Oncologic Conditions Flashcards
1. Assess and plan care for children diagnosed with cancer. 2. Describe interventions for the child being treated for cancer. 3. Anticipate the psychosocial and palliative care needs of the child and family impacted by cancer. 4. Assess the child's perception of death at various stages of development, and plan appropriate interventions when death is imminent.
Cancer
Overview
Oncologic Conditions
Overview
1. An alteration in cell function resulting from the overproduction of immature and nonfunctional cells; tissues enlarge for no physiologic function
2. Cause unknown; some types have a genetic basis; some are related to viruses or to environmental carcinogenic agents; and others have a higher incidence with other conditions (e.g., Down syndrome)
3. Goal of treatment is to achieve remission; a 5-year remission is considered a “cure”.
Pediatric cancers
1. They are second to accidents as the greatest cause of death in children 1 to 14 years of age.
2. They occur primarily in rapidly differentiating tissues, such as bone marrow and neural tissue.
3. Most solid tumors are sarcomas.
4. Cancers in order of frequency in children are leukemia, central nervous system tumors, lymphomas, neuroblastoma, Wilms’ tumor, and bone tumors.
5. Any tumor in the child is considered malignant until histologically identified, even if it is encapsulated.
6. Childhood cancers grow more quickly than adult cancers because body tissues are normally in a state of rapid growth and high metabolic rate.
7. The incidence of cancer increases with age.
8. Children are placed on treatment protocols that provide roadmaps to follow (e.g., pre-treatment blood count requirements to asssue adequate platelt counts and absolute neutrophil counts prior to chemo admin). Kidney function is determined before chemo via requirements in output, specific gravity and urine pH. It is essential that the nurse caring for a child being treated for cancer be familiar with the treatment roadmaps.
Cancer
Assessment
Oncologic Conditions
- Signs and symptoms vary with the type and location of cancer.
- Assess for pain, abnormal skin lesions, fatigue, fever, fractures, and weight loss.
- Assess for any unusual mass or swelling.
- Assess for a sudden tendency to bruise.
- Note any persistent localized pain or limping.
- Ask about headaches that may be associated with vomiting.
- Assess for vision changes.
- Lab studies will identify abnormal or immature cells; imaging studies will identify masses; biopsies will identify cancerous cells and assist with histology staging.
- Assess for invasion of or pressure on body structures by the tumor.
Cancer
Interventions
Oncologic Conditions
Be aware that a multifaceted treatment program to prolong survival may include surgery, irradiation, chemotherapy, and occasionally immunotherapy and targeted therapy drugs; treatment plans are often based on national cancer protocols.
Assist with IV and intrathecal chemotherapy.
1. Be aware that chemotherapy may include such drugs as cyclophosphamide (Cytoxan), methotrexate, vincristine, and prednisone.
2. Help the child deal with the side effects of chemotherapy, such as alopecia, vomiting, stomatitis, neurotoxicity, hemorrhagic cystitis, and bone marrow depression. Monitor carefully for signs of infection during periods of chemotherapy-induced neutorpenia. This typically occurs 10-14 days after chemotherapy has been administered. Different chemotherapeutics have various effects on the bone marrow causing neutropenia. Follow labs carefully. Calculate absolute neutrophil counts to determine ability to fight off infection. Place a neutropenic child (under 500) on neutropenic precautions and institute thorough and frequent handwashing.
3. Initiate measures to prevent the sequelae of chemotherapy.
a. For stomatitis, provide a bland, soft diet; use a soft sponge toothbrush; and rinse the mouth frequently with saline or local anesthetic mouthwashes. Stomatitis can lead to serious infections and fevers. No flossing when a child’s platelet count is low.
b. Do not press the child to eat during chemotherapy for for several hours to a day after.
4. If child is anemic, oxygen may be needed; if platelets are low, great caution should be taken regarding any invasive treaments. Both packed RBC infusions and platelet infusions are common during periods of bone marrow nadir (lowest blood counts approximately 10-14 days after chemo administered).
5. Tumor Lysis Syndrome
a. A complication of chemotherapy when icnreased number of cells are killed releasing their contents into the bloodstream.
b. Results in hyperuricemia (give allopurinol); hyperkalemia (restrict potassium intake [including in IV fluid] and check cardiac status); hypocalcemia (assess for nausea/vomiting/diarrhea, muscle cramps, tingling and numbness)
c. Assess for kidney failure; may need dialysis
6. Assist with radiation and help the child deal wtih its side effects, such as vomiting, alopecia, mucosal ulceration, diarrhea, desquamation of the skin, and myelosuppression.
a. Administer antiemetics as ordered before chemo and around the clock; provide mouth care. Have additional orders for PRN antiemetics if there is breakthrough nausea.
b. Provide good skin care, but do not remove skin markings for radiation fields.
7. Prepare for possible biopsy, staging protocols, tumor removal, bone marrow transplantation, organ removal, and palliation.
8. Anticipate late-effects years after treatment, such as genetic changes, learning disabilities, secondary cancers, and altered function of specific organ systems.
9. Use coping strategies (e.g., play therapy, relaxation techniques, and imagery) to deal with the pain and disability. Involve Child Life.
Leukemia
Overview
Oncologic Conditions
Overview
1. Abnormal, uncontrolled proliferation of WBCs
a. WBCs are producing so rapidly that immature cells (blast cells) are released into the circulation, where they normally do not appear.
b. Blast cells are nonfuncitonal, cannot fight infection, and multiply continuously without respect to the body’s needs.
c. **Blast cells may be as high as 95% in the bone marrow (they are normally less than 5%) as measured by marrow aspiration in the posterior iliac crest (the sternum cannot be used in children). **
d. The increased proliferation of WBCs robs healthy cells of nutrition.
e. Bone marrow first udnergoes hypertrophy, possibly resulting in pathologic fractures.
f. Bone marrow then undergoes atrophy, resulting in a decrease in all blood cells, which leads to anemia, bleeding disorders, and immunosuppression.
g. Leukemia is highly associated with ionizing radiation, checmicals, and viruses.
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Acute lymphoblastic leukemia (ALL)
a. This is the most common type of leukemia and cancer in children.
b. Peak age is 2 to 5 years.
c. 5 year survival rate > 92%
The child between ages 3 and 9 with ALL and an initial WBC count of less than 50,000 mm3 at the time of diagnosis has the best prognosis. - Acute myelogenous leukemia (AML)
a. More common than ALL among adolescents.
b. 5 year survival rate: 67%
c. Death usually follows overwhelming infection.
Leukemia
Assessment
Oncologic Conditions
- Assess for bone pain from hypertrophy of the marrow cavity.
- Review the child’s history for infections.
- Assess for signs and symptoms of anemia.
- Observe for petechiae and ecchymosis.
- Test urine, sputum, stool, and any emesis for blood.
- Ask about nsoebleeds, poor wound healing, and oral lesions.
- Palpate for lymphadenopathy.
- Prepare for lumbar puncture, which indicates whether leukemic cells have crossed the blood-brain barrier.
Leukemia
Interventions
Oncologic Conditions
- Prevent infection; give special attention to mouth care. Assess the skin daily for development of loss of skin integrity and signs of infection.
- Teach the family to inspect the skin frequently and to report any pain in the anal area (fissures or sores).
- Use interventions for anemia and thrombocytopenia.
- Give increased fluids to flush chemotherapy through the kidneys.
- Provide a high-protein, high-calorie, bland diet.
- Provide pain relief.
- Monitor the central nervous system for involvment.
- Gear nursing measures toward easing the side effects of radiation and chemotherapy.
- Help the child and the family allay their fears and fuilt.
- Offer hope, if appropriate.
- Help the child adjust to changes in body image.
- Refer parents and adolescents with cancer to support groups.
- For fever, give acetaminophen only after reporting fevers to the oncologist. Do not give ibuprofen due to the adverse effect of preventing platelets from aggregating. Blood cultures must be drawn for every fever spike when the child is immunocompromised from cancer treatment.
Hodgkin’s Lymphoma
Oncologic Conditions
Overview
1. A malignant neoplasm of the lymphoid tissue
2. Most commonly seen in adolescents and young adults
3. Usually originates in a localized group of lymph nodes and proliferates via lymphoctes
4. Excellent prognosis
Diagnosis and staging
1. Methods of making a definite diagnosis
a. Computed tomographic scan and positron emission tomography
b. Lymphangiogram
(1) Dye is injected IV into the feet.
(2) X-rays track the dye as it travels up the body and is absorbed by the infected nodes.
c. Lymph nodes and bone marrow biopsies, looking for Reed-Sternberg cells
Stages
1. In stage 1, a single lymph node is involved.
2. In stage II, two or more lymph nodes on the same side of the diaphragm are involved.
3. In stage III, nodes on both sides of the diaphragm are involved.
4. In stage IV, there is diffuse metastasis.
5. Any stage is also designated as “A” exhibits no systemic symptoms; or “B” with symptoms of fever, night sweats, and weight loss in the preceding 6 months.
Assessment
1. Asess for painless, firm, persistently enlarged lymph nodes that appear insidiously; they are most common in the lower cervical region.
2. Ask about night sweats and pruritus.
3. Review the child’s or adolescent’s history for recurrent fever.
4. Assess for weight loss.
Interventions
1. Assist wtih chemotherapy and radiation.
2. Gear nursing measures toward easing the side effects of radioation and chemotherapy.
Non-Hodgkin’s Lymphoma
Oncologic Conditions
Introduction
1. It includes lymphoscaroma, reticulum cell sarcoma, and Burkitt’s lymphoma.
2. It metastasizes faster than Hodgkin’s.
a. The primary tumor arises in any lymphoid tissue.
The lymphoma spreads beyond nodes into neighboring tissue.
3. Prognosis for aggressively treated localized disease approaches 90% survival; for those with advanced disease, survival is greater than 75%
Assessment
1. Assess for genlarged lymph nodes, most common in the lower cervical region.
2. Note that symptoms depend on the organ involved.
3. Assess for night sweats, fatigue, malaise, weight loss, and fever.
Interventions
1. Implement nursing care as for the child with leukemia.
2. Aggressive chemotherapy is implemented.
Neuroblastoma
Oncologic Conditions
Overview
1. Tumors arise from embryonic cells in the neural crest that give rise to the adrenal medulla and the sympathetic ganglia.
2. Tumors usually arise from the adrenal gland but can also arise at multiple other sites.
3. It is most common in those under age 2.
4. The cancer usually metastasize before it is diagnosed.
a. Highly malignant
b. Poor prognosis ( < 50%) for the child over age 1; prognosis approaches 75% survival for children diagnosed under age 1 year.
5. If a tumor is in the abdomen, it resembles Wilms’ tumor.
Diagnosis and staging
1. Methods of making a definite diagnosis
a. Skeletal scans/computed tomographic scan
b. 24 hour urine collection to measure catecholamines
2. Stages
a. In stage I, the tumor is confined to the organ or structure of origin.
b. In stage II, continuity extends beyond the primary site but not across the midline.
c. In stage III, the tumor extends beyond the midline with bilateral regional lymph node involvement.
d. In stage IV, the tumor metastasizes.
Assessment
1. Note the location and stage of the tumor, which is usally firm and nontender.
2. Be aware that the symptoms vary and are often from compression of the tumor on adjacent structures.
Interventions
1. These depend on the location and stage of the tumor.
2. Chemotherapy is initiated.
Nephroblastoma (Wilms’ Tumor)
Oncologic Conditions
Overview
1. Wilms’ tumor is an embryonal cancer of the kidney originating during fetal life.
2. The average afe at diagnosis is 2 to 4 years.
3. The tumor favors the left kidney and is usually unilateral.
4. The tumor remains encapsulated for a long time.
5. The prognossi is excellent if there is no metastasis.
Staging
1. In stage I, the tumor is limited to the kidney.
2. In stage II, the tumor extends beyond the kidney but can be completely excised.
3. In stage III, the tumor spreads but is confined to the abdomen and lymph nodes.
4. In stage IV, the tumor metastasizes to the lung, liver, bone and brain.
Assessment
1. Assess for a nontender mass, usually midline near the liver; it is often identified by the parent while bathing or dressing the child.
2. Expect IV pyelongraphy to assess kidney function.
3. Note any abdominal pain, hypertension, hematuria, anemia, or constipation.
Interventions (preoperative)
1. Do not palpate the abdomen, and prevent others from doing so; it may disseminate cancer cells to other sites.
2. Handle and bathe the child carefully.
3. Loosen clothing near the abdomen.
4. Prepare the family for a nephrectomy within 24 to 48 hours of diagnosis.
Interventions (postoperative)
1. Provide routine care as for a nephrectomy patient.
2. Be aware that chemotherapy and radiation will follow healing.
Osteogenic Sarcoma
Oncologic Conditions
Overview
1. This is the most common bone cancer in hildren.
2. Peak age is late adolescence; rare in young children.
3. It usually involves the diaphyseal long bones; about 50% of cases are in the femur.
4. It is highly malignant; metastasizes quickly to the lungs.
5. Survival rate is approximately 60%.
Assessment
1. Note a sunburst effect on the X-ray of the affected bone.
2. Assess pain and swelling at the site.
3. Assess for a history of trauma preceding the pain.
4. Assess for pathologic fractures, which may result from bone marrow involvement.
Interventions
1. Reinforce the fact that the child did not cause the tumor.
2. Anticipate amputation at the joint proximal to the tumor; some institutions rremove only the bone and salvage the limb.
3. Provide psychological support and reinforcement of the child’s strengths.
4. Provide support through phamtom limb pain.
5. Provide stump care and help the child prepare for a prosthesis.
6. Assist with chemotherapy.
Ewing’s Tumor or Sarcoma
Oncologic Conditions
Overivew
1. Arises from cells within the bone marrow rather than the osseous tissue.
2. Occurs between ages 4 and 25.
3. Highly malignant to lungs and bone.
Assessment
1. Note pain and swelling at the site.
2. Note that the bone has a moth-eaten appearance on the X-ray.
Interventions
1. Assist with radiation and chemotherapy.
2. Note that amputation is not routine, since the tumor spreads easily through the bone marrow.
Rhabdomyosarcoma
Oncologic Conditions
Refers to soft tissue sarcomas
- Muscles, tendons, fibrous connective tissue, vascular tissue
- Can occur in the orbits, nasopharynx, sinuses, middle ear, abdomen, or perineum
Retinoblastoma
Oncologic Conditions
- Arises from the retina
- Child may show leukokoria, a clinical sign that resembles cat’s eye reflex.
- Best prognosis occurs when the tumor is limited to one eye and metastasis to local structures has not occurred. Survival rate is 95% if tumor can be treated.
- Treated with surgery (possible enucleation), radiation therapy and laser therapy.
Graft-versus-host Reaction Following Tissue Transplantation
Oncologic Conditions
Overview
1. A grapft-versus-host reaction may occur only if the host is immunologically incompetent; receives live, functioning, and immunologically competent cells; and is genetically different from the host.
2. The graft rejects the entire host.
3. The spleen, lymph nodes, thymus, and bone marrow are rich sources of immunocompetent cells that react against the HLA of non-self antigens.
4. The reaction occurs 10 days to several months after a transplantation, from cell-mediated cytotoxicity.
5. Graft-versus-host reaction primarily affects the liver, GI tract, and skin.
Assessment
1. Note increased bilirubin.
2. Assess for diarrhea.
3. Observe for a rash leading to desquamation.
Interventions
1. Expect to suppress the rejection with immunosuppressive durgs such as steroids, azathioprine (Imuran), or cyclosporine.
2. Observe for signs of infection; ensure protective isolation.
