Care of Mother & Child: Infectious, Inflammatory Responses - PDF

BACHELOR OF SCIENCE IN NURSING CARE OF MOTHER AND CHILD AT RISK OR WITH PROBLEMS (ACUTE AND CHRONIC): COURSE MODULE COURSE UNIT WEEK 3 11 13...

BACHELOR OF SCIENCE IN NURSING CARE OF MOTHER AND CHILD AT RISK OR WITH PROBLEMS (ACUTE AND CHRONIC): COURSE MODULE COURSE UNIT WEEK 3 11 13 Alterations with Infectious, Inflammatory and Immunologic Responses/ Cellular Aberrations ✓ Read course and unit objectives ✓ Read study guide prior to class attendance ✓ Read required learning resources; refer to unit terminologies for jargons ✓ Proactively participate in classroom discussions ✓ Answer and submit course unit tasks At the end of the course unit (CU), learners will be able to: Cognitive: 1. Identify and understand the different alterations with infectious, inflammatory and immunologic responses / cellular aberrations in children. 2. Verbalize the importance and relevance of these topics to nursing practice Affective: 1. Listen attentively during class discussions 2. Demonstrate tact and respect when challenging other people’s opinions and ideas 3. Accept comments and reactions of classmates on one’s opinions openly and graciously. Psychomotor: 1. Participate actively during class discussions and group activities 2. Express opinion and thoughts in front of the class  OVERVIEW: I. ALTERATIONS WITH INFECTIOUS, INFLAMMATORY AND IMMUNOLOGIC RESPONSES 1. Juvenile Rheumatoid Arthritis 2. Allergic Rhinitis 3. Eczema 4. Asthma II. CELLULAR ABERRATIONS 1. Basic Concepts on Oncology A. Leukemia B. Lymphomas C. Wilms’ tumor D. Brain tumors 2. Basic Concepts on Cancer management and Nursing care I. ALTERATIONS WITH INFECTIOUS, INFLAMMATORY AND IMMUNOLOGIC RESPONSES JUVENILE RHEUMATOID ARTHRITIS ( JUVENILE IDIOPATHIC ARTHRITIS) Juvenile idiopathic arthritis (JIA) is the name replacing juvenile rheumatoid arthritis (JRA) in the research literature and now in clinical practice. The JRA nomenclature revision to JIA was partly attributable to the minimally applicable reference to “rheumatoid” in JRA. Only a small percentage of children have a positive rheumatoid factor, yet the name burdens the family with images of adult disfiguring rheumatoid arthritis, a distinctly different disease. JIA is a chronic autoimmune inflammatory disease causing inflammation of joints and other tissue with an unknown cause. JIA starts before age 16 years with a peak onset between 1 and 3 years of age. Twice as many girls as boys are affected. The reported incidence of chronic childhood arthritis varies from 1 to 20 cases per 100,000 children with a prevalence of 10 to 400 per 100,000 (Cassidy and Petty, 2011). The cause is unknown, but two factors are hypothesized: immunogenic susceptibility and an environmental or external trigger such as a virus (e.g., rubella, Epstein-Barr virus, parvovirus B19). PATHOPHYSIOLOGY: The disease process is characterized by chronic inflammation of the synovium with joint effusion and eventual erosion, destruction, and fibrosis of the articular cartilage. Adhesions between joint surfaces and ankylosis of joints occur if the inflammatory process persists. CLINICAL MANIFESTATIONS: The outcome of JIA is variable and unpredictable. The disease, even in severe forms, is rarely life threatening but can cause significant disability. The arthritis tends to wax and wane; however, patterns of clinical remission indicate approximately 25% will obtain clinical remission off medication for a follow-up duration of at least 4 years. Children with arthritis in four or fewer joints had the greatest likelihood for a sustained remission. Children with extensive arthritis and a positive rheumatoid factor were less likely to have a sustained remission (Wallace, Huang, and Bandeira, 2005). Their arthritis can cause significant joint deformity and functional disability, requiring medication, physical therapy, and perhaps future joint replacement. Chronic and acute uveitis can cause permanent vision loss if undiagnosed and not aggressively treated. Classification of Juvenile Idiopathic Arthritis: 1. Systemic arthritis is arthritis in one or more joints associated with at least 2 weeks of quotidian fever, rash, lymphadenopathy, hepatosplenomegaly, and serositis. 2. Oligoarthritis is arthritis in one to four joints for the first 6 months of disease. It is subdivided to persistent oligoarthritis if it remains in four joints or fewer or becomes extended oligoarthritis if it involves more than four joints after 6 months. 3. Polyarthritis rheumatoid factor negative affects five or more joints in the first 6 months with a negative rheumatoid factor. 4. Polyarthritis rheumatoid factor positive also affects five or more joints in first 6 months, but these children have a positive rheumatoid factor. 5. Psoriatic arthritis is arthritis with psoriasis or an associated dactylitis, nail pitting, or onycholysis or psoriasis in a first-degree relative. 6. Enthesitis-related arthritis is arthritis or enthesitis associated with at least two of the following: sacroiliac or lumbosacral pain, HLA-B27 antigen, arthritis in a boy older than 6 years, acute anterior uveitis, inflammatory bowel disease, Reiter syndrome, or acute anterior uveitis in a first-degree relative. 7. Undifferentiated arthritis fits no other category above or fits more than one category. DIAGNOSTIC EVALUATION: Juvenile idiopathic arthritis is a diagnosis of exclusion; there are no definitive tests. Classifications are based on the clinical criteria of age of onset before age 16 years, arthritis in one or more joints for 6 weeks or longer, and exclusion of other causes. Laboratory tests may provide supporting evidence of disease. The ESR may or may not be elevated. Leukocytosis is frequently present during exacerbations of systemic JIA. Antinuclear antibodies are common in JIA but are not specific for arthritis; however, they help identify children who are at greater risk for uveitis. Plain radiographs are the best initial imaging studies and may show soft-tissue swelling and joint space widening from increased synovial fluid in the joint. Later films can reveal osteoporosis, narrow joint space, erosions, subluxation, and ankylosis. THERAPEUTIC MANAGEMENT: There is no cure for JIA. The major goals of therapy are to control pain, preserve joint range of motion and function, minimize effects of inflammation such as joint deformity, and promote normal growth and development. Outpatient care is the mainstay of therapy; lengthy hospitalizations are infrequent in this era of managed care. The treatment plan can be exhaustive and intrusive for the child and family, including medications, physical and occupational therapy, ophthalmologic slit lamp examinations, splints, comfort measures, dietary management, school modifications, and psychosocial support. MEDICATIONS: Many arthritis medications are available, and most are effective in suppressing the inflammatory process and relieving pain. These drugs may be given alone or in combination and are prescribed in a stepwise manner dependent on arthritis severity. NONSTEROIDAL ANTIINFLAMMATORY DRUGS (NSAIDS) are the first drugs used. Naproxen, ibuprofen, tolmetin, indomethacin, celecoxib, meloxicam, and aspirin are approved for use in children. They are effective with few common side effects other than gastrointestinal irritation and bruising; with naproxen, skin fragility is a possible side effect. NSAIDs must be taken with food. Aspirin, once the drug of choice, has been replaced by other NSAIDs because they have fewer side effects and easier administration schedules. METHOTREXATE is the second-line medication used in children who have failed with NSAIDs alone. It is started in combination with an NSAID. It is effective, with acceptable toxicity, which requires monitoring of complete blood cell counts and liver functions. Patient education about possible side effects, including discussions with teens about birth defects and avoiding alcohol, is essential. Corticosteroids are potent immuno-suppressives used for life- threatening complications, incapacitating arthritis, and uveitis. They are administered at the lowest effective dosage for the briefest period and discontinued on a tapering schedule. Prolonged use of systemic steroids is associated with significant side effects, including Cushing syndrome, osteoporosis, increased infection risk, glucose intolerance, cataracts, and growth suppression. BIOLOGIC AGENTS that work by several mechanisms to interrupt and minimize the inflammatory process are used in children with severe or progressive arthritis. Biologic agents may be used in combination with methotrexate. The Food and Drug Administration (FDA) has approved etanercept, adalimumab and abatacept use in children with JIA. NURSING CARE: Relieve Pain. The pain of JIA is related to several aspects of the disease, including disease severity, functional status, individual pain threshold, family variables, and psychological adjustment. The aim is to provide as much relief as possible with medication and other therapies to help children tolerate the pain and cope as effectively as possible. Non-pharmacologic modalities such as behavioral therapy and relaxation techniques have proved effective in modifying pain perception and activities that aggravate pain. Opioid analgesics are typically avoided in juvenile arthritis; however, for children immobilized with refractory pain, short-term opioid analgesics can be part of a comprehensive plan that uses multiple pain relief techniques (Connelly and Schanberg, 2006). Promote General Health. The child’s general health must be considered. A well-balanced diet with sufficient calories to maintain growth is essential. If the child is relatively inactive, caloric intake needs to match energy needs to avoid excessive weight gain, which places additional stress on affected joints. Encourage Heat and Exercise. Heat has been shown to be beneficial to children with arthritis. Moist heat is best for relieving pain and stiffness, and the most efficient and practical method is in the bathtub with warm water. ALLERGIC RHINITIS Allergic rhinitis is inflammation of the inside of the nose caused by an allergen, such as pollen, dust, mold or flakes of skin from certain animals. Allergic rhinitis is caused by the immune system reacting to an allergen as if it were harmful. This results in cells releasing a number of chemicals that cause the inside layer of your nose (the mucous membrane) to become swollen and too much mucus to be produced. Common allergens that cause allergic rhinitis include pollen (this type of allergic rhinitis is known as hay fever), as well as mold spores, house dust mites, and flakes of skin or droplets of urine or saliva from certain animals. Symptoms of allergic rhinitis Allergic rhinitis typically causes cold-like symptoms, such as sneezing, itchiness and a blocked or runny nose. These symptoms usually start soon after being exposed to an allergen. Some people only get allergic rhinitis for a few months at a time because they're sensitive to seasonal allergens, such as tree or grass pollen. Other people get allergic rhinitis all year round. Most people with allergic rhinitis have mild symptoms that can be easily and effectively treated. But for some people symptoms can be severe and persistent, causing sleep problems and interfering with everyday life. The symptoms of allergic rhinitis occasionally improve with time, but this can take many years and it's unlikely that the condition will disappear completely. Treatment / Management. It's difficult to completely avoid potential allergens, but you can take steps to reduce exposure to a particular allergen you know or suspect is triggering your allergic rhinitis. This will help improve the symptoms. If the condition is mild, it can also help reduce the symptoms by taking over-the-counter medications, such as non-sedating antihistamines, and by regularly rinsing the nasal passages with a salt water solution to keep the nose free of irritants. A stronger medication, such as a nasal spray containing corticosteroids may be prescribed. ATOPIC DERMATITIS (ECZEMA) Eczema or eczematous inflammation of the skin refers to a descriptive category of dermatologic diseases and not to a specific etiology. AD is a type of pruritic eczema that usually begins during infancy and is associated with an allergic contact dermatitis with a hereditary tendency (atopy) (Jacob, Yang, Herro, and others, 2010). AD manifests in three forms based on the child’s age and the distribution of lesions: 1. Infantile (infantile eczema)—Usually begins at 2 to 6 months of age; generally undergoes spontaneous remission by 3 years of age 2. Childhood—May follow the infantile form; occurs at 2 to 3 years of age; 90% of children have manifestations by age 5 years 3. Preadolescent and adolescent—Begins at about 12 years of age; may continue into the early adult years or indefinitely CLINICAL MANIFESTATIONS OF ATOPIC DERMATITIS Distribution of Lesions Infantile form—Generalized, especially cheeks, scalp, trunk, and extensor surfaces of extremities Childhood form—Flexural areas (antecubital and popliteal fossae, neck), wrists, ankles, and feet Preadolescent and adolescent form—Face, sides of neck, hands, feet, face, and antecubital and popliteal fossae (to a lesser extent) APPEARANCE OF LESIONS Infantile Form Erythema Vesicles Papules Weeping Oozing Crusting Scaling Often symmetric Childhood Form Symmetric involvement Clusters of small erythematous or flesh-colored papules or minimally scaling patches Dry and may be hyperpigmented Lichenification (thickened skin with accentuation of creases) Keratosis pilaris (follicular hyperkeratosis) common Adolescent or Adult Form Same as childhood manifestations  Dry, thick lesions (lichenified plaques) common Confluent papules Other Physical Manifestations Intense itching Unaffected skin dry and rough African-American children likely to exhibit more papular or follicular lesions than are white children May exhibit one or more of the following: Lymphadenopathy, especially near affected sites Increased palmar creases (many cases) Atopic pleats (extra line or groove of lower eyelid) Prone to cold hands Pityriasis alba (small, poorly defined areas of hypopigmentation) Facial pallor (especially around nose, mouth, and ears) Bluish discoloration beneath eyes (“allergic shiners”) Increased susceptibility to unusual cutaneous infections (especially viral) Therapeutic Management The major goals of management are to (1) hydrate the skin, (2) relieve pruritus, (3) reduce flare-ups or inflammation, and (4) prevent and control secondary infection. The general measures for managing AD focus on reducing pruritus and other aspects of the disease. Management strategies include avoiding exposure to skin irritants or allergens; avoiding overheating; and administrating medications such as antihistamines, topical immunomodulators, topical steroids, and (sometimes) mild sedatives as indicated. Enhancing skin hydration and preventing dry, flaky skin are accomplished in a number of ways, depending on the child’s skin characteristics and individual needs. NURSING CARE: Assessment of the child with AD includes a family history for evidence of atopy, a history of previous involvement, and any environmental or dietary factors associated with the present and previous exacerbations. The skin lesions are examined for type, distribution, and evidence of secondary infection. Controlling the intense pruritus is imperative if the disorder is to be successfully managed because scratching leads to new lesions and may cause secondary infection. Fingernails and toenails are cut short, kept clean, and filed frequently to prevent sharp edges. Gloves or cotton stockings can be placed over the hands and pinned to shirtsleeves. One-piece outfits with long sleeves and long pants also decrease direct contact with the skin. If gloves or socks are used, the child needs time to be free from such restrictions. An excellent time to remove gloves, socks, or other protective devices is during the bath or after receiving sedative or antipruritic medication. ASTHMA Asthma is a chronic inflammatory disorder of the airways characterized by recurring symptoms, airway obstruction, and bronchial hyperresponsiveness (National Asthma Education and Prevention Program [NAEPP], 2007). In susceptible children, inflammation causes recurrent episodes of wheezing, breathlessness, chest tightness, and cough, especially at night or in the early morning. The airflow limitation or obstruction is reversible either spontaneously or with treatment. Inflammation causes an increase in bronchial hyperresponsiveness to a variety of stimuli (NAEPP, 2007). Recognition of the key role of inflammation has made the use of antiinflammatory agents, especially inhaled steroids, a major component in the treatment of asthma. The classic manifestations of asthma are dyspnea, wheezing, and coughing. An attack may develop gradually or appear abruptly and may be preceded by An upper respiratory tract infection. ASTHMA SEVERITY CLASSIFICATION IN CHILDREN TRIGGERS TENDING TO PRECIPITATE OR AGGRAVATE ASTHMA EXACERBATIONS Allergens Outdoor—Trees, shrubs, weeds, grasses, molds, pollens, air pollution, spores Indoor—Dust or dust mites, mold, cockroach antigen Irritants—Tobacco smoke, wood smoke, odors, sprays Exposure to occupational chemicals Exercise Cold air Changes in weather or temperature Environmental change—Moving to new home, starting new school, and so on Colds and infections Animals—Cats, dogs, rodents, horses Medications—Aspirin, NSAIDs, antibiotics, beta-blockers Strong emotions—Fear, anger, laughing, crying Conditions—Gastroesophageal reflux, tracheoesophageal fistula Food additives—Sulfite preservatives Foods—Nuts, milk or other dairy products Endocrine factors—Menses, pregnancy, thyroid disease Therapeutic Management. The overall goals of asthma management are to maintain normal activity levels, maintain normal pulmonary function, prevent chronic symptoms and recurrent exacerbations, provide optimum drug therapy with minimum or no adverse effects, and assist the child in living as normal and happy a life as possible. Drug Therapy. Asthma medications are categorized into two general classes: longterm control medications (preventive medications) to achieve and maintain control of inflammation, and quick-relief medications (rescue medications) to treat symptoms and exacerbations (NAEPP, 2007) Corticosteroids are anti-inflammatory drugs used to treat reversible airflow obstruction, control symptoms, and reduce bronchial hyperresponsiveness in chronic asthma. β-Adrenergic agonists (short acting) (primarily albuterol, levalbuterol [Xopenex], and terbutaline) are used for treatment of acute exacerbations and for the prevention of exercise-induced bronchospasm  Salmeterol (Serevent) is a long-acting β2-agonist (bronchodilator) that is used twice a day (no more frequently than every 12 hours). This drug is added to antiinflammatory therapy and used for long-term prevention of symptoms, especially nighttime symptoms, and exercise induced bronchospasm. Theophylline is a methylxanthine drug used for decades to relieve symptoms and prevent asthma attacks; however, it is now used primarily in the ED when the child is not responding to maximal therapy. Cromolyn sodium is a medication used in maintenance therapy for asthma. It stabilizes mast cell membranes; inhibits activation and release of mediators from eosinophil and epithelial cells; and inhibits the acute airway narrowing after exposure to exercise, cold dry air, and sulfur dioxide. Anticholinergics (atropine and ipratropium [Atrovent]) may also be used for relief of acute bronchospasm. However, these drugs have adverse side effects that include drying of respiratory secretions, blurred vision, and cardiac and CNS stimulation. II. CELLULAR ABERRATIONS 1. BASIC CONCEPTS OF ONCOLOGY CANCER is a complex of diseases which occurs when normal cells mutate into abnormal cells that take over normal tissue, eventually harming and destroying the host A large group of diseases characterized by: Uncontrolled growth and spread of abnormal cells Proliferation (rapid reproduction by cell division) Metastasis (spread or transfer of cancer cells from one organ or part to another not directly connected) ONCOLOGY Branch of medicine that deals with the study, detection, treatment and management of cancer and neoplasia. Characters of Neoplasia: Uncontrolled growth of abnormal cells 1. Benign Well-differentiated Slow growth Encapsulated Non-invasive Does NOT metastasize 2. Malignant Undifferentiated Erratic and Uncontrolled Growth Expansive and Invasive Secretes abnormal proteins METASTASIZES  3. Borderline ETIOLOGY 1. PHYSICAL AGENTS  Radiation  Exposure to irritants  Exposure to sunlight  Altitude, humidity 2.CHEMICAL AGENTS  Smoking  Dietary ingredients  Drugs 3. Genetics and Family History  Colon Cancer  Premenopausal breast cancer A. LEUKEMIA Leukemia is cancer that starts in the tissue that forms blood. Most blood cells develop from cells in the bone marrow called stem cells. In a person with leukemia, the bone marrow makes ABNORMAL WHITE BLOOD CELLS. The abnormal cells are leukemia cells. Unlike normal blood cells, leukemia cells don't die when they should. They may crowd out normal white blood cells, red blood cells, and platelets. This makes it hard for normal blood cells to do their work. The four main types of leukemia are: Acute lymphoblastic leukemia (ALL) Acute myelogenous leukemia (AML) Chronic lymphocytic leukemia (CLL) Chronic myelogenous leukemia (CML) ETIOLOGY: THE RISK FACTORS OF LEUKEMIA Genetic disorders  Down syndrome  Klinefelter syndrome  Patau syndrome  Ataxia telangiectasia  Shwachman syndrome  Kostman syndrome  Neurofibromatosis  Fanconi anemia  Li-Fraumeni syndrome Radiation exposure  Nontherapeutic, therapeutic radiation Physical and chemical exposures  BenzeneDrugs such as pipobroman  PesticidesCigarette smoking  Embalming fluids  Herbicides Chemotherapy  Alkylating agents  Topoisomerase-II inhibitors  Anthracyclines  Taxanes MANIFESTATIONS: The symptoms of Acute Leukemia develop very quickly (within a few days or weeks ) whereas, Chronic Leukemia can go unnoticed for years and is usually found in a routine blood test. The following conditions can develop in Leukemia patients Anemia (a deficiency of red blood cells and hemoglobin) Thrombocytopenia (a low blood platelet count) Enlarged liver or Spleen (leukemia cells build up in the liver or spleen ) Leukopenia (A low white blood cell count Other Symptoms o Leukemia can also cause vomiting, confusion, loss of muscle control and seizures. o Swollen Lymph nodes o Fever or Chills o Night Sweating o Joint and bone pain CHRONIC MYELOID LEUKEMIA This type affects the lymphoid cells created in the bone marrow. It is classified as chronic leukemia, because the affected cells carry out some of their normal functions initially, making it difficult to detect. ACUTE MYELOID LEUKEMIA The more severe form of the disease is acute myeloid leukemia, which is characterized by faster progression of the disease. This is the most commonly incident type among adults. If detected early, statistics show that 20% to 40% of patients survive for at least 60 months. CHRONIC LYMPHOCYTIC LEUKEMIA This type almost never occurs among children and has a very high incidence rate among people aged more than 60. Men are more likely to be affected by it, than women. Progression of this disease is slow.  If the disease has affected the B-cells, then life expectancy can be anywhere between 10 to 20 years, if treatment begins early. However, those with T cell chronic lymphocytic leukemia have a very low life expectancy. ACUTE LYMPHOCYTIC LEUKEMIA The most common form of cancer in children is acute lymphocytic leukemia. One-fourth of all cancers in children belong to this type. It has a high incidence rate among adults, older than 45 years of age. Chemotherapy is the established treatment method for this disease. Before chemotherapy and other cancer cure methods were invented, a patient with acute lymphocytic leukemia could survive for 4 months at the most. However, thanks to modern treatment methods, about 80% of the affected children are completely cured. Adults have been seen to have a 40% chance of complete cure. The prognosis for this type will vary, depending on the stage of disease progression, but children in the age group of 3 to 7 seem to have the highest chance of complete recovery. DIAGNOSTICS: Physical exam. Your doctor will look for physical signs of leukemia, such as pale skin from anemia and swelling of your lymph nodes, liver and spleen. Blood tests. By looking at a sample of your blood, your doctor can determine if you have abnormal levels of white blood cells or platelets, which may suggest leukemia. Bone marrow test. Your doctor may recommend a procedure to remove a sample of bone marrow from your hipbone. The sample is sent to a laboratory to look for leukemia cells. TREATMENT: Most treatment plans for acute lymphoblastic leukemia have 3 steps. These are induction, consolidation, and maintenance. Induction Therapy: Killing of leukemia cells in the blood and bone marrow. Treatments include chemotherapy. Induction usually lasts for 4 weeks. Consolidation Therapy: Killing of leukemia cells that may be present even though they don’t show up in tests. If these cells are not killed, they could regrow and could cause a relapse. Treatment include chemotherapy and may include stem cell transplant (replacement of damaged bone marrow cells with healthy ones). Maintenance Therapy: Preventing any remaining leukemia cells from growing by using low doses of chemotherapy and intravenous treatment (the infusion of liquid substances directly into a vein). B. LYMPHOMAS Pediatric lymphomas are the third most common group of malignancies in children and adolescents. The lymphomas, a group of neoplastic diseases that arise from the lymphoid and hematopoietic systems, are divided into Hodgkin lymphoma (HL) and non-Hodgkin lymphoma (NHL). These diseases are further subdivided according to tissue type and extent of disease. Whereas NHL is more prevalent in children younger than 14 years of age, HL is prevalent in adolescence and the young adult period, with a striking increase between ages 15 and 19 years. Hodgkin Lymphoma Hodgkin lymphoma is a neoplastic disease that originates in the lymphoid system and primarily involves the lymph nodes. It predictably metastasizes to non-nodal or extralymphatic sites, especially the spleen, liver, bone marrow, and lungs, although no tissue is exempt from involvement. It is classified according to four histologic types: (1) lymphocytic predominance, (2) nodular sclerosis, (3) mixed cellularity, and (4) lymphocytic depletion. Accurate staging of the extent of disease is the basis for treatment protocols and expected prognoses. Asymptomatic enlarged cervical or supraclavicular lymphadenopathy is the most common presentation of HL. Other systemic symptoms may be manifested, including cough, abdominal discomfort, and anorexia. Because multiple organs may be involved, diagnosis is based on several tests and the extent of metastatic disease. Tests include a CBC, erythrocyte sedimentation rate, serum copper, ferritin level, fibrinogen, immunoglobulins, uric acid level, liver function tests, T-cell function studies, and urinalysis. Radiographic tests include chest radiography and computed tomography (CT) of the neck and chest; CT and magnetic resonance imaging of the abdomen and pelvis; and positron emission tomography (PET), which is replacing the gallium scan and bone scan to identify metastatic disease. A lymph node biopsy is essential to establish histologic diagnosis and staging. The presence of Reed-Sternberg cells is characteristic of HL. These large cells, which are multilobed and nucleated with abundant cytoplasm and a typically halolike clear zone around the nucleolus, are often described as having an “owl’s eyes” appearance (Metzger, Krasin, Hudson, and others, 2011). A bone marrow aspiration and biopsy is usually performed in patients with advanced disease, B symptoms, or disease recurrence (Metzger, Krasin, Hudson, and others, 2011). With the advent of CT and PET scans to identify metastatic disease and multiagent therapy to eradicate metastatic disease, surgical staging involving a laparotomy with splenectomy is no longer performed. The primary modalities of therapy are radiation and chemotherapy. Each may be used alone or in combination based on the clinical staging. Radiation may involve only the involved field (IF), an extended field (EF) (involved areas plus adjacent nodes), or total nodal irradiation (TNI), depending on the extent of involvement. Prognosis. Long-term survival for all stages of HL is excellent. The goal for pediatric HL’s curative treatment is to provide minimal morbidity with the highest quality of life (Metzger, Krasin, Hudson, and others, 2011). Nursing Care Management. Nursing care involves the same objectives as for patients with other types of cancer, specifically: (1) preparation for diagnostic and operative procedures, (2) explanation of treatment side effects, and (3) child and family support. Because this is most often a disease of adolescents and young adults, the nurse must have an appreciation of their psychologic needs and reactions during the diagnostic and treatment phases. Non-Hodgkin Lymphoma Non-Hodgkin lymphoma occurs more frequently in children than HL. Histologic classification of childhood NHL is strikingly different from that of HL, as demonstrated in the following statements: The disease is usually diffuse rather than nodular. The cell type is either undifferentiated or poorly differentiated. Dissemination occurs early, more often, and rapidly. Mediastinal involvement and invasion of meninges are common. NHL exhibits a variety of morphologic, cytochemical, and immunologic features, similar to the diversity seen in leukemia. Classification is based on the histologic pattern: (1) lymphoblastic, (2) Burkitt or non-Burkitt, or (3) large cell. Immunologically, these cells are also classified as T cells; B cells; or non-T, non-B cells (lacking immunologic properties). The clinical staging system used in HL is of little value in NHL, although it has been modified, and other systems have been developed. Diagnostic Evaluation. Because the clinical presentation of most children with NHL is widespread disseminated disease, thorough pathologic staging is unnecessary. Clinical manifestations depend on the anatomic site and extent of involvement. These manifestations include many of those seen in Hodgkin disease and leukemia, as well as organ symptoms related to pressure from enlargement of adjacent lymph nodes, such as intestinal or airway obstruction, cranial nerve palsies, and spinal paralysis. Recommendations for staging include a surgical biopsy of an enlarged node, histopathologic confirmation of disease with cytochemical and immunologic evaluation, bone marrow examination, radiographic studies (especially tomograms of the lungs and GI organs), and lumbar puncture. Therapeutic Management. The treatment protocols for NHL include aggressive use of irradiation and chemotherapy. Similar to leukemic therapy, the protocols include induction, consolidation, and maintenance phases, some with intrathecal chemotherapy. Several antineoplastic agents used in the treatment of NHL include vincristine, prednisone, L-asparaginase, methotrexate, 6-mercaptopurine, cytarabine, cyclophosphamide, anthracyclines, and teniposide or etoposide. Chemotherapy is the main component of treatment for NHL in children (Gross and Perkins, 2011). Prognosis. The prognosis is excellent for children with NHL. In developed countries, more than 80% of children with NHL are now cured with modern therapy, even patients with widely disseminated disease (Gross and Perkins, 2011). C. WILMS TUMOR Wilms tumor, or nephroblastoma, is the most common malignant renal and intra-abdominal tumor of childhood. The incidence is estimated to be 8.0 cases per million children. Approximately 500 new cases are diagnosed each year in the United States, with 6% involving both kidneys (Cendren and Gomez, 2010).Wilms tumor occurs about three times more often in African Americans than in East Asians in the United States. The peak age at diagnosis is approximately 3 years, and occurrence is slightly more frequent in boys than in girls. The majority of patients with Wilms tumor are diagnosed at younger than 5 years of age, with 1% to 2.5% having a familial origin. Unfortunately, there is no method of identifying gene carriers at this time. CLINICAL MANEFESTATIONS: Abdominal swelling or mass: Firm Nontender Confined to one side Hematuria (less than one fourth of cases) Fatigue and malaise Hypertension (occasionally) Weight loss Fever Manifestations resulting from compression of tumor mass Secondary metabolic alterations from tumor or metastasis If metastasis, symptoms of lung involvement:  Dyspnea Cough Shortness of breath Chest pain (sometimes) Diagnostic Evaluation. In a child suspected of having Wilms tumor, special emphasis is placed on the history and physical examination for the presence of congenital anomalies, a family history of cancer, and signs of malignancy (e.g., weight loss, size of liver and spleen, indications of anemia, lymphadenopathy). Most children with Wilms tumor are brought to the practitioner because of abdominal swelling or an abdominal mass. Specific tests include radiographic studies, including abdominal ultrasonography and abdominal and chest computed tomography scan; hematologic studies; biochemical studies; and urinalysis. Studies to demonstrate the relationship of the tumor to the ipsilateral kidney and the presence of a normal, functioning kidney on the contralateral side are essential. If a large tumor is present, an inferior venacavogram is necessary to demonstrate possible tumor involvement adjacent to the vena cava. A bone marrow aspiration may be performed to rule out metastasis, which is rare in children with Wilms tumor. STAGING OF WILMS TUMOR Stage I—Tumor is limited to kidney and completely resected. Stage II—Tumor extends beyond kidney but is completely resected. Stage III—Residual nonhematogenous tumor is confined to abdomen. Stage IV—Hematogenous metastases; deposits are beyond stage III, namely, to lung, liver, bone, and brain. Stage V—Bilateral renal involvement is present at diagnosis Therapeutic Management. Combined treatment with surgery and chemotherapy with or without radiation is based on the histologic pattern and clinical stage Nursing Care Management. Nursing care of the child with Wilms tumor is similar to that of children with other cancers treated with surgery, irradiation, and chemotherapy. However, there are some significant differences; these are discussed for each phase of nursing intervention D. BRAIN TUMORS Brain tumors are the most common solid tumor in children and are the second most common childhood cancer. In children, the use of reference terms benign or malignant is generally avoided because any tumor, despite its nature, can be fatal or associated with significant morbidities in the developing brain of a child. Diagnostic Evaluation. The signs and symptoms of brain tumors are directly related to their anatomic location and size and, to some extent, the child’s age. Diagnosis of a brain tumor is based subjectively on presenting clinical signs, objectively on neurologic tests, along with surgical confirmation of the histologic diagnosis. A number of tests may be used in the neurologic evaluation, but the most common diagnostic procedure is MRI, which determines the location and extent of the tumor. Other tests that may be used include CT, angiography, EEG, and lumbar puncture. CT or MRI is routinely performed before a lumbar puncture procedure to identify intracranial abnormalities that may cause a contraindication to the procedure (Lin and Safdieh, 2010). Lumbar puncture is dangerous in the presence of increased ICP because of the possibility of brainstem herniation after a sudden release of pressure. The definitive diagnosis of a brain tumor is based on brain tissue specimens obtained during surgery. Therapeutic Management. Treatment may involve the use of surgery, radiotherapy, and chemotherapy or a combination of these treatment modalities. The optimum treatment is complete surgical resection of the primary tumor with preservation of adequate neurologic function. Radiation therapy is an integral part of treatment for many brain tumors but can cause significant neurocognitive side effects as well as endocrinopathies. Because rapid brain development occurs during the first 3 years of life, radiation therapy, particularly craniospinal radiation, is avoided in children younger than 3 years of age. Chemotherapy may be used as primary treatment or in an effort to delay radiation therapy until patients are older and may experience fewer neurocognitive side effects Nursing Care Management. If a brain tumor is suspected in a child admitted to the hospital for cerebral dysfunction, establishing baseline data with which to compare preoperative and postoperative changes is an essential step. It also allows the nurse to assess the degree of physical incapacity and the family’s emotional reaction to the diagnosis. Vital signs, including blood pressure and pulse pressure (the difference between systolic and diastolic pressures), are taken routinely and more often when any change is noted. Any sudden variations are reported immediately. Observation for symptoms of Cushing triad—a hallmark sign of increased ICP, which includes bradycardia, hypertension, and irregular respirations—is a crucial role of the nurse. It is also important to note a change in vital signs during or after diagnostic procedures. A routine neurologic assessment is performed at the same time as vital signs, and head circumference should be measured for infants and very young children. The child is observed for evidence of headache, vomiting, and any seizure activity. The location, severity, and duration of the headache are noted, as well as its relationship to activity, time of day, and any associated factors. Behaviors such as lying flat and facing away from light or refusing to engage in play are clues to discomfort in nonverbal children. The child’s gait is observed at least once daily. Head tilt while talking or performing an activity as well as other changes in posturing should always be documented. TREATMENT MODALITIES Aimed towards: – CURE - free of disease after treatment → normal life – Control - Goal for chronic cancers – Palliative Care: Quality of life maintained at highest level for the longest possible time Surgery – surgical removal of tumors; most commonly used treatment Preventive or prophylactic Diagnostic surgery Curative surgery Reconstructive surgery Palliative surgery Chemotherapy – use of antineoplastic drugs to promote tumor cell death, by interfering with cellular functions and reproduction Radiotherapy – directing high-energy ionizing radiation to destroy malignant tumor cells without harming surrounding tissues Types: – Teletherapy (external): radiation delivered in uniform dose to tumor; Teletherapy is external beam irradiation and uses a device located at a distance from the patient. It produces X-rays of varying energies and is administered by machines a distance from the body 31½ to 39 inches (80 to 100 cm). – Brachytherapy: delivers high dose to tumor and less to other tissues; radiation source is placed in tumor or next to it; In brachytherapy, the radiation device is placed within or close to the target tissue. Radiation is delivered in a high dose to a small tissue volume with less radiation to adjacent normal tissue, but requires direct tumor access. Immunotherapy – use of chemical or microbial agents to induce mobilization of immune defenses. Biologic response modifiers (BRMs) – use of agents that alters immunologic relationship between tumor and host in a beneficial way Bone marrow peripheral stem cell transplantation – aspirating bone marrow cells from compatible donor and infusing them into the recipient Gene therapy – transfer of genetic materials into the client’s DNA NURSING MANAGEMENT 1. Promote measures that relieve pain and discomfort. Pharmacologic and non-pharmacologic interventions 2. Promote measures to maintain intact skin integrity 3. Promote measures that maintain oral mucosa 4. Promote measures to prevent injury from abnormal bleeding Monitor platelet count; avoid aspiring products, etc NURSING MANAGEMENT 1. Promote measures that identify and prevent infection Monitor WBC count; encourage frequent handwashing and overall cleanliness 2. Help decrease the client’s fatigue and increase his activity level 3. Promote measures that ensure adequate nutritional intake High protein, high calorie diet 4. Ensure adequate fluid and electrolyte balance NURSING MANAGEMENT 1. Promote measures to enhance body image. Take an honest gentle, caring approach; encourage client to express and verbalize feelings 2. Promote measures that address preventing complications of cancer therapy 3. Instruct client and family about the disease process and treatments; provide necessary information for self- care. 4. Help client and family cope effectively 5. Promote measures to reduce social isolation. Care of Clients Receiving Chemotherapy Classes of Chemotherapy Drugs: Alkylating agents: – Action: create defects in tumor DNA – Ex: Nitrogen Mustard, Cisplatin – Toxic Effects: reversible renal tubular necrosis Classes of Chemotherapy Drugs Antimetabolites: – Action: phase specific – Ex: Methotrexate; 5 fluorouracil – Toxic Effects: nausea, vomiting, stomatitis, diarrhea, alopecia, leukopenia Classes of Chemotherapy Drugs Antitumor Antibiotics: – Action: non- phase specific; interfere with DNA – Ex: Actinomycin D, Bleomycin, adriamycin (doxorubicin) – Toxic Effect: damage to cardiac muscle Miotic inhibitors: – Action: Prevent cell division during M phase of cell division – Ex: Vincristine, Vinblastine – Toxic Effects: affects neurotransmission, alopecia, bone marrow depression Hormones: – Action: stage specific G1 – Ex: Corticosteroids Hormone Antagonist: – Action: block hormones on hormone- binding tumors ie: breast, prostate, endometrium; cause tumor regression – Ex: Tamoxifen (breast); Flutamide (prostate) – Toxic Effects: altered secondary sex characteristics Effects of Chemotherapy Tissues: (fast growing) frequently affected Examples: mucous membranes, hair cells, bone marrow, specific organs with specific agents, reproductive organs (all are fetal toxic; impair ability to reproduce) Chemotherapy Administration Routes of administration: – Oral – Body cavity (intraperitoneal or intrapleural) – Intravenous Use of vascular access devices because of threat of extravasation (leakage into tissues) & long term therapy Types of vascular access devices: – PICC lines: (peripherally inserted central catheters) – Tunneled catheters: (Hickman, Groshong) – Surgically implanted ports: (accessed with 90o angle needle- Huber needles) NURSING CARE OF CLIENTS RECEIVING CHEMOTHERAPY Assess and manage: – Toxic effects of drugs (report to physician) –Side effects of drugs: manage nausea and vomiting, inflammation and ulceration of mucous membranes, hair loss, anorexia, nausea and vomiting with specific nursing and medical interventions  Monitor lab results (drugs withheld if blood counts seriously low); blood and blood product administration Assess for dehydration, oncologic emergencies Teach regarding fatigue, immunosuppression precautions Provide emotional and spiritual support to clients and families M. Hockenberry, D. Wilson (2013). Wong’s Essentials of Pediatric Nursing 9th Edition Devakumar (2019). Oxford Textbook of Global Health of Women, Newborns, Children, and Adolescents. PB Publishing. Hockenberry (2019). Wong’s Nursing Care of Infants and Children, 11th edition. Elsevier. Leifer (2019). Introduction to Maternity and Pediatric Nursing, 8 th edition. Elsevier. Murray (2019). Foundations of Maternal-Newborn and Women’s Health Nursing, 7th edition. Elsevier. Flagg (2018). Maternal and Child Health Nursing: Care of the Childbearing and Chilrearing Family. Wolters Kluwer 1. Create a summary table consisting of definition, etiology, manifestations, diagnosis, treatment and management for the following: (100pts) a. ALTERATIONS WITH INFECTIOUS, INFLAMMATORY AND IMMUNOLOGIC RESPONSES Juvenile Rheumatoid Arthritis Allergic Rhinitis Eczema Asthma b. CELLULAR ABERRATIONS Leukemia Lymphomas Wilms’ tumor Brain tumors