I am a pediatric hemalogy oncology nurse! Flashcards
neoplastic
refers to cells that abnormally proliferate
how is cancer started
d/t an alteration in cellular regulation that leads to out-of-control cell growth
accounts for the most deaths from disease in children older than one year old
when does blood cell production begin
occurs in the embryo by 8 weeks gestation
when does physiological anemia occur?
between the age of 2 and 6 months
how do most pediatric cancer begin?
arise from primitive embryonal and neuroectodermal tissues
leading to leukemias, lymphomas, sarcomas or CNS tumors
** in comparison to adult cancers which mostly arise from epithelial cells –> carcinomas **
common warning signs of cancer
changes in blood cell production –> fatigue, pallor, frequent or severe infection or easy bruising
what happens when infilration, obstruction or compression of a tumor occurs
may result in bone or abdominal pain or pain in other parts of the body, swelling or unusual discharge
chemotherapy
- some txs can impair a child’s growth and development
- recommends decision making for an older child/adolescents should include the assent of the older child or adolescent
- chemo disrupts the cell cycle of cancer cells and normal rapidly dividing cells… bone marrow, digestive tract especially mouth, reproductive system and hair follicles are impacted
adverse effects of chemo
immunosuppression
infection
myelosuppression
nausea
vomiting
constipation
oral mucositis
alopecia
pain
long term complications of chemo
microdontia and missing teeth
hearing and vision changes
hematopoietic
immunologic
endocrine dysfunction
altered and delayed puberty
development of a 2nd cancer as an adolescent or adult
radiation therapy overview
uses high energy radiation to damage or kill cancer cells
impacts cancer cells and normal cells
can be used alone or in combo with chemo
can be used to shrink a tumor prior to surgical resection
adverse effects of radiation
fatigue
nausea
vomitting
oral mucositis
myelosuppression
alteration in skin integrity
hormonal dysfunction
hearing and vision alterations
learning problems
cardiac dysfunction
pulmonary fibrosis
hepatic, sexual or renal disfunction
osteoporosis
development of secondary cancer
hematopoietic stem cell transplant
** bone marrow transplantation **
- stem cells infused intraveneously into the child
- transplanted cells migrate to the empty spaces in child’s bone marrow and reestablish hematopoisis in child
- used in leukemia, lymphoma, brain tumors, neuroblastoma and another solid tumor
what is first line tx for most peds cancer
hematopoietic stem cell transplantation … but also used for refractory or advanced disease
allogenic HSCT
refers to transplantation using cells from another individual
requires human leukocyte antibody matching
degree of match is inversely related to risk for graft rejection and development of graft versus host disease
complications of HSCT
infection
electrolyte imbalance, bleeding and organ, skin, mucous membrane toxicities
long term complications of HSCT
include impaired growth, infertility related to endocrine dysfunction, developmental delay, cataracts, pulmonary and cardiac disease, avascular necrosis of bone and development of secondary cancers
assessment
inspection
hx
palpation
labs
education
inspection
inspect for skin changes such as pallor, bruising and flushing are often the first signs that there is a problem developing
changes in mental status such as lethargy can indicate a decrease in hemoglobin and a decrease in o2 being delivered to the brain
note of thin or frail appearance, fatigue or altered LOC
hx
explore family hx for inherited disorders such as hemophilia, sickle cell disease, thalassemia or hx of cancer
determine risk for lead exposure and malnutrition
palpation
palpate abdomen for tenderness, hepatomegaly, splenomegaly, or presence of a mass
labs
MCV
MCH
MCHC
RDW
MPC
Platelets
mcv
average size of the RBC
MCH
calculated value of the o2 carrying capacity of the hemoglobin in the RBC
MCHC
a calculated value that reflects the concentration of hemoglobin inside the RBC
RDW
calculated value that is the measure of the width of the RBC
MPC
measurement of the size of the platelets
platelets
decreases can result if the platelets are being used up when bleeding is present, if an inherited disorder is present or if the spleen holds them, as in hypersplenism
Education
- seek med care immediately if child’s temp is 101 degrees or higher
- call oncologist if any of the following occur –> cough or rapid breathing, increase bruising bleeding or petechiae, pallor, sore throat, blisters, rashes, ulcers, abdominal pain, difficulty/pain with eating, constipation or diarrhea
- for children with CVC pus, redness, swelling at site needs to be reported IMMEDIATELY
- don’t give child aspirin
about administering chemo
- wear double gloves
- nonpermeable gowns
- chemotherapy doses in children are based on their body surface area
adverse effects with chemo
- myelosuppression leads to low blood counts in all cell lines –> child at increased risk for infection, hemorrhage and anemia = pancytopenia
- cooling the scalp during chemotherapy administration with the use of the cool cap may decrease hair loss
preventing infection with chemo
- many cause significant bone marrow suppression and decrease amounts of circulated mature neutrophils
- administering granulocyte colony stimulating factor as ordered to promote neutrophil growth and maturation
- administer varicella zoster immunoglobin within 72 hours of exposure to active chickenpox… if child is actively infected with chx pox administer IV acyclovir as ordered
- children receiving tx for acute lymphoblastic leukemia are at risk for opportunistic infection with pneumocystis jiroveci as most children are colonized with this fungus…. administer prophylactic antibiotics as ordeered and teach the parents to administer them at home
- practice meticulous hygiene
- avoid anyone ill… especially with chickenpox
- avoid crowded areas
- don’t let child receive live vaccines (MMR)
- do not take child’s temp rectally or give meds rectal route
- administer 2x trimethoprim-sulfamethoxazole for 3 days consecutive each week as ordered for prevention of pneumocystis pneumonia
bone suppression from chemo
- nadir is the time after administration of the drug when BM suppression is expected to be at its greatest in the neutrophil count is expected to be at its lowest neutropenia
- Nadir is indiv for each drug in ranges from 7 to 28 days after dose and period
- absolute neutrophil count below 500 places the child at greatest risk although an absolute neutrophil count below 1500 usually warrants evaluation
mucositis
mouth or gut is sore and inflamed
myelosuppression
condition in which bone marrow activity is decreased, resulting in fewer RBCs, white blood cells and platelets
when severe it is called myeloablation
hematopoiesis
the process of creating a wide variety of blood and bone marrow cells, namely erythrocytes, platelets, granulocytes, lymphocytes, and monocytes
neutropenic precaution
child in private room
hand hygiene before and after contact with child
assess S/S infection every 8 hours minimum
avoid rectal suppository’s, enemas or examinations, urinary caths, invasive procedures
restrict visitors with fever, cough, other S/S of infection
no raw fruits, veggies, fresh flowers, live plants, standing water in room
place a mask on child during transport
dental care with soft toothbrush if platelet count is inadequate
preventing hemorrhage
assess for petechiae, purpura, bruising or bleeding
avoid blowing nose
administer stool softener to prevent straining with constipation
avoid rectal temps
avoid IM injections in lumbar puncture if possible to decrease risk for bleeding from puncture site
if BM aspiration is needed, apply pressure to site to prevent bleeding
for active/uncontrolled bleeding –> transfuse platelets
preventing anemia
adequate iron
administer EPO/procrit injections as ordered
Nausea, vomiting and anorexia
N/V –> anorexia
taste alterations are common
prevent nausea with antiemetics prior to chemo and on routine schedule for first 1-2 days
bright lights and noise may worsen nausea, keep environment dimly lit and calm
foot massage may decrease nausea and pain
radiation about
damage to the cells in a localized area
skin radiation
encourage moisture retention in skin by applying aqueous creams or moisture
do not apply deodorant or perfumed lotion to radiation site
avoid heat/ice at this site
instruct clothes/fam that clothes should fit loosely as to not irritate the site
during and 8 weeks after radiation tx the skin will be more photosensitive –> educate on importance of sunscreen
pre- stem cell transplant phase
child will be hospitalized bc they are at extreme risk for infection
maintain protective isolation in PRIVATE POS PRESSURE ROOM, limit visitors
administer gamma globulin, acyclovir or antibiotics to prevent/tx of infection
post stem cell transplant phase
monitor closely for s/s of GVHD
if GVHD occurs, administer immunosuppressive drugs such as cyclosporine, tacrolimus, mycophenolate which places child at increased risk for infection
symptoms of GVHD
severe diarrhea and maculopapular rash progressing to redness or the loss of the skin especially palms or soles
first sign of GVHD
may be maculopapular rash
supportive care for stem cell transplant
continue to monitor for and prevent infection
administer PRBC’s or platelets and granulocyte colony stimulating factors as needed
anemias
may be related to nutritional deficiency and also result from toxin exposure such as lead poisoning or as an adverse reaction to a medication such as aplastic anemia
iron deficiency anemia
peak prevalence in children btw 6-24 months and again at puberty
cows milk contributes to deficiency in older infants and young children d/t poor iron content
associated with growth delays, cognitive delays and behavioral changes
lab results: decreased hemoglobin and microcytic and hypochromic RBCs
s/s of iron deficiency anemia
irritability
headache
dizziness
weakness
SOB
pallor
fatigue
difficult feeding, pica, muscle weakness or unsteady gait
note spooning of nails = concave shape
tachycardia and palpate abdomen for splenomegaly
risk factors for iron deficiency anemia
maternal anemia during pregnancy
poorly controlled diabetes during pregnancy
prematurity or low birthweight
cow’s milk before 12 months of age
excessive cow’s milk before 12 months of age
excessive cow’s milk greater than 24 ounces a day
lack of iron supplementation after 6 months in breastfed infants
restricted diet
promoting safety with iron deficiency anemia
child is at increased risk for changes in neurologic function, related to decreased O2 supply to brain
this can lead to fatigue and inability to eat enough
assist older child with ambulation
dietary interventions for iron deficiency anemia
infants –> only fed with formulas with fortified iron
breastfed infants –> begin iron supplementation around 4/5 months –> iron fortified cereals or give iron containing drops
iron sup. can stain teeth –> give via straw in back of mouth and give btw meals… can cause constipation
increase fluid intake
encourage breastfeeding mothers to increase dietary intake of iron or take iron supplements so it can be passed to infant
limit cows milk intake to 24 ounces per day
iron rich foods –> red meat, tuna, salmon, eggs, leafy green veggies
lead poisoning
lead exerts toxic effects on the bone marrow, erythroid cells, nervous system and kidneys
lead poisoning assessment
classic signs of anemia
- anorexia
- fatigue
- abdominal pain
determine whether behavioral problems, irritability, hyperactivity, or lack of ability to meet developmental milestones have occurred in the recent months
BLOOD LEVELS OF LEAD HIGHER THAN 10
management of lead poisoning
chelation therapy
removal of heavy metals from the body via chelating agents
ensure adequate fluid with chelation and monitor I&O closely
lead poisoning complications
include behavioral problems and learning difficulties and with higher lead levels, encephalopathy, seizures and brain damage
aplastic anemia
failure of the bone marrow to produce cells
complications of aplastic anemia
severe overwhelming infection, hemorrhage and death
management of aplastic anemia
- stem cell transplant or immunosuppressive therapy
- hematopoietic stem cell transplantation from a human leukocyte antigen if one is not available
- immunosuppressive therapy or high dose cyclophosphamide can be given
- safety is one of the most concerns
- stool softeners may prevent anal fissures associated with constipation
- administer only irradicated and leukocyte depleted PRBCs or platelet transfusions, as necessary
symptoms of aplastic anemia
- low RBC, WBC, and platelets since BM cannot produce them
- may lead to headache and fatigue
- on physical exam note ecchymosis, petechiae, purpura, anal ulcerations, tachycardia or tachypnea
- guaiac positive stool
- blood in urine
sickle cell anemia
- inherited hemoglobin disease in which RBCs do not carry the normal adult hemoglobin but instead carry a less effective type
- most common indiv at risk are africans, mediterranean, middle eastern, indian
- cells are sickled in shape
- recess of genes for sickle cell are passed on from both parents who have the gene or trait
- each parent has two gene hemoglobin heterozygous AS
- AUTOSOMAL RECESSIVE HOMOZYGOUS DISORDER
- hemoglobin S refers to the sickle cell hemoglobin
- 1/4 infants… typically asymptomatic until 3 to 4 months of age
causes of acute exacerbations of sickle cell anemia
fever
dehydration
emotional/physical stress
increased need for O2/exercise
complications with sickle cell anemia
- recurrent vasoocclusive pain crisis
- stroke
- sepsis
- acute chest syndrome
- splenic sequestration
- reduced visual acuity r/t the decreased retinal blood flow
- chronic leg ulcers
- cholestasis
- gallstones
- delayed growth and development
- sickled cells are very sticky making them stick together –> vasoocclusive crisis –> stroke or infarction
management of sickle cell anemia
- prevent crisis/tx vasoocclusive process
- pain crisis d/t decr. circulation… tx –> pain control, o2, hydration with IV fluids is critical… ABTs … transfusion of PRBCs = not routinely given but in severe cases… potential for hemolysis of the cells –> incr potassium level in serum… DECR STRESS, no exercise of high alt, no cold!
- take pneumococcal conjugate vaccine annually after age 2
- prophylactic antibiotics in young child… appropriate immunizations can decr risk of serious infection… penicillin***
- teach parents about genetics… encourage fam to seek med eval for any febrile illness
- o2… monitor LOC
- splenectomy may be necessary for pts with recurrent splenic sequestration crisis
- nutrition - high protein, high cal, folic acid
symptoms of sickle cell anemia
- splenomegaly and abdominal pain, hypoxia + tissue ischemia
- note BP may be decr with severe anemia or increased with sickle cell nephropathy
- determine baseline MS
- HR is often elevated with pain
- immediately report symmetric swelling of the hands and feet in infant/toddler termed = dactylitis
diagnosis of sickle cell anemia
- hbg electrophoresis is only accurate test
- newborn screening
- dithionite (sickledex) but can’t differentiate whether its a carrier or active sickle cell disease
thalassemia
- inherited autosomal recessive process
- children have reduced production of normal hemoglobin
- problems with the B chain occur more often and the condition of B thalassemia can be divided into three subcategories
1. thalassemia minor –> mild, requires no tx
2. thalassemia intermedia –> requires blood transfusions to maintain adequate quality of life
3. thalassemia major –> blood transfusions and iron removal
TX with multiple blood transfusions causes hemosiderosis, excess iron, therefore iron needs to be removed
complications of thalassemia
- growth retardation and pathologic fractures and skeletal deformities
- hemosiderosis –> excessive supply of iron… occurs as a result of rapid hemolysis of RBCs, the decrease in hemoglobin production and the increased absorption of dietary iron in response to the severely anemic state
tx of thalassemia
- use of blood transfusions and chelation to remove iron –> administer chelation therapy with transfusion… deferoxamine binds to the iron and allows it to be removed through the stool or urine
- minimal GI side effects
- teach family to administer it subcutaneously with a small battery powered infusion pump over a several hour period each night usually while the child is sleeping
- if oral prescribed… tell family to dissolve the tablet in juice or water to administer
- monitor hemoglobin and hct and transfusion of PRBCs at regular intervals
- assess bony deformities
symptoms of thalassemia
- RBCs are rigid and hemolyzed easily
- too much iron –> bronze pigmentation of the skin, bony changes (frontal bossing), maxillary prominence, wide set eyes with a flattened nose, altered organ function especially cardiac
- severe hemolytic anemia and chronic hypoxia
- iron overload r/t thalassemia leads to bony changes such as frontal bossing and maxillary prominence
- infants are usually diagnosed by 1 year of age… hx of pallor, jaundice, FTT and hepatosplenomegaly
- bilirubin levels are elevated
- iron levels are elevated
idiopathic thrombocytopenia purpura
- bleeding times are prolonged when clotting disorder is present
- an immune response following a viral infection that produces antiplatelet antibodies… these antibodies destroy platelets which then lead to petechiae, purpura and excessive bruising
- purpura are larger areas of hemorrhage in which blood collects under the tissues, they are purplish
- ITP usually develops a few weeks after viral infection, can recover spontaneously
risk factors for ITP
- current viral infection
- recent MMR vaccine
- ingestion of meds that cause thrombocytopenia
complications of ITP
- SEVERE hemorrhage
- bleeding into vital organs
- intracranial hemorrhage (RARE)
management of ITP
- children with complete platelet counts below 10,000 –> corticosteroids may be administered for 2-3 weeks
- acute/chronic ITP IV immunoglobulin IVIG may be used as an adjunct, if it is infused for 1-2 days
- platelet transfusions are not indicated unless life threatening bleeding is present
- usually self limited but if persists for 1 year plus –> splenectomy may be needed
- educate family on AVOIDING ASPIRIN, NSAIDS, ANTIHISTAMINES
assessment for ITP
- usually a healthy child who recently developed epistasis or bleeding in gums and blood in stool
- inspect for bruising, petechiae and purpura
- platelets are usually below 50,000
Von Willebrands Disease
similar to hemophilia
- deficiency in protein von willebrand factor
- hereditary bleeding disorder
- easy bruising occurs in mucous membrane - causes platelets to adhere to damaged endothelium
S/S and TX Von Willebrands disease
s/s - bleeding gums, epistaxis, easy bruising, excessive menstrual bleeding
tx - similar to hemophilia, preventing bleeding
disseminated intravascular coagulation
- complex condition that leads to the activation of coagulation
- common triggers of DIC include septic shock, presence of endotoxins, and viruses, tissue necrosis or injury and cancer tx
- hemorrhage and organ tissue damage result and can be irreversible if not recognized and tx immediately
DIC complications
- inspect for signs of bleeding
- evaluate respiratory status and determine level of tissue oxygenation via pulse oximetry
- careful abdominal palpation may reveal hepatomegaly or splenomegaly
- if bleeding is observed apply pressure to the area along with cold compress
- elevate affected body part
management of DIC
- if DIC occurs secondary to infection appropriate antibiotic would be used
- heparin is also used in a lower dose to counteract the deficiency in the coagulation and anticoagulation pathway
- heparin reduces consumption of platelets –> improved platelet count
- since heparin is an anticoagulant this increases risk for bleeding
- administer anticoagulant therapy
- administer clotting factors, platelets and cryoprecipitate as to prevent severe hemorrhage
hemophilia
- deficiency in one of the coagulation factors in the blood
- X linked recessive disorders are transmitted by carrier mothers to their sons so usually only males are affected
- inability of the platelets to be used in clot formation
complications of hemophilia
- without intervention, hemophilia could lead into shock
- note chest pain or abdominal pain which may indicate internal bleeding
management of hemophilia
- primary goal is to prevent bleeding
- of bleeding/injury occurs, factor administration as prescribed –> factor VII replacement, PTT is the only abnormal lab
- factor replacement should be given before surgeries or other procedures that could lead to bleeding… like IM injections or dental care
- in mild cases, desmopressin may be effective to stop bleeding
- wear medical alert bracelet
- prevent bleeding –> protect toddlers with helmets, children should stay active, avoid intense contact sports and trampoline use
s/s of hemophilia
black tarry stools
hematemesis
easy bruising
severe nose bleeds
large vascular hematoma in knee
joint pain
significant swelling in discoloration associated with the bleeding episode in hemophiliac knee
