Transcript Child Health Nursing Partnering with Children & Families

Kristine Ruggiero CPNP,
MSN, RN
Chapter 29
Alterations in
Cellular Growth
Differences between Pediatric and
Adult presentation of Cancer
• Incidence of Cancer in Childhood:
– Approximately 9,000 children diagnosed in
United States in 2003
– Cancer is the leading cause of death for
children under age 15
– In 2003, about 1,500 children died of cancer,
1/3rd from leukemia
– Types of tumors vary by age and affect
survival rate
Percentage of primary tumors by site of origin for different age groups. Notice that in the early
years of life, in addition to leukemia, cancers that derive from embryonic cells such as sympathetic nervous
system (neuroblastoma) and eye (retinoblastoma) are common. As the child grows, lymphoma becomes
more common in school years, and germ cell cancers of ovary and testes emerge as more common causes
in teens.
FIGURE 29–1
Jane W. Ball and Ruth C. Bindler
Child Health Nursing: Partnering with Children & Families
© 2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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Anatomy and Physiology of
Pediatric Differences
• Immune system more immature in children
– This affects how well body can defend itself
– Nonspecific and specific cellular responses are
immature in infants and premies
• Children are still growing and developing
– As a result, some cancers grow and progress more
rapidly
– Apoptosis (programmed-cell death) not welldeveloped in young children
– Children more commonly present with metastases at
time of dx than adults d/t the difficulty in recognizing
s/sx of cancer (usually mistaken for childhood illness)
Differences between adults and
children with cancer
• Childhood cancers respond better to
chemotherapy
• Children tolerate chemotherapy better
than adults
• Childhood survivors of cancer need to be
monitored for late-effects and long-term
side effects of cancer treatment
– “Late-effects” clinics
Etiology and Pathophysiology
• Alterations in cellular growth occur in
response to external and internal stimuli
• Neoplasms are caused by one or a
combination of three factors;
– External stimuli that cause genetic mutations
– Innate immune system and gene
abnormalities
– Chromosomal abnormalities
FIGURE 29–2
A protooncogene normally regulates cellular growth and development. When altered by a virus or other
external cause, it can change to an oncogene, which allows unregulated genetic activity and tumor growth. Tumor-suppressor
genes regulate the effects of oncogenes to decrease wildly proliferating cellular growth.
Jane W. Ball and Ruth C. Bindler
Child Health Nursing: Partnering with Children & Families
© 2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Clinical Manifestations
• Vary by type and location
– Pain
– Cachexia
• (syndrome characterized by anorexia, weight loss, anemia,
asthenia (weakness) and early satiety)
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–
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Anemia
Infections
Bruising
Neurologic symptoms
Palpable mass
Diagnostic Tests
• CBC
• Bone marrow
aspiration
• Bone marrow biopsy
• Lumbar puncture
• CXR
• Radiographic
examination
• MRI
• CTscan
• US
• Biopsy of Tumor
• (See Table 29-2)
Important blood work
• CBC w/ diff
• Hgb and Hct
• RBC incices
– Mean corpuscular volume (MCV), mean corpuscular hgb
concentration (MCHC) and mean corpusuclar hgb (MCH)
• WBC indices
– Basophils, eosinophils, monocytes, lymphocytes, neutrophils
(segmented and banded)
• ANC
– (neutrophils x WBC count)= infection-fighting capacity (ANC >
1,000 = nml; ANC< 500= risk for infection)
• Chem 7
• Others: BUN/ creat, Liver function tests, tumor markers
Clinical Therapy
• Child managed by Pediatric Oncology Team
• Therapy may be singular or combination
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–
–
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Surgery
Chemotherapy (protocol-action plan for chemo)
Radiation
Biotherapy (antibodies developed to target tumor cells
for apoptosis; cancer vaccines)
– HSCT (hematopoietic stem cell transplant)
– Complementary therapies
– Palliative care (presence of palliative care team)
Chemotherapy drugs either act at specific parts of the cell cycle
or are nonspecific for action (act throughout all cell phases).
FIGURE 29–4
Jane W. Ball and Ruth C. Bindler
Child Health Nursing: Partnering with Children & Families
© 2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Chemotherapy protocol. A protocol is a map or plan of action that directs therapy
by identifying the drug and its accompanying treatment.
FIGURE 29–5
Jane W. Ball and Ruth C. Bindler
Child Health Nursing: Partnering with Children & Families
© 2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Chemotherapy Side Effects
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Nausea/ Vomiting
Alopecia
Malaise
Bone Marrow Depression
– Infection
– Bleeding
– Anemia
• Stomatitis
Nursing Care Plan
• Based on type of cancer and therapy
– Infection control
– Pain
– Nutrition
– Growth and Development
– Emotional
– Spiritual
Three Types of Oncological
Emergencies
• Oncologic emergencies result from the
cancer itself or as a side effect of
treatment.
• Most common emergencies are tumor
lysis syndrome, septic shock, brain
herniation, spinal cord compression, and
superior vena cava compression.
• 3 Types of Oncological Emergencies:
– Metabolic
– Hematologic
– Space-occupying lesions
Types of Oncological Emergencies
• Metabolic
– Tumor lysis syndrome:
• Metabolic emergency results from lysis of tumor
cells. This cell destruction releases high levels of
uric acid, K+, and phosphates into the blood. Low
levels of Na and Ca occur and metabolic acidosis
results.
• Most commonly seen in Burkit’s lymphoma and
ALL
• Tx: see table on pg 1049
Types of Oncologic Emergencies
• Metabolic
– Septic Shock
• During period of immune suppression the child is vulnerable
to overwhelming infection, resulting in circulatory failure,
hypo/hyperthermia, tachypnea, mental changes, inadequate
tissue perfusion, and hypotension
– Hypercalcemia
• Elevated calcium in serum.
• Occurs when large amounts of bone are destroyed by
treatment
• Most common in children w/ ALL and rhabdomyosarcoma
• Tx includes hydration and adequate intake of oral phosphate
Types of Oncologic Emergencies
• Hematologic:
– Results from bone marrow suppression or
infiltration of brain and respiratory tissue w/
high numbers of leukemic blast cells
(hyperleukocytosis)
– Bone marrow suppression results in anemia
and thrombocytopenia
– This leads to coagulation problems and
hemorrhage.
Types of Oncologic Emergencies
• Space-occupying lesions
– Tumors w/ extensive growth that may result in
life-threatening situations (ie spinal cord
compression, increased intracranial pressure,
brain herniation, respiratory complications,
etc.)
Nursing Management for a child
with Cancer
• Nursing interventions focus on preventive
teaching for all families about risk factors for
cancer
• Health promotion and health maintenance of the
child undergoing cancer treatment
• Carrying out treatment interventions
• Managing health problems r/t both cancer and
the side effects of tx
• Partnering w/ families to manage the challenging
psychosocial needs that emerge when cancer is
diagnosed.
FIGURE 29–11 A vascular access device allows chemotherapeutic agents to be administered without the need for
repeated “sticks” to the child.
Jane W. Ball and Ruth C. Bindler
Child Health Nursing: Partnering with Children & Families
© 2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
FIGURE 29–6 (continued)
A, The child with cancer depends on parents and family members to provide support.
B, A special relationship often develops between the nurse and the child receiving treatment.
B
Jane W. Ball and Ruth C. Bindler
Child Health Nursing: Partnering with Children & Families
© 2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nursing Assessment and Diagnosis
• Obtain a thorough history. Including:
– Family hx of cancer
– Hx of exposure to known carcinogens
– Does parent work w/ chemicals/ asbestos
– Was child tx’d w/ radiation/ chemo for cancer
previously
– Does the child have any known conditions
such as Down’s syndrome
– Any congenital anomalies
Nursing Assessment
• Physiologic Assessment
– Includes possible s/sx of cancer or thorough
physical assessment if cancer already
identified
• Psychosocial Assessment
– Stress and coping
– Knowledge
– Support systems
– Body Image
FIGURE 29–7
One of the most common threats to a child’s body image at any age is hair loss induced by
chemotherapy. Use of hats can improve self-concept.
Jane W. Ball and Ruth C. Bindler
Child Health Nursing: Partnering with Children & Families
© 2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nursing Assessment
• Developmental Assessment
– Children under 6 should be regularly screened for
developmental surveillance
– If changes in development are noted, or regression in
milestones occurs during tx, refer to specialist
• Assessment for Impact of Cancer Survival
– 1 in 1,000 young adults is survivor of childhood
cancer
– Ongoing care is essential: long-term follow-up clinics
– Help families manage long-term effects of cancer tx
Nursing Care of the hospitalized
child with Cancer
• (Review Nursing care plans on pp 1057-1061)
• Planning and Implementation:
– Ensure optimal nutritional intake
• 30% of children w/ cancer are malnourished
• High metabolic rate of cancer depletes nutritional
stores
• 24 hour dietary recall to assess nutritional intake
• Antiemetic drugs to decrease N/V from chemo
• w/ parenteral nutrition, weekly labs should be
performed including: chem 7, liver function studies
and glucose
• Oral hygiene
Nursing care of the hospitalized
child w/ cancer
• Planning and Implementation:
– Administer Medication
• Most chemo drugs calculated based on child’s
weight (dose/meter squared)
• Polypharmacy
– Manage Treatment side effects
• Myelosuppression (suppression of blood cell prod)
• Neutropenia (ANC < 500)
– Broad spectrum abx, G-CSF, isolation
Nursing Care of the Hospitalized
Child with Cancer
• Planning and Implementation:
– Ensure adequate hydration
• Strict I’s and O’s
• Adequate hydration
• IVFs
– Prevent and treat infection
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Ensure standard precautions
Proper care of central lines
Teach parents infection control
Immunizations utd
Nursing Care of the Hospitalized
Child with Cancer
• Planning and Implementation:
– Manage Pain ***
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From disease and medical interventions
Incorporate Pain management team when possible
Conscious sedation for some procedures (ie LPs)
Topical anesthetics (EMLA creams) for IV access
Group painful procedures during sedation when
possible (ie LP and Port access)
• Include parents/family, when possible to comfort
child
FIGURE 29–10
A child in a pediatric oncology clinic giving injections to a doll. This type of play therapy helps the
child deal with fear, thus lowering his or her stress level.
Jane W. Ball and Ruth C. Bindler
Child Health Nursing: Partnering with Children & Families
© 2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nursing care of the Hospitalized
Child with Cancer
• Planning and Implementation:
– Provide Psychosocial Support
• To child and family
– Care in the Community
• Assist family in preparation for home therapy
– Health Promotion/ Health Maintenance
• Treatment is often a long process (2-3 years)
• Still important to have health maintenance visits
during this time
Leukemia
• Most commonly diagnosed malignancy in
children under 14
• Cancer of the blood or bone marrow,
characterized by an abnormal proliferation
of blood cells, usually wbc’s.
Childhood Leukemia
• Acute Lymphocytic Leukemia (ALL) 75% of all
leukemias in children
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Peak age of onset is 2-4 years
90-95% of children w/ ALL will achieve a 1st remission
Almost 80% will live 5 years
Rapid proliferation of immature blood cells which
makes the bone marrow unable to produce healthy
blood cells
• Acute nonlymphocytic (ANLL) or Acute
Myelomonocytic leukemia
– Most common in children under 2 y.o and adolescents
– 17% of all leukemias; 50-70% of adolescents achieve
a 1st remission
– 40% live 5 years
Leukemia
• The cause…
– Exact cause of most leukemias remains
unknown
– Increasing evidence suggests a combination
of contributing factors
– Predisposing factors
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Familial tendency
Monozygotic twin w/ leukemia
Congenital disorders, such as Down’s, AT
Viruses
Ionizing radiation
Exposure to the chemical benzene and cytotoxins
such as alkylating agents
Pathophysiology of Leukemia
• WBCs are produced so rapidly that immature
cells (blast cells) are released into circulation
• Blast cells multiply continuously w/o respect to
the body’s needs
• Blast cells may be as high as 95% in the bone
marrow (nml= <5%)
• Increased proliferation of WBCs robs healthy
cells of nutrition
• Bone marrow undergoes hypertrophy (can lead
to fxs)
• Bone marrow then undergoes atrophy, leading to
anemia, bleeding disorders, and
immunosuppression
Leukemia
• Clinical Manifestations:
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High fever
Thrombocytopenia
Abdominal or bone pain
Pallor, chills, and recurrent infections
Petechiae and ecchymosis
Abnormal bleeding, (nosebleeds, wounds, and oral
lesions
– Confusion, lethargy, and HA if the blood-brain barrier
has been crossed
– Fatigue
– Painless lumps in neck, underarm, stomach and groin
Diagnostic Test findings in
Leukemia
• Bone marrow biopsy confirms dx:
– aspirate showing a proliferation of immature
WBCs (>25% blasts)
• Blood counts show thrombocytopenia,
neutropenia, and anemia
• Differential leukocyte count determines
cell type
• LP detects meningeal involvement (if CNS
involved)
• Cytogenetic analysis shows a
“Philadelphia chromosome” in ALL
Treatment of Leukemia
• Systemic chemo aims to eradicate
leukemic cells and induce remission
• Intrathecal chemo to prevent or tx CNS
infiltration
• Abx, antifungal and antiviral drugs and
granulocyte injections to control infection
• Transfusions of plts to prevent bleeding
and of RBCs to prevent anemia
• Bone marrow transplant
Nursing Interventions
• Prevent infection (private room, oral hygiene,
screen visitors for infections)
• Inspect skin frequently (avoid rectal meds,
temps)
• Give increased fluids to flush chemo through
kidneys
• Provide pain relief
• Monitor CNS for involvement
• Group nursing interventions
• Help child adjust to changes in body image
Soft Tissue Tumors
• Hodgkin’s Disease
– Disorder of the lymphoid system
– Usually arises from a single or group of lymph
nodes
– Incidence: 3/100,000; peaks in adolescent
boys
– Clinical Manifestations include: main sx= a
nontender, firm lymphadenopathy, fever, night
sweats, weight loss
– Prognosis excellent: Tx based on staging: 5
year survival 90%
FIGURE 29–15
Lymph nodes and organs affected in Hodgkin disease in children.
Jane W. Ball and Ruth C. Bindler
Child Health Nursing: Partnering with Children & Families
© 2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Soft tissue tumors
• Non-Hodgkin’s Lymphoma
– 3 types:
• Lymphoblastic Lymphoma (30-40%)
• Small noncleaved cell (Burkit’s) Lymphoma (4050%)
• Large cell Lymphoma (15%)
– Malignant tumors of lymphoreticular (internal
framework of the lymph sx) origin
– Peak incidence b/t 7-11 y.o; 3X more common
in boys
Soft Tissue Tumors
• Non-Hodgkin’s Lymphoma
– Clinical Manifestations include: enlarged
lymph glands usually in the axillary, cervical,
inguinal and femoral nodes.
– Tx based on type and staging
Any Questions….Let’s do a case study!!
A
Jane W. Ball and Ruth C. Bindler
Child Health Nursing: Partnering with Children & Families
© 2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.