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Nursing Assessment of Child with Cancer Flashcards

1
Q

Childhood Cancer: Symptom Onset

A

May be rapid or insidious
Diagnosis often delayed
Symptoms often vague
There are no classic or universal symptoms of cancer, but instead there are often vague and nonspecific complaints, which are usually consistent with very common, benign childhood illnesses. Because it is rare there may be delayed diagnosis.

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2
Q

S&S of Cancer

A

Pallor, bleeding, bruising
Fatigue
Infection/Persistent fever
Headache, visual changes
Lymphadenopathy
Bone pain, joint pain, limp
Abdominal mass
Cough, respiratory difficulties
Cachexia (anorexia)
Anemia
Wide variation in the symptoms and intensity of symptoms that occur in a child with cancer. Vague and nonspecific and often be thought to be attributed to the flu or a viral syndrome initially. Cancer in children is rare, and vague symptoms do not automatically mean cancer but sustained or more serious illness often does initiate more in-depth testing and evaluation. Headaches should also be looked into.

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3
Q

Diagnostic Tests for Childhood Cancer

A

Bone marrow aspiration
Lumbar puncture
Complete blood count and differential
Absolute neutrophil count (ANC)
CT

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4
Q

Cancer Treatment

A

Multimodal treatment (come at it from different angles)
Goal is to cure and/or prolong survival
Aimed at reducing or stopping cells from reproducing/growing
Chemo, surgery, biopsy or removal, radiation, steriods)

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5
Q

Surgery

A

Resection, debulking, diagnosis (biopsy)

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6
Q

Chemotherapy

A

Shrink the tumor
Stop cells from dividing

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7
Q

Radiation

A

To shrink tumor
cause cell death; wait until older than 5 years if possible (affects growth & mental ability -> an irradiated brain will not grow further)

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8
Q

Hematopoietic Stem Cell Transplant (Bone Marrow Transplant)

A

Given via IV (HIGHLIGHTED)
give mega doses of chemo and rescue patient with own stored stem cells or allogeneic.
Wipe out cancer and marrow first to make room for donor. want to get to the point where they have almost no WBC, RBC, or platelets. Require platelet infusion and blood transfusions. very immunocompromised. Giving packed RBC and platelets and waiting and watching the numbers

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9
Q

Treatment Protocols

A

Every child with cancer is on a treatment protocol
Plan of action for treatment (chemo/radiation) based on staging of the cancer (type of cancer, location, and particular cell type)
A recipe or roadmap outlining drugs, timing, schedule, dosages, modifications due to toxicity

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10
Q

Chemotherapy

A

Goal = CURE
Given IV, po, sc, intrathecal (into the CNS system - IT), IM
Benefits must outweigh the side effects
Attacks cells a different points in cell cycle

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11
Q

Principles of Combination Chemotherapy (HIGHLIGHTED)

A
  • Intermittent therapy: several different drugs
  • better response rates, longer remissions
  • provides optimum cell destruction
  • least toxic effects
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12
Q

Intrathecal Chemotherapy

A

Children with leukemia are given IT to prevent metastasis to the brain
Bypasses blood brain barrier; prevents relapse in CNS -> sanctuary site. Will give even if CSF clear. into the CNS
Chemo placed in the CSF space to prevent cancer form spreading to the brain (HIGHLIGHTED)

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13
Q

Chemo is Selective to Rapidly Dividing Cells

A
  • cancer cells
  • bone marrow
  • hair follicles
  • GI tract
  • oral mucosa
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14
Q

Chemotherapy Side Effects

A

Numerous and can be life threatening:
- nausea/vomiting
- constipation/diarrhea
- anorexia
- mucositis/stomatitis (sores inside the mouth)
- alopecia
- organ damage
- myelosuppression

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15
Q

Myelosuppression

A

Immune system, RBC, WBC, platelet goes down
Can be life-threatening

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16
Q

Nadir

A

Period after chemotherapy when your blood counts are at their lowest point
usually 7-14 days after chemotherapy
-can vary depending on your treatment regimen

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17
Q

Nausea and Vomiting

A

Due to stimulation of the chemoreceptor zone and the vomiting center in the brain
From mucositis and damage to GI tract from Chemo
Prevention is key - give meds before !!! (HIGHLIGHT)
Antiemetic regime individualized to patient needs and desires

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18
Q

Constipation/Diarrhea

A

Constipation: due to neurotoxic effects of some chemo agents on autonomic nervous system. Bowel assessment daily, prophylactic stool softeners
Diarrhea: due to destruction of epithelial cells lining GI tract and/or infection

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19
Q

Anorexia Causes:

A

nausea/vomiting
taste alterations (due to disease, chemotherapy, radiation or surgery to the oral cavity or surrounding areas)
mucositis/stomatitis
psychological/sociocultural factors
abdominal mass
DO NOT PRESSURE THE CHILD TO EAT (HIGHLIGHTED)

20
Q

Anorexia: Nursing Care

A
  • Managing treatment toxicities
  • Manage alteration in taste sensation problems
  • Patient/family teaching
  • Provide diet supplements
  • Enteral or parenteral feeding
  • Offer frequent small meals/snacks
  • Deal with control issues
    Quick to start NG feeds -> maintain integrity of GI tract, therefore even 5 ml/hr is helpful.
21
Q

Mucositis/Stomatitis

A
  • From cytotoxic effects on the rapidly dividing epithelial cells causing Myelosuppression
  • Occurs within 2-7 days of chemo
  • As WBC decreases, risk of microbial infections in the mouth increase from myelosuppression
  • Also affects nutritional status
22
Q

Mucositis/Stomatitis: Nursing Care

A

Frequent assessment of oral mucosa (at least once per shift)
In patients with myelosuppression: frequent and meticulous mouth care is essential to avoid mucositis
Bicarb rinses, Chlorhexidine rinses, magic mouthwash
Use of antifungal agents to prevent oral condidiasis
Pain management

23
Q

Oral care with Mucositis/Stomatitis

A

MUST brush teeth 4x/day even if not eating -> brush & rinse
In patients with myelosuppression: frequent and meticulous mouth care is essential to avoid mucositis (HIGHLIGHTED)

24
Q

Alopecia

A

Usually temporary
Thinning to complete baldness
Regrowth may occur while still on therapy
Areas that have been irradiated are usually permanently bald

25
Organ Toxicity
Many chemo agents are toxic to certain organs Commonly affected are the kidneys, liver, skin, heart, bladder and sense of hearing Screening pre each course of chemo via GFRs, LFTs, audiology exams, ECHOs Organ protective agents
26
WBC Differential: Types of cells
Neutrophils (infection-fighters) - Segs or polys (mature) - bands or stabs (young) - myelocytes, metamylocytes (very young) Lymphocytes (immunity) Monocytes (phagocytosis) Eosinophils (allergy, parasites) Basophils (hypersensitivity) Blasts (very immature) BLASTS SHOULD ALWAYS BE CONSIDRED ABNORMAL
27
Myelosuppression 3 components
1. Anemia (RBC) 2. Neutropenia (WBC) 3. Thrombocytopenia (platelets)
28
What is Myelosuppression
Rapidly dividing cells affected by chemo Severity depends on dosage, schedule, individual response Most drugs cause myelosuppression resulting: - Neutropenia - Thrombocytopenia - Anemia Patients at increase risk of infection: HAND HYGIENE is important (HIGHLIGHTED) Signs of infection may be very subtle because unable to mount infectious process (swelling, warmth, pus)
29
Evaluating the Neutrophil Count
Patients with low neutrophil counts are at high risk of developing bacterial infections The lower the neutrophil count, and the longer it stays low, the higher the risk of infection Patients with very low neutrophil counts may not be able to mount a response (show an increase in WBC) in the presence of infection NEUTROPHILS FIGHT BACTERIAL INFECTIONS
30
Absolute Neutrophil Count (ANC) levels
> 1.500 = normal (in oncology patients) < 1.000 = impaired ability to fight infection (myelosuppression is occurring) < 0.500 = at risk for serious infection
31
What is ANC
Absolute Neutrophil Count - indicator of the child's ability to right bacterial infections. For healthy people the ANC is generally over 2.500 but for practical purposes, an ANC of > 1.500 is considered normal ANC: adding the neutrophil counts with the bands (immature) May got to school if >0.5: depends on type of cancer and treatment to determine discharge and return to school
32
Neutropenia
Add Neutrophils + Band Cells = ANC ANC < 1.000 = neutropenia Fever in a child with neutropenia is an emergency Infection is the #1 cause of death in children with cancer (infection leads to sepsis or septic shock)
33
Neutropenia: S&S only appear if infection present
FEVER (> 38.5 PO or > 38 C axilla) - cough, sore throat, redness @ wounds, subtle signs of inflammation, prolonged healing - children with cancer have something else that puts them at higher risk for septicemia: CENTRAL LINES There will always be fever Prompt intervention is KEY
34
Evaluating Children with Neutropenia
Usual signs of infection may be absent (patients vital signs, report of pain, and overall appearance may be the only way to gauge their status and response to treatment measures) - erythema - warmth - drainage/pus - crackles Pain/tachycardia/fever may be only signs of infection Fever or shaking chills require immediate intervention. Assessment of the febrile neutropenic patient should include routine visualization of the oral mucosa or perianal area
35
Fever/Neutropenia Nursing Care
q4h vital signs including BP (temp q2h if febrile) Assess for S/S of sepsis Blood cultures Broad spectrum antibiotics STAT Hydration Tylenol - wait before giving (check with oncologist first; all cultures done & antibiotics started. dont want to mask fever and delay treatment)
36
Platelets
important for blood clotting life span is 72 hrs to 10 days low platelets = thrombocytopenia S&S: - easy or excessive bruising - prolonged bleeding - bleeding from gums or nose - blood in urine or stool - fatigue - pale skin color TX: platelet transfusion
37
Nursing Consideration (Thrombocytopenia) - highlighted
encourage parents to avoid contact sports and activities that could cause the child bodily injury including using a soft toothbrush
38
Red Blood Cells (anemia)
Transport oxygen and carbon dioxide Lifespan = 120 days Low RBCs = anemia S/S - increased HR, increased RR, fatigue, pallor, listlessness, cranky, tissue anoxia, flank pain TX: blood transfusion
39
Evaluating Vital Signs
Know norms for age Measure precisely using correct technique and equipment Weights are very important aspect of assessment
40
Temperature Considerations
No rectal temperatures for oncology patients because the rectal mucosa is fragile and easily injured. (bleeed because of thrombocytopenia and risk for infection because of neutropenia) Fever is an emergency: - in patients with neutropenia in patients with central lines or other implanted apparatus - in immunodeficiency or asplenia
41
Fever Considerations
Shaking chills - may occur before onset of fever - also considered an emergency Check capillary refill and other perfusion parameters - normal = brisk - report if delayed Notify MD immediately - urgent evaluation/intervention required
42
Evaluating Vital Signs: Tachycardia
Potential Causes: - anxiety, anemia, hypovolemia, shock, fever, pain
43
Evaluating Vital Signs: Tachypnea
Evaluate: retractions, nasal flaring, colour (dusky, cyanotic), breath sounds, O2 sats Potential Causes: anxiety, hypoxia, fever, pain, respiratory compromise
44
Evaluating Vital Signs: Hypotension
Hypotension is an emergency - report immediately LATE SIGN - potential causes: septic shock (can be rapidly fatal) and hypovolemia (dehydration, bleeding) Fluid resuscitation is the immediate treatment
45
Evaluating Vital Signs: Hypertension
Requires prompt assessment and intervention Potential etiology: - steroids - renal - increased intracranial pressure - report! May require routine medication
46
Nursing Assessment
Thorough Physical Assessment Special Attention to: - mouth - skin - perianal area - vital signs - fluid balance - lab results
47
Family Centered- Care
Parents as partners in their child's care Family: the constant in the child's life Nursing strategies to promote the family's role Honoring diversity Recognizing family strengths and individuality

Pediatrics (25 decks)

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