Ch. 19 Flashcards
cardinal signs of cancer in children
Unusual mass or swelling
Unexplained paleness and loss of energy
Sudden tendency to bruise
Persistent, localized pain or limping
Prolonged, unexplained fever or illness
Frequent headaches, often with vomiting
Sudden eye or vision changes
Unexplained excessive, rapid weight loss
care of child with cancer (immune system)
- want to depress the immune system so that cancer does not regenerate/can kill the cancer with chemo/radiation
Risk for infection related to depressed body defenses: expected outcomes
The child exhibits no evidence of infection.
The child will not come in contact with infected persons.
Risk for infection related to depressed body defenses: interventions
- Place child in private room and screen all visitors and staff for signs of infection to minimize exposure to infective organisms.
- Teach child and family about good hygiene and careful handwashing techniques to prevent spread of infection.
- Use good handwashing for all contacts with child and scrupulous aseptic technique for all invasive procedures to minimize exposure to infection.
- Encourage a nutritionally complete diet to support body´s natural defenses.
- Administer antibiotics and G-CSF per HCP order to prevent infection.
- Monitor vital signs (esp. T) and observe skin and mucosa to detect signs of infection.
- Do not administer live attenuated virus vaccines (i.e., measles-mumps-rubella, oral polio, varicella zoster) to child with depressed immune system to prevent overwhelming the system and introducing an infectious disease; use inactivated virus vaccines as prescribed (i.e., chickenpox, Salk polio, influenza) to prevent common childhood illnesses.
- Screen all visitors and staff for signs of infection to minimize exposure to infective organisms.
- Evaluate needle puncture sites, mucosa, and minor abrasions for possible signs of infection to detect possible infection/sources of infection.
Risk for injury (hemorrhage, hemorrhagic cystitis) related to interference with cell proliferation: expected outcome
The child exhibits no evidence of bleeding or hematuria.
Risk for injury (hemorrhage, hemorrhagic cystitis) related to interference with cell proliferation: interventions
- Monitor platelet counts and administer platelets per physician order to raise platelet count and minimize bleeding tendencies.
- Do not administer aspirin products because they interfere with platelet function.
- Teach child and family to limit activity when platelet count drops to minimize chances of accidental injury.
- Use care in the administration of therapy (e.g., avoid grabbing with fingers and friction with clothing and bedclothes when turning; keep skin clean and dry and sheets clean and wrinkle free; use soft sponge for oral care) to reduce bruising and injury.
- Turn and reposition frequently, use pressure-relieving mattresses to prevent pressure ulcers.
Implement only essential skin puncturing procedures; monitor puncture site carefully; apply gentle pressure, ice to bleeding sites to minimize bleeding. - Teach child and parents how to manage nosebleeds to reduce blood loss.
- Administer ordered drugs that are irritating to the bladder mucosa early in day to allow sufficient fluid intake and voiding for flushing of irritants.
- Ensure increased oral intake as ordered and encourage frequent voiding to flush metabolites from system and prevent irritation.
- Observe for and report signs of cystitis (burning and pain on urination) to ensure prompt medical treatment.
Risk for fluid volume deficit related to chemotherapy-induced nausea and vomiting: expected outcome
The child is adequately hydrated.
Risk for fluid volume deficit related to chemotherapy-induced nausea and vomiting: interventions
- Administer initial dose of antiemetic before starting chemotherapy to reduce incidence of nausea and vomiting.
- Administer regular doses of antiemetic as ordered for the duration of expected cycle of nausea and vomiting to decrease or prevent nausea and vomiting episodes.
- Administer IV fluids as ordered to maintain hydration; encourage oral fluids and foods in small amounts to increase tolerance. Popsicles.
- Monitor child’s response to antiemetic because reactions are idiosyncratic and adjustments in drugs or dose may be needed.
- Monitor intake and output to ensure adequate hydration.
- Avoid foods with strong odors because they may induce nausea and vomiting.
- Encourage frequent intake of fluids in small amounts because small portions are usually better tolerated.
Impaired Nutrition (less than body requirements) r/t chemotherapeutically induced anorexia: expected outcome
The child will have adequate nutritional intake.
Impaired Nutrition (less than body requirements) r/t chemotherapeutically induced anorexia: interventions
- Encourage parents to reduce pressure placed on eating to promote acceptance of anorexia as a consequence of treatment.
- Allow child any food tolerated to promote nutrition, knowing that the quality of food selections can improve once appetite resumes.
- Explain anticipated increase in appetite with steroid use to prepare the child and family for changes.
- Fortify foods with nutritious supplements to maximize the quality of intake.
- Allow the child to become involved in food prep and selection to increase intake and tolerance.
- Monitor the child’s weight to track his/her status.
- Make food appealing to encourage eating.
- Take family history to assess any food issues that may require intervention (e.g., use of food as control mechanism or reward and punishment).
Altered mucous membranes related to administration of chemotherapeutic agents: expected outcome
The child exhibits no evidence of oral mucositis or rectal ulceration.
Altered mucous membranes related to administration of chemotherapeutic agents: interventions
- Institute meticulous oral hygiene (e.g., soft-sponge toothbrush to avoid trauma; frequent mouthwashes to promote healing; lip balm to keep lips moist). Do not use lemon glycerin swabs, which irritate eroded tissue and induce tooth decay; hydrogen peroxide, which delays healing of ulcers; and milk of magnesia, which dries oral mucosa.
- Inspect oral mucosa daily for ulcers and report immediately to ensure early treatment.
- Apply local anesthetics as ordered to ulcerated areas before meals to relieve pain and increase food intake. - Do not use viscous lidocaine in young children because it may depress gag reflex.
- Serve a bland, moist, soft diet; avoid juices with ascorbic acid; use a straw for fluids; avoid oral and rectal temperature-taking to decrease pain and injury to ulcerated areas.
- Administer prescribed anti-infective agents to prevent or treat mucositis, analgesics to control pain.
Wash perianal area after stools to lessen irritation. - Use warm sitz baths to ease pain and promote healing.
- Expose reddened mucosal areas to air; apply protective skin barriers to perianal area to protect mucosa and promote healing.
- Use stool softeners, bulk laxatives to prevent constipation.
- Track frequency and description of bowel movements to assess for constipation.
Disturbed body image r/t changes caused by disease process and treatment: expected outcome
The child will exhibit positive coping skills.
Disturbed body image r/t changes caused by disease process and treatment: interventions
- Encourage child to decide how he/she will cope with alopecia (ex. Wig, cap, nothing) to promote early adjustment and preparation for anticipated body changes.
- Provide adequate covering during exposure to sunlight, wind, or cold to provide protection, since natural hair protection is lost.
- Explain that hair begins with regrowing in 3-6 months and may be a different color and texture to prevent anxiety about alopecia.
- Encourage rapid return to peer group and friends to promote peer support.
- Encourage visits from friends before discharge to prepare the child for anticipated reactions from others.
- Depending on age of patient, may need to discuss egg harvest or sperm banking before treatment
common dx procedures for cancer
Injections (IM, intradermal)
Bone marrow aspiration
Lumbar puncture
Implanted port access
Needle sticks (venipuncture)
possible interventions for dx procedure prep
Parents’ and caretakers’ presence
Developmentally appropriate non-pharmacological approaches
Pharmacological treatment
Proper timeline for pre-procedure preparation (age specific p. 681-682)
- infants/toddlers: not much prep needed
- school age: little bit of lee-way
- teenagers: as much time as possible
sedation may be used if child has to lay completely still
common, anticipated fears in children with heme/onc dx
fear of leaving parents: toddlers, preschoolers
fear of pain: school-age, adolescents
body image: adolescents
mild pain mngmnt (1, 2, 3 level)
- nonopioid analgesics: acetaminophen, ibuprofen, naproxen
- +/- adjuvants: anticonvulsants for neuropathic pain, antidepressants ir anxiolytics for coexisting disturbances
moderate pain mngmnt (4, 5, 6)
- opioid analgesics for step 2: codeine, oxycodone, hydrocodone, morphine
- nonopioid analgesics: acetaminophen, ibuprofen, naproxen
- +/- adjuvants: anticonvulsants for neuropathic pain, antidepressants or anxiolytics for coexisting disturbances
severe pain mngmnt (7, 8, 9, 10)
- opioid analgesics from step 3: higher doses of morphine; fentanyl, hydromorphone; PCA delivery of IV opioid
- nonopioid analgesics: acetaminophen, ibuprofen, naproxen
- +/- adjuvants: anticonvulsants for neuropathic pain, antidepressants ir anxiolytics for coexisting disturbances
pain mngmnt overview
Good working knowledge of non-opioid and opioid preparations
Use of interdisciplinary pain mgmt. team
Titrate dosing
Trial and error
dental health promotion
If ANC >500:
Regular brushing
Flossing
Fluoride
Dental checkups
if ANC <500:
Toothette
Wiping gums/teeth
Fluoride rinse
immunizations for cancer patients: health promotion
Omit live vaccines in patient until 6 months post-treatment
Encourage vaccinations in family members (including live)
Administer immune globulin if exposed
Antivirals if disease develops
Delay inactivated when possible
managing eating: considerations
Should you offer the child their favorite foods?
Does nutritional value matter?
Do you need to premedicate?
managing bathing: considerations
Avoid getting dressings and surgical sites wet.
Keep central lines and other important equipment dry.
Keep sutures dry.
managing skin: considerations
Radiation will cause burns. How do we prevent or treat them?
Watch for s/sx bleeding and infection (ex. dressings)
Where are you focusing your assessment?
managing sleeping: considerations
Cluster care
Do you anticipate anxiety with rest?
How can you make the environment friendly and restful?
managing psychosocial: considerations
Consider consultations with social work, child life, spiritual care dept., PT, OT
Visits with family and friends, if allowed or tolerated.
Favorite things. Regular routine.
cessation of treatment
Cessation can signify treatment completion but also mean the family (or pt.) decided to stop treatment.
Need to determine what is the “new normal” post treatment.
Things to consider post-treatment
- Delayed growth
- Secondary malignancies; often progression of disease (POD) results in the termination of one treatment, the start of a new treatment, discussion of trial medications, or goals of care discussions (GOC)
- Lingering body system disturbances
- Continued medical supervision
- Genetic counseling
- Fertility options (If applicable before treatment begins)
- AAP’s guidelines for long-term f/u care for children and families (Long document)
brain tumors
Second most common form of pediatric cancer
- Can arise from any type of cell
- 60% occur in the posterior portion of the brain
- Difficult to treat, survival rates have not improved; d/t blood brain barrier, difficult for meds to take effect
- Signs/symptoms may be vague. Vomiting and headache upon waking common. Consider age of child
treatment of brain tumors
- Surgery-depending location
- Radiation- Difficult with younger patients as brain cell are developing; radiation for children > 2 years
- Chemotherapy-adjunct therapy or to delay surgery in younger patients
- Consider the blood-brain barrier (h2O soluble crosses barrier)
- pre-op: preparation (age appropriate)
brain tumor: post-surgical care
- Neuro assessment: symmetry, muscle strength, pupils
- Emergence from coma, if decline-serious
- Midline positioning, elevate HOB (30-45° generally)
- Do not position on side where tumor was removed; or flat
- Pain management without masking neuro assessment
- Environment-focus on family, G&D etc
brain tumor: nursing mngmnt/ sx to look out for
- Family support
- Adaptation
- Pain
- Nutrition
- Nausea/vomiting
- Anorexia
- Mucosal irritation
- Neuropathy
- Hemorrhagic cystitis
- Alopecia (s/e steroids)
- Moon face (s/e steroids)
- Mood changes (s/e steroids)
- Fatigue
- Sterility
- Altered sexual function
double flush & double glove
during and for 48 hours after chemo
for bathroom and vomiting; wipe seat down in between people- having own toilet will be best
- High risk medication
- Potential harm- how to reduce
- Safety
- Toxicity
wilms’ tumor
- Most common renal tumor in children (kidney tumor)
- 75% of cases diagnosed in children <5 yrs (infant/young children)
- does not move up and down with lungs
- Can affect 1 (most common) or two kidneys (dialysis, kidney transplant talk if affects both kidneys)
- Unknown etiology (? Genetic link)
- Rapidly growing
- Metastasis to bloodstream, perirenal tissues, liver, diaphragm, lungs, abd muscles, and nodes.
- Prognosis is dependent upon degree of metastasis
wilms’ tumor presentation
Visible abd. mass
DO NOT PALPATE!!!
Abd pain
Hx constipation, vomiting, anorexia, wt. loss, diff breathing
HTN (25% of cases) - may be renal instead of systemic: swishing, bruis
Lymphadenopathy
wilms’ tumor goal of treatment
- Goal to remove tumor (encapsulated) without damage. May have pre-op chem to shrink. Standard of care=combined treatment (surgery and chemo, possible radiation based on staging and histology).
wilms’ tumor treatment
- 5-point grading system (Stage 1 has better prognosis than Stage 5)
- Surgical removal of the tumor
- Surgical removal of the affected kidney (nephrectomy)
- Radiation and/or chemo pre and/or post-op: to shrink tumor before
testicular cancer
a young boy/man’s cancer
- self exams: have to know your own body
- in shower, warm water monthly basis
- palpate vas deferens, testes
Children’s understanding of death is influenced by:
- Developmental age: no scary words: blood, death, needles (is there a book or a toy to explain; medical play)
- Culture
- Religion
- Spirituality
- Children react to death differently, but their developmental age influences their perceptions.
aspects of death and dying for pediatrics
- Pain and symptom mgmt.
- Child and family support
- Preparation for death
- Physical signs of death
- Terminal care
testicular cancer self exams should be done
monthly
Since TC is usually isolated to a single testicle, comparison of your testicle with the other can be helpful. It is normal for one testicle to be slightly larger than the other. Your focus should be noticing any changes from the previous month.
Upon reaching puberty, all men should conduct a monthly testicular self-exam and ask your doctor during your yearly physical to perform one as well.
testicular cancer presentation
a painless lump in the testicle (the most common sign)
a feeling of weight in the scrotum
swelling of the testicle (with or without pain)
pain or a dull ache in the testicle, scrotum or groin
testicular cancer risk factors
- intersex disorders
- history of undescended testes
- age and race
testicular cancer: stage 1
Cancer is found only in the testicle
testicular cancer: stage 2
Cancer has spread to the lymph nodes in the belly
testicular cancer: stage 3
Cancer has spread beyond the lymph nodes in the belly. There may be cancer in parts of the body far away from the testicles such as the lungs and liver
neutropenic patient that develops a fever
serious!
want to find out where the infection is:
- PAN culture
- CXR
- culture a line
- blood culture
treat w/ broad-spectrum antibiotics
consider GSF if done with cancer treatment therapy
can GSF be given during cancer treatments?
NO
- have to be all done with cancer treatment therapy in order to give GSF to neutropenic patient
