Peds Exam 4 - Super Awesome Finals Set Flashcards
Child with leukemia undergoing bone marrow aspiration
For bone marrow aspiration, conscious or unconscious sedation should be used in children.
In adults usually done only with local, but with kids always under sedation
Clinical trials
Clinical trials - what have made treating pediatric cancers so successful
Control group - patients receive best available therapy currently known
Experimental group - receives treatment thought to be even better
Protocols - outline the therapy plan
- Developed for most pediatric cancers
- Accessed by ped oncologists throughout US
- Designed to optimize therapy based on type/stage
Bone marrow transplant (BMT) vs stem cell transplant (SCT)
- Difference between SCT/BMT is how it is collected
- Both are given to pt via IV infusion (usually through central line)
SCT collection
- Colony-stimulating factor given to stimulate production of many stem cells - then collected by “apheresis” machine
- Stem cells separated from whole blood - remaining blood cells and plasma returned to pt
- Stem cells frozen for later transfusion to patient
Acute Tumor Lysis Syndrome
Cause
- Can occur during initial treatment with chemo
- Cancer cells get destroyed –> cell’s contents rapidly released –> causes metabolic abnormalities
S/S
- High uric acid, low calcium, high phosphorous, high potassium
- High WBC at diagnosis
- Flank pain, lethargy, N&V, oliguria, pruritus, tetany, altered LOC
Prevention
- IV hydration
- Frequent lab monitoring
- Medication to decrease uric acid levels (allopurinol)
Managing side effects of cancer treatments
Bleeding
- Need to avoid ASA and ibruprofen
- Can do tylenol
N/V
- Best thing nurses can do is administer zofran as scheduled
- Also will give other antiemetics such as emend prior to chemo as preventive
Stomatitis/mouth sores
- Let child select foods that they feel they can eat
- Things like soft bland food may feel the best
- Avoid hot or cold foods
- Nothing spicy
Alopecia
- Allow child to pick hat, scarf or wig they prefer to wear
- Hair will grow back after chemo - usually 3-6 mo after completing treatment - warn that it may be a different texture
- Protect from sunlight
Leukemia
Four Phases of Therapy
- Induction therapy - 4 to 6 weeks
- CNS prophylactic therapy - intrathecal (IT) chemotherapy ** given to prevent central nervous system disease
- Intensification (consolidation therapy) - to eradicate residual leukemic cells and prevent resistant leukemic clones
- Maintenance therapy - to preserve remission
Nervous system tumors - diagnosis
- Signs and symptoms are related to anatomic location, size, and child’s age
- Presenting clinical signs (infratentorial: usually associated with ICP changes, HA and vomiting especially upon awakening; supratentorial - depends on area affected but may see seizures, contralateral weakness, behavioral changes, if affect pituitary or hypothalamus may see DI or growth failure)
- Neurologic evaluation
- MRI, CT, EEG, LP
- *** MRI is gold standard for diagnosis
- Histologic diagnosis via surgery
Wilms Tumor - nursing considerations
- Same as other cancers
- One special precaution is DO NOT PALPATE ABDOMEN UNLESS ABSOLUTELY NECESSARY
Retinoblastoma
- Congenital malignant tumor - arises from the retina
* ** Know that there is potentially a hereditary basis, so would want to screen for this
Awareness of dying in children with life-threatening illness
- Kids have an adult concept of death by the time they are 9-11 years old
- Adolescents because of their mature understanding of death and issues with not being “normal” tend to have the most difficult time coping with death
CRIES Neonatal Pain Scale
Scale to assess pain in neonates: Crying Requiring increased oxygen Increased vital signs Expression Sleeplessness
- Pain pathways and neurochemical systems associated with pain transmission ARE intact and functional in neonates
- Painful stimuli trigger global stress response - cardiorespiratory changes, palmar sweating, increased ICP, hormonal and metabolic changes
- Adequate analgesia and anesthesia necessary to treat stress response
Physiologic Effects of Immobilization
Muscular system
Decreased muscle strength and endurance
Atrophy
Loss of joint mobility
Skeletal system
Bone demineralization
Metabolism
Decreased metabolic rate
Cardiovascular system
Altered distribution of blood volume
Venous stasis
Dependent edema
Respiratory system Decreased need for oxygen Diminished vital capacity Poor abdominal tone and distention Mechanical or biochemical secretion retention Loss of respiratory muscle strength
GI system Distention caused by poor abdominal muscle tone Difficulty feeding in prone position Gravitation effect on feces Anorexia
Integumentary system
Decreased circulation and pressure leading to decreased healing capacity
Urinary system Alteration of gravitational force Difficulty voiding in supine position Urinary retention Impaired ureteral peristalsis
Assessment of Fractures - the 5 Ps
Pain and point of tenderness
Pulse—distal to the fracture site (no pulse = decreased blood flow to extremity)
Pallor – sign of decreased perfusion
Paresthesia—sensation distal to the fracture site
Paralysis—movement distal to the fracture site
Bone healing and remodeling
- Typically rapid healing in children
- In general, the younger the child, the more rapid the bone healing
- The healthier the person is, the more easily the bone will heal
Adequate nutrition – no special diet – but need to correct any existing nutritional deficits
Sprain
Trauma to a joint from ligament partially or completely torn or stretched by force (** sprain = ligament)
May have associated damage to blood vessels, muscles, tendons, and nerves
Presence of joint laxity as indicator of severity (pain not principal complaint) – may feel popping sensation
Rapid onset of swelling with disability
Strain
A microscopic tear to musculotendinous unit (**strain = tendon)
Similar to sprain
Swollen, painful to touch
Generally incurred over time
Scoliosis - when seen?
- Generally becomes noticeable after preadolescent growth spurt
- Seldom seen before age 10
What reflexes are present at birth?
Moro- startle reflex elicited by a loud noise or sudden change in position
Rooting- when side of mouth is touched causes infant to turn toward that side
Tonic neck- when infant lies supine and head turned to one side, the infant will assume a “fencing position”
Grasp- hands and feet will grasp when stimulated
Babinski- fanning of toes when sole of foot is stroked upward
***All reflexes are gone by 4 months except Babinski
When do fontanels close?
Posterior fontanel closes at 2-3 mo
Anterior fontanel closes by 12 to 18 mo
Treatment for osteomyelitis
** Prompt, vigorous IV antibiotics for extended period (3 to 4 weeks or up to several months)
Monitor hematologic, renal, hepatic responses to treatment (frequent CBCs, CMPs)
What to know about osteogenesis imperfecta (OI)
Know that it’s an inherited disease and general info about each type
Type I - most common and most mild; blue sclera
Type II - lethal - most stillborn or die in early infancy
Type III - prognosis - most don’t live past 30 y.o.; severe bone fragility leads to progressive deformities; marked growth failure; normal sclera
Type IV - mild to moderate; normal sclera; short stature; variable deformity
Drug treatment for OI
Know that some meds promote bone density and prevent fractures
Don’t need to know specifics about type
What is the most common pediatric cancer?
Leukemia
Cause of cancer
Unknown - NOT lifestyle in children
Leading theory: genetic alteration which results in unregulated cell proliferation
Cardinal symptoms 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 change
- Excessive, rapid weight loss
Biologic response modifiers (BRMs)
Monoclonal antibodies
One mode of therapy for treating cancer
Modifies the relationship between tumor and host by changing host’s biologic response to tumor cells
Types of bone marrow transplant (BMT)
Allogenic - match histocompatible donor with recipient - limited by presence of suitable marrow donor
Umbilical cord blood - is rich source of hematopoietic stem cells and found in circulation of newborns, to be used for treatment
Autologous - patient’s own marrow; collected from disease-free tissue - sometimes treated to remove malignant cells
S/S of cancer in children
- Pain
- Fever
- Skin changes
- Anemia
- Abdominal mass
- Swollen lymph nodes
Health Promotion for Children with Cancer
- Dental care
o Daily tooth brushing if platelet count okay
o If
Most commonly used pain medications in order
Morphine used most frequently
Hydromorphone (Dilaudid)
Fentanyl
NHL
Approximately 60% of pediatric lymphomas are NHL
- Clinical appearance
o Disease usually diffuse rather than nodular
o Cell type undifferentiated or poorly differentiated
o Dissemination occurs early, often and rapidly
o Mediastinal involvement and invasion of meninges - Diagnostic evaluation
o Bone marrow aspiration
o LP
o Imaging – CT of lungs and GI organs - Treatment
o Aggressive chemo and radiation - Prognosis
o
Infratentorial vs supratentorial
Infratentorial - primarily in cerebellum or brainstem
Supratentorial - mainly in cerebrum
Prognosis for brain tumors
Generally - more tumor they can resect, better prognosis
o Typically better for midbrain tumors
o Lower brain stem tumors often inoperable – so will do chemo/radiation to prolong life/function as much as possible
Postop for brain tumor
o Interventions to reduce ICP (spread care out vs clustering, HOB >30, etc)
o Frequent vitals
o Monitor for s/s infection (increased temp, increased drainage on dressing)
o Neuro checks are essential!
- Promote return to optimum functioning
o Neurosurgeon will dictate any restriction
o May need to wear helmet for protection
o May need to go to rehab if any neuro deficits after surgery or d/t disease
