Care of Children with Cancer PDF

Care of Children with Cancer Childhood Cancers Compared to Adult Cancers E E Etiologic Factors  Characteristics → birth weight, advanced parental age & congenital anomalies/cancer predi...

Care of Children with Cancer Childhood Cancers Compared to Adult Cancers E E Etiologic Factors  Characteristics → birth weight, advanced parental age & congenital anomalies/cancer predisposition syndromes  Intrinsic risk factors → genetic mutations/existence of familial cancer predisposition syndromes  Risk Factors associated with childhood cancers  Infections, radiation  Prevention Diagnostic Evaluation  Complete history & review of symptoms  Physical examination baseline  Laboratory tests ↑  Complete blood count (CBC), serum chemistries, liver function tests, coagulation studies & urinalysis  Diagnostic procedures →OLP, BMA  Diagnostic Imaging → MRI, CT, PET  Pathologic & Molecular Evaluation Treatment  Surgery kills  Need to consider tumor location and size, resulting effects, preservation of function/cosmetic result ano bon  Chemotherapy - > ↓  Different classes of drugs, protocol, Clinical trials need protective kells Fastgrowing : Cells ↓ kills  Effects normal and cancer cells hair - gear gl system Mouth anus > - can a Fast :  Nurses handling chemo agents - ↳oned lining  Radiation-conventional or proton beam  Hematopoietic Stem Cell Transplantation HSCT bone marrow - stem  Autologous, allogenic, GVHD ↓ RBC WBC pIt , , Cells *- Multi-model—surgery and chemo surgney first More than 1 > - chumo now ↳ x mode : in Hematopoietic mu Stem Cell Transplantation (HSCT) - > havent figured - out  Sibling donor protocols where what their job  Umbilical cord blood transplantation IS From umbicus :  Potential cure for patients with SCD  Difficult decision for HSCT transplant ⑪  Child may face death without the transplant  Preparing the child for transplant places the child at great risk  No “rescue” procedure if complications follow transplants Hematopoietic Stem Cell Transplantation (HSCT)  Hospitalized for several weeks → procedures/treatment chemotherapy/transplant/infection protocols  first up : discoloration of stin rus *  skin/GI/liver - Most common complication in allogenic transplantation → Graft versus host disease (GVHD) → prevention/treatment →  steroids/immunosuppressive therapy/irradiated blood  Skin breakdown & Complications Autologous Transplantation  Use the patient’s own marrow that was collected from disease-free tissue, frozen & may have been treated to remove malignant cells  Peripheral blood stem cell transplant (PBSCT) is also used in children with cancer → Colony stimulating factor (CSF) given prior to transplant  Apheresis → involves blood components removed from a patient, separated & then either returned to the bloodstream or replaced with donor blood products  Used for solid tumors Signs/Symptoms of Childhood Cancer * Headache  Anemia ↳ child can't show  Pallor ↳ through  Fatigue/Lethargy  Persistent headache-often w/vomiting play  Persistent vomiting  Unusual mass / swelling  Enlarged lymph nodes  Especially if “fixed and hard” (firm and non-mobile)  Loss of a developmental milestone-always a red flag  Prolonged, unexplained fever or illness Sudden eye or vision changes Unexplained, excessive, rapid weight loss Sudden tendency to bruise Abdominal Distention/Mass Skin changes – (changes in moles, etc..); rash – easy bruising * Fever/night sweats/pruritis (“B” symptoms)* Persistent localized pain/limping (usu leukemia, neuroblastoma, bone tumors) ↳ bone pain Chemotherapeutic Agents  Careful administration of Vesicants—sclerosing agents even in minute amounts  Interventions for extravasation (accidental administration of (vesicant)intravenous medication into surrounding tissue/structures)  Risk for- anaphylaxis * watch for burnt &  Have anaphylaxis “kit” on hand  Observe patient closely for one hour after administration of medicines (like L-Asparaginase)  Pre-medications if indicated Drug Toxicity  Nausea/vomiting--Ondansetron  Anorexia  Ototoxicity  Mucosal ulceration due to gi irritation *  Stomatitis- give sufficient liquids, try soft, blander foods, milkshakes or pudding; avoid citrus, sour, acidic or high-sugar foods; try to make food as appealing as you can, but try not to give their favorite foods so that they do not develop an - aversion to them. -  Neuropathy-may need to decrease dosages if severe  Hemorrhagic cystitis-fluids, bladder irrigation  - Alopecia  Mood changes > stenods Moon face :  Moon face !! - > Ability to fight ABOVE 1000 Major Risks of Cancer Treatment - ↳ immune # old  INFECTION (calculate ANC) says if its new or  BLEEDING ↳ bands ? fight  ORGAN DYSFUNCTION · 81 and calculation. pg10.   FUNCTIONAL ABNORMALITIES  PSYCHO-SOCIAL CONSEQUENCES of the malignant cells > lysis Acute Tumor Lysis Syndrome - - A potentially life-threatening effect of[ rapid tumor destruction by chemotherapeutic agents * - Metabolic abnormalities result from rapid release of intracellular contents during lysis of malignant cells: Hyperuricemia, hypocalcemia, hyperphosphatemia, hyperkalemia doe to need to excrcrete - Can lead to acute renal failure and death ATLS Risk Factors  Large tumor burden, sensitivity to chemotherapy, & high proliferative rate  High WBC at diagnosis  Clinical symptoms * flank pain, lethargy, nausea & vomiting, oliguria, pruritus, tetany & altered level of consciousness ATLS Management ↑ And  Early ID of patients at risk → prophylaxis & early interventions  Laboratory monitoring  I&O →administration of IV fluids  Medications →# allopurinol or recombinant urate oxidase or rasburicase -  Exchange transfusions ↳ viic and production Superior Vena Cava Syndrome (SVCS) :Tumor pressing on it  Can be caused by space occupying lesions in the chest → Hodgkin or NHL  2nd leading cause → thrombotic complications of implanted devices - #  Cyanosis of the face, neck, upper chest, facial/upper extremity edema, distended - - - neck & chest veins → anxiety, dyspnea, wheezing or frequent cough -  Airway protection/alleviation of respiratory distress Immunizations * No live vaccines - Do not want to give an immunization if the patient cannot mount and maintain an - immune response to it = - Patients should be=re-immunized after cessation of therapy redo vaccines  Schedules vary with disease type and treatment regimen  Post-BMT patients will need to wait longer to restart most immunizations - Avoid any LIVE vaccines—MMR, oral polio, varicella during chemotherapy and/or as long as immune system is compromised - - Siblings/parents can receive live vaccines Nursing Care  Child and family - educated on disease and treatment  Treatment administered on schedule with appropriate drug doses  Side effects of treatment managed  Treatment complications prevented  Child and family coping skills supported  Quality of life during treatment maintained  Child and family adjusted to chronic illness  Growth and development maintained during treatment  DON’T FORGET ABOUT SIBLING! Nursing Diagnoses  Risk for injury related to malignant process, treatments  Risk for deficient fluid volume related to nausea, vomiting  Altered nutrition  Impaired skin integrity  Altered family processes  Fear related to diagnosis, procedures, treatments  !!! need to know ?! O QUESTION - Chemotherapy dosage is frequently based on total body surface area (BSA), so it is important for the nurse to do which of the following before administering chemotherapy? O 1. Measure abdominal girth 2. Calculate BMI 3. Ask the client about his/her height and weight 4. Weigh and measure the client on the day of medication administration Common Types of Childhood Cancers  Blood  ALL--most common  AML  Lymphomas  Hodgkin disease  Non-Hodgkin lymphoma  CNS  Brain  Neuroblastoma  Bone  Osteosarcoma  Ewing  Wilms Tumor  Retinoblastoma  Rhabdomyosarcoma LEUKEMIA - > boys  There are two main types of white blood cells in your body: lymphoid cells (most common) and myeloid cells. Leukemia can happen in either type.  Peak onset between 2 & 3 years old  Occurs more often in boys than girls immate rapid WSC : 100 000 count !" ,  Risk factors  Prenatal exposure to x-rays 8  Previous treatment with chemotherapy  Certain genetic conditions  Immature cells predominate in acute leukemias  Liver & spleen most severely affected organs - Consequences of Leukemia * booe pain  Anemia from decreased RBCs (fatigue, shortness of breath, pallor) over clowed due to MBC  Infection from lack of or malfunctioning WBC with neutropenia and/or lymphopenia  Bleeding tendencies, easy bruising from decreased Plt production  Spleen, liver, and lymph glands show marked infiltration, enlargement, and fibrosis  Bone involvement-increasing crowding of bone marrow with leukemic cells causes pressure and bone pain Leukemia  Diagnostic evaluation  Based on history, physical manifestations  Peripheral blood smear  Immature leukocytes  Frequently low blood counts bad O-  LP to evaluate CNS involvement > pass blood-asf  Bone marrow aspiration or biopsy = : Inject Chemo to CSF  Therapeutic management  IV & intrathecal chemotherapeutic agents  Radiation (in some cases) Clinical Staging & Prognosis  Immunophenotyping is standard method  Chromosomal number & structural rearrangements → molecular genetic analysis  Prognostic factors →  Child’s age, WBC at time of diagnosis, CNS involvement, testicular involvement, Down syndrome, sex, race, ethnicity & nutritional status  Leukemic cell characteristics →ploidy & structural rearrangements → response to initial treatment & minimal residual disease (MRD) determination Younger-better thes do Iow NBC= does better  Four Phases of Therapy 1. Induction therapy—4-5 weeks 2. Consolidation (Intensification) therapy—to eradicate residual leukemic cells and prevent resistant leukemic clones (length avere varies) 3. Maintenance therapy—to preserve remission, 2-3 yrs 4. CNS prophylactic therapy—intrathecal chemotherapy (administered into the CSF), given periodically LYMPHOMAS  Lymphomas 10-15% of childhood cancer  Hodgkin lymphoma-lymph nodes closer to the surface (cervical, axillary, inguinal)  Non-Hodgkin lymphoma-lymph nodes deep inside the body Hodgkin Lymphoma  Most common in 15-19 yo  Malignant B lymphocytes  Lymph node biopsy for diagnosis and staging  EBV possible causative agent  Enlarged lymph nodes that are usually painless, firm and movable  Low grade, intermittent fever, anorexia, wt loss, night sweats  Presence of Reed-Sternberg cells is characteristic of Hodgkin’s disease Classifications of Hodgkin Lymphoma  Accurate staging is basis for treatment & prognosis  Lymphocytic predominance  Nodular sclerosis  Mixed cellularity  Lymphocytic depletion  Clinical staging & Prognosis  Stage A →asymptomatic  Stage B →temperature of 38° C, night sweats, weight loss of 10% or more over previous 6 months Management  Diagnostic Evaluation  Clinical manifestations of Hodgkin disease  Lymph node biopsy for diagnosis & staging  Therapeutic management  Radiation  Chemotherapy (alone or with radiation)  Goal of treatment  Nursing Care Management Non-Hodgkin’s Lymphoma (NHL)  Mutations in B and T lymphocytes  Prognosis depends on cell type and extent of involvement  Can have mediastinal involvement and invasion of meninges (CNS)  Clinical appearance  Disease usually diffuse rather than nodular  Dissemination occurs early, often, and rapidly CNS Tumors  Brain tumors & neuroblastoma are derived from neural tissue  Account for approximately 25% of childhood cancers  Tumors are difficult to treat, with poor survival rates Brain Tumors  Most common form of solid tumor  60% are infratentorial  Occur in the posterior third of the brain  Primarily in cerebellum or brainstem  Medulloblastoma, astrocytoma, ependymomas   40% are supratentorial  Occur in the anterior two thirds of the brain  Mainly in the cerebrum  Prognosis depends on location and extent Brain Tumors  Diagnostics  Signs and symptoms are related to anatomic location, size, and child’s age  Presenting clinical signs: headache, head circumference, vomiting, behavioral changes  Neurologic evaluation  MRI, CT, EEG, LP  Histologic diagnosis via surgery  Treatment-depends on type of tumor  surgery, chemo, radiation -> Avoid under Syr - Neuroblastoma 70% Metastasis hard to +y : = = X Find primary site  The most common malignant extracranial solid tumor of childhood  Majority of tumors develop in the adrenal gland or retroperitoneal sympathetic chain -  Other sites—head, neck, chest, pelvis  Metastasis may have already occurred before diagnosis in 70% cases  Signs/symptoms → depend on location & extent of disease  Diagnostics  locate the primary site and sites of metastasis, s/s depend on location and stage of the disease  Radiologic studies, bone marrow evaluation  Treatment  Surgery, radiation, chemo  HSCT teen age > OS - EWS males during early , , Bone Tumors , long bones> -  Rule out trauma or infection first  Definitive diagnosis based on radiologic studies (CT scans, bone scans) and bone biopsy  MRI to evaluate neurovascular and soft tissue extension  Labs—elevated alkaline phosphatase with some bone tumors  Osteosarcoma (OS) & Ewing sarcoma (EWS) account for 8% of all malignant neoplasms in children in the United States -  OS is the most common bone tumor in adolescents & young adults -  Occur more commonly in males, with highest incidence during accelerated growth rate of adolescence Osteogenic Sarcoma  The most frequent malignant bone tumor type in children  Peak incidence—10-25 yo, freq males [ -  Most primary tumor sites are long bones-proximal humerus, proximal tibia, distal femur (50%)I most times  Occurs in osseous tissue  Complications—metastasis toO - lungs check ligs Continuous - : replace piece  Treatment—chemo to shrink tumor, surgery, possible amputation of metal to grow with child - - Management  Therapeutic Management  Traditional approach →radical surgical resection or amputation of affected area  Limb-salvage procedures →resection of bone with prosthetic replacement of affected area  Chemotherapy accompanying surgical treatment  Nursing Care Management  Preoperative preparation is crucial  Support during adjustment to concept of amputation, surgical resection  Body image concerns →issues of adolescents  Pain management for - Phantom limb pain (usu 1st yr after amputation) very real : 17 year med give = Ewing Sarcoma  Second most common malignant bone tumor in children & adolescents; rare in age more ↳ than 30 years  Family of tumors ↓ 30yr , in marrow   Arises in the- marrow, especially in  Femur, tibia, ulna, humerus  Vertebrae, pelvis, scapula, ribs, skull  - Radiation most common first approach  Chemotherapy as adjunct to radiation -  Surgical resection in some cases →usually able to preserve affected limb  Prognosis best if no metastasis at time of diagnosis; distal lesions have best potential for cure Rhabdomyosarcoma  Malignant neoplasm originating from undifferentiated mesenchymal cells in muscle, tendon, bursa & fascia or in fibrous, connective, lymphatic, or vascular tissue  Name reflects tissue of origin  Myosarcoma (myo—muscle)  Rhabdomyosarcoma (rhabdo—striated muscle)  Common sites-head, neck, GU tract, extremities  Symptoms-based on location  Prognosis based on staging at diagnosis. Age 1-9 yo do best  Treatment—surgery, radiation, chemo - Wilms Tumor  Also called nephroblastoma  Malignant renal and intra-abdominal tumor of childhood  Typically seen less than 5 yo  More frequent in males  Presents with abd mass, firm nontender  Staging, surgical removal, chemo, poss radiation  Nursing considerations  Do NOT palpate abdomen Retinoblastoma  Congenital malignant tumor; arises from the retina  60% are nonhereditary & unilateral  15% are hereditary & unilateral  25% are hereditary & bilateral  Diagnostic Evaluation/Clinical Manifestations  Cat’s eye reflex →most common sign  Strabismus →second most common sign  Red, painful eye, often with glaucoma  Blindness →late sign Retinoblastoma Treatment Retino problem - Treatment based on stage of tumor at time of diagnosis  Therapeutic Management  Early stage unilateral  Irradiation, cryotherapy  Attempt to preserve useful vision in affected eye  Bilateral disease  Attempt to preserve useful vision in least affected eye  Advanced tumor  Enucleation  Chemotherapy →with metastasis  Prognosis  Concern with development of secondary neoplasms Childhood Cancer Survivor  Long-term sequelae of treatment  Psychosocial, cognitive, emotional, and physical development may be affected by treatment as well as by the disease  Specific effects of radiation therapy  Specific effects of chemotherapy → Some issues: Secondary cancers-especially if on long term immunosuppressant therapy; Heart /Lung/ Other Organ damage, Cataracts; Hearing Loss; Infertility; Alterations in growth and development; Impaired cognitive abilities and psycho-social abilities Palliative Care & End-of-Life Care  Palliative Care (supportive care) is specialized medical care that benefits those suffering from a chronic and/or terminal illness by placing priority on pain and symptom management to achieve optimal quality of life.  Pediatric palliative care is the holistic care of the child’s mind, body, and spirit beginning at diagnosis and continuing through the illness trajectory, whether or not the child receives curative therapy. Palliative vs. Hospice Care - Palliative care is NOT hospice care. - Hospice care is targeted end-of-life care, focusing on the quality of life rather than length, accepting death as the final stage of life. - Hospice care involves supportive care in the sense of symptom management but with an emphasis on the dying patient and the family. - Hospice may allow palliative care to be given along with potentially curative treatments. Communicating with Dying Child  Discuss at child’s level  Let child’s questions guide  Allow expression of feelings  Encourage feedback  Use other resources  Use different means of expression Meeting Dying Child’s Needs  Infant—love and trust  Toddler—familiarity and routine, sense parent reaction  Preschool—may see death as punishment for wrong doing  School age—concrete understanding  Adolescent—reinforce self-respect, self-worth, want to feel involved and listened to; less likely of all to accept cessation of life Dilemmas Caring for Terminally Ill  Relief of pain & other symptoms→ foundation of palliative care  Pain & symptom management  Clear communication of intent of any intervention  Understanding of family's views  Quality of life/Religious & cultural values/Level of acceptance  Holistic approach  Pharmacologic & non-pharmacologic  Consider route of medications/higher doses needed to achieve relief Family needs  Parental Empowerment  Emotional support-Assisting Family Members in Managing Their Feelings  Shock & Denial  Adjustment  Reintegration & Acknowledgement  Educational needs  Personal and physical care  Support System : Spiritual/religious support  Sibling support  Caregiver support Care at Time of Death  Physical changes  Increased sleeping, muscle weakness, loss of appetite, loss of sensation, mottling of skin, confusion/LOC, loss of bowel/bladder control, Cheyne-Stokes respiration, death rattle  Emotional changes  Experience visions  Family  Varied emotions  Care of the Family Experiencing Unexpected Childhood Death   Anticipatory Grief  Community-based follow up  Special Decisions at the Time of Dying & Death  Right to die/DNR  Viewing the body  Organ/tissue donation & autopsy  Sibling attendance at funeral services  Research focus → Children's Involvement in the Death Process  Family-Centered Care → Children Need to Say Good-Bye