyed –> cytokines released –> over active immune system
Potassium –> hard on kidneys
When does N/V begin with chemo? When should antiemetics be given?
Acute - within first 24 hours and 1-2 hours post chemo
Delayed - greater than 24 hours, second peak at 24-48 and can last 5 days
Anticipatory - conditioned response to chemo
Antiemetics should be given scheduled NOT prn
What is mucocytis? Major concerns? How do you manage it?
Blisters that can occur mouth to anus from chemo
Pain and refusal to eat
Magic mouth wash and pain medication
What are the nursing goals r/t to chemo administration?
Control N/V
Treat mucocytis and manage pain
Optimize and maintain weight gain with TPN, NG tube and control odor triggers
Should a child having chemo infusions eat their favorite foods?
No, it will ruin their favorite foods for them during this time because will associated them with SE of chemo
What are the nursing interventions r/t chemo admin?
Monitor I&Os
Daily weight
Oral care
Swish/spit/swallow gargles
Antiemetics
Steroids
High caloric intake with high protein small frequent melas
What are the late effects of chemo on the endocrine?
Pituitary dysfunction
Hypothyroidism
Impaired gowth
DI
DM
SIADH
GH deficiency
Delayed puberty
Infertility
What are the late effects of chemo on the neuro/psych?
Behavioral changes
Learning disabilities
What are the late effects of chemo on the endocrine?
What are the late effects of chemo on the cardiac?
Cardiomyopathy
Heart failure
May need heart transplant
What are the late effects of chemo on the renal?
AKI
CKD
May need kidney transplant
What are the late effects of chemo on the skeletal?
Impaired bone density and growth
