Module 5A: Responses To Malignancies In Children PDF

FAR EASTERN UNIVERSITY INSTITUTE OF HEALTH SCIENCES AND NURSING FIRST SEMESTER – AY 2024-205 NUR 1210 – NCM 109 CARE OF THE MOTHER AND CHILD AT RISK OR WITH PROBLEM Module 5A:...

FAR EASTERN UNIVERSITY INSTITUTE OF HEALTH SCIENCES AND NURSING FIRST SEMESTER – AY 2024-205 NUR 1210 – NCM 109 CARE OF THE MOTHER AND CHILD AT RISK OR WITH PROBLEM Module 5A: RESPONSES TO MALIGNANCIES IN CHILDREN INTRODUCTION The terms malignant and cancerous describe cells that are growing and proliferating in a disorderly, chaotic fashion. In adults, cancer usually occurs in the form of a solid tumor. In children, the most frequent type of cancer is that of immature white blood cell (WBC) overgrowth, or leukemia. Many parents assume that a diagnosis of cancer means their child’s life will be very limited. Because of the tremendous advances in cancer research and treatment over the past 20 years, however, the prognosis for children and the chances for a cure improve daily. Up to 95% of children with the most common form of leukemia, for example, can expect to be cured. To help both parents and children adjust to this serious illness, however, nursing support is necessary from the time of diagnosis throughout the long-term therapy required. Because decreasing the incidence of cancer is important to the nation, 2020 National Health Goals related to malignancies and children address this concern. LEARNING OUTCOMES After the successful completion of the module the student should be able to: 1. Integrate concepts, theories and principles of sciences and humanities in the formulation and application of appropriate care during childbearing and childrearing years. 2. Formulate with the client a plan of care to address needs/problems of at-risk/high risk mother and child 3. Implement safe and quality nursing interventions to address needs/problems of at-risk/high risk mother and child 4. Manage resources (human, physical, financial, time) efficiently and effectively 5. Use of appropriate technology to perform safe and efficient nursing activities 6. Customize nursing interventions based on Philippine culture and values 7. Conduct individual/group health education activities based on the priority learning needs of at-risk/high risk mother and child 8. Evaluate with the client the health outcomes of nurse-client working relationship 9. Document client’s responses/nursing care services and outcomes of nursing care rendered 10. Adhere to established norms of conduct based on the Philippine Nursing Law and other legal, regulatory, and institutional requirements relevant to safe nursing practice Prepared by MCN FEU Faculty Lecturers January  FAR EASTERN UNIVERSITY INSTITUTE OF HEALTH SCIENCES AND NURSING FIRST SEMESTER – AY 2024-205 NUR 1210 – NCM 109 CARE OF THE MOTHER AND CHILD AT RISK OR WITH PROBLEM TOPIC OUTLINE I. Cellular Aberrations A. Leukemia B. Osteogenesis Sarcoma C. Wilm’s tumor CONTENT NEOPLASIA All body tissue undergoes continuing growth to develop into and maintain that specific type of tissue. Normally, the body is able to balance the proliferation necessary to replace old cells that die plus produce new cells for physical growth needs. Cancerous, or malignant, tissue however, is unable to maintain this balance and begins to proliferate in disorderly, chaotic ways. The word neoplasm means “new growth,” although it is typically used to refer to a new abnormal growth that does not respond to normal growth-control mechanisms. Whether this process is one that produces a solid tumor or one that involves blood-forming elements, growth begins insidiously and usually has been happening for some time before the parents or child realize it is present. Even after they are aware a change exists some time may pass before they realize the few symptoms, they feel are serious enough to require health care. Although cancer in children is rare compared to unintentional injury or infection, it is a leading cause of death among children younger than 15 years of age. Fortunately, the overall survival rate for children with cancer today has improved. The overall 5-year survival rate is 83%, and for acute lymphoblastic leukemia (the most common form of childhood cancer). The 5-year survival rate is 90%. CELL GROWTH The normal cell cycle consists of two main divisions: an interphase (resting) phase and a mitosis (dividing) phase. The interphase has four separate stages GO, GI,, S, and G2. The time span of a cell’s life varies based on the type of tissue involved. The rate of the cycle is slowed or increased by outside stimuli, such as hypoxia, genetic and immunologic factors, and physical and chemical agents. Normally, an organ has some cells in both resting and active cells. Cells have the ability to recognize their own type, possibly by recognizing surface enzymes or glucose particles on cell membranes. As a result, cells of like type do not migrate away from each other but instead recognize and adhere to each other to form a solid mass. In contrast, neoplastic cells seem to lose this ability to adhere to one another (they are autonomous cells). The reason for this is not well documented but may be related to decreased calcium in the cell membrane or to an increased negative charge that repels other cells rather than bonds them together. Another feature of healthy cells is that they appear to be able to recognize when they are being Prepared by MCN FEU Faculty Lecturers January  FAR EASTERN UNIVERSITY INSTITUTE OF HEALTH SCIENCES AND NURSING FIRST SEMESTER – AY 2024-205 NUR 1210 – NCM 109 CARE OF THE MOTHER AND CHILD AT RISK OR WITH PROBLEM crowded for the space they must occupy and, at that point, are able to halt growth to reduce overcrowding. Neoplastic cells do not respond to this communication or cannot receive it, so, despite how crowded they become, they continue to grow. By the time a tumor mass is detected by palpation, it is probably about 30 times the size of its original aberrant cell. Phases of the Cell Cycle Phase Activity G Gap, or the phase between mitosis and synthesis G0 Cell at rest. Cells remain in this state until some stimulant, such as death of surrounding cells, triggers the cell to enter an active phase; it is difficult to destroy cells in this resting state. G1 Period until DNA stabilization is complete; it remains difficult to destroy cells in this phase S (synthesis) Period (6-8 hrs) during which DNA and chromosomes are duplicated or a cell readies itself for division into two daughter cells. G2 Cell doubling in size as preparations for dividing into two daughter cells; if protein synthesis can be stopped at this point so that the cell cannot reach a “critical mass,” mitosis (cell division) cannot take place. M (mitosis) Period of cell division into two like daughter cells NEOPLASTIC GROWTH Neoplasms are either benign (growth is limited) or malignant (cancerous or with unlimited growth). Even when a tumor is benign, however, it doesn’t mean it is completely harmless because it can cause damage by pressing on adjacent tissue. For example, brain tumor in children are often benign, but they may cause life-threatening neurologic complications by compressing other areas of the brain. CAUSES OF NEOPLASTIC GROWTH The exact origin of neoplastic growth is unknown, and any growth may actually involve more than one cause. As more and more evidence is compiled on the nature of genes, specific markers in tumor that apparently fail to suppress, or stimulate, cancer-causing genes are being identified: almost all childhood cancers have such markers or a genetic trigger or predisposition to cancer. In adults, tumors may grow because normal cell growth has been altered by environmental exposures, such as chronic exposure to chemical irritants or cigarette smoke. In adults, the skin, bladder, lungs, and intestines involve organs exposed to such outside influences and irritation and thus become common sites for abnormal growths. In children, in contrast, tumors most frequently occur in organs unexposed to the environment such as leukemia of the bone marrow, Prepared by MCN FEU Faculty Lecturers January  FAR EASTERN UNIVERSITY INSTITUTE OF HEALTH SCIENCES AND NURSING FIRST SEMESTER – AY 2024-205 NUR 1210 – NCM 109 CARE OF THE MOTHER AND CHILD AT RISK OR WITH PROBLEM nephroblastoma of the kidney (Wilm tumor), tumors of the brain, or neuroblastoma in the abdomen, and because many tumors occur in children younger than 5 years of age who haven’t had long-term exposure to environmental carcinogens, this cause of tumors is probably not a great influence in childhood cancer. Somatic mutation theory postulates that an accumulation of mutations in the cell is what ultimately results in the transformation to a neoplastic state. This theory explains why the growth of neoplastic cells is not reversible (the cells cannot return to a normal state because they are intrinsically changed at the genomic level) and why neoplasms occur in some people but not in others (both an intrinsic and extrinsic factor, or an inherited tendency and an environmental insult, must be present). It is difficult to document this process, however, because if there is a lengthy time span between these steps, the cause-and-effect relationship is difficult to trace and in general is more pertinent to adult cancers in which decades of time contribute the amount of potential mutations. In other cancers, oncogenic viruses (cancer-causing virus) such as HPV may be directly responsible for tumor growth. According to this viral theory, oncogenic viruses have the ability to change the structure of DNA or RNA in cells. C-type RNA viruses, for example, have been implicated in leukemia. The Epstein-Barr virus (EBV) is associated with Burkitt lymphoma. This theory is supported by the fact that an immunodeficient state appears to increase the risk for development of a neoplastic growth. In some children, because of their genetics, tumor suppressor cells may not be present, allowing abnormal growth stimulated by viruses to continue I. A. LEUKEMIA ♦ Is the distorted and uncontrolled proliferation of WBCs ♦ Is the most frequently occurring type of cancer in children. Risk Factors 1. Radiation (Atomic bomb explosions, radiation therapy as treatment for cancer & other conditions, diagnostic X-rays) Prepared by MCN FEU Faculty Lecturers January  FAR EASTERN UNIVERSITY INSTITUTE OF HEALTH SCIENCES AND NURSING FIRST SEMESTER – AY 2024-205 NUR 1210 – NCM 109 CARE OF THE MOTHER AND CHILD AT RISK OR WITH PROBLEM 2. Smoking 3. Exposure to benzene in the workplace (chemical industry), found in cigarette smoke and gasoline 4. Chemotherapy 5. Human T-cell leukemia virus type I (HTLV-I) 6. Viruses have also been linked to some forms of leukemia 7. Some people have a genetic predisposition towards developing leukemia. 8. Chromosomal abnormalities or certain other genetic conditions have a greater risk of leukemia. 9. Children born to mothers who use fertility drugs to induce ovulation are more than twice as likely to develop leukemia during their childhoods than other children. Pathophysiology of Leukemia Most blood cells develop from cells in the bone marrow called stem cells. Bone marrow is the soft material in the center of most bones. Stem cells mature into different kinds of blood cells. Leukemia, a group of cancers that usually begins in the bone marrow and results in high numbers or unrestricted proliferation if immature WBCs in the blood- forming tissues of the body. These white blood cells are not fully developed and are called blasts or leukemia cells. Leukemia, results from mutations in the DNA. Certain mutations can trigger leukemia by activating oncogenes or deactivating tumor suppressor genes, and thereby disrupting the regulation of cell death, differentiation or division. These mutations may occur spontaneously or as a result of exposure to radiation or carcinogenic substances. In lymphoblastic or lymphocytic leukemias, the cancerous change takes place in a type of marrow cell that normally goes on to form lymphocytes, which are infection-fighting immune system cells. Most lymphocytic leukemias involve a specific subtype of lymphocyte, the β cell. In myeloid or myelogenous leukemias, the cancerous change takes place in a type of marrow cell that normally goes on to form red blood cells, some other types of white cells, and platelets. ♦ Goal of therapy is complete cure, complete remission or absence of leukemia cells Forms of Leukemia: 1. Acute lymphoblastic leukemia (ALL) ♦ Malignant proliferation of lymphoblast (immature lymphocytes), thus, the production of RBCs and platelets decline. ♦ Most common among children 2 to 6 yrs old Children younger than 1 yo or older is not as good as in those between 2 and 10 years of age ♦ Incidence is slightly higher in boys than in girls Prepared by MCN FEU Faculty Lecturers January  FAR EASTERN UNIVERSITY INSTITUTE OF HEALTH SCIENCES AND NURSING FIRST SEMESTER – AY 2024-205 NUR 1210 – NCM 109 CARE OF THE MOTHER AND CHILD AT RISK OR WITH PROBLEM ♦ First symptom are those associated with decreased RBC production (anemia) such as pallor; low-grade fever, and lethargy. Low thrombocyte (platelet) count leads to petechiae and bleeding from oral mucous membranes and easy bruising on arms and legs. Spleen and liver begin to enlarge from infiltration of abnormal cells, abdominal pain, vomiting and anorexia occur. As abnormal lymphocytes invade the bone periosteum, child experiences bone and joint pain. CNS invasion leads to symptoms such as headache or unsteady gait. ♦ On PA,: painless, generalized swelling of lymph nodes is revealed. ♦ Bone marrow aspiration to determine type of leukemia, Lumbar puncture to assess CNS Involvement. Bone marrow aspiration – findings of 25% blast cell confirms the diagnosis. Site: illac crest ♦ Bone scan to assess bone involvement. ♦ Chest x-ray to detect mediastinal involvement ♦ Renal, liver & spleen scans to assess leukemic infiltrates. ♦ Lymph node Biopsy to diagnose certain types of leukemia ♦ Blood Chemistry tests to determine the degree of liver and kidney damage or the effects of chemotherapy on the patient. ♦ MRI of brain ♦ Ultrasound of kidneys, spleen, and liver ♦ CT scans of lymph nodes in the chest 2. Chronic lymphocytic leukemia (CLL) ♦ affects lymphoid cells and usually grows slowly. ♦ People diagnosed with the disease are over age 55. ♦ It almost never affects children. 3. Acute myelogenous leukemia (AML) ♦ Malignant disorder that involves the over proliferation of granulocytes (neutrophils, basophils, and eosinophils) ♦ Granulocytes grow so rapidly that they are forced out into the bloodstream while still in the blast stage: these immature cells are not able to carry out normal immune function and put the child at risk for infection. The over proliferation of granulocytes limits the production of RBCs and platelets. ♦ Often seen in adults and accounts for 20% of all childhood leukemias ♦ It is incurable, but there are many effective treatments. 4. Chronic myeloid leukemia (CML) ♦ affects myeloid cells and usually grows slowly at first; It mainly affects adults. Prepared by MCN FEU Faculty Lecturers January  FAR EASTERN UNIVERSITY INSTITUTE OF HEALTH SCIENCES AND NURSING FIRST SEMESTER – AY 2024-205 NUR 1210 – NCM 109 CARE OF THE MOTHER AND CHILD AT RISK OR WITH PROBLEM Nursing Diagnoses 1. Risk for infection related to non-functioning WBCs and Immunosuppressive effects of therapy 2. Risk for deficient fluid volume related to increased chance of hemorrhage from poor platelet production. 3. Pain related to invasion to leukocytes 4. Ineffective health maintenance related to long term therapy for leukemia. Therapeutic Management ♦ The goal of treatment is to destroy signs of leukemia in the body and make symptoms go away. This is called a remission and to prevent a relapse A. Watchful Waiting ♦ People with chronic lymphocytic leukemia who do not have symptoms may be able to put off having cancer treatment. By delaying treatment, they can avoid the side effects of treatment until they have symptoms. ♦ Regular checkups (such as every 3 months) then start treatment if symptoms occur. B. Chemotherapy ♦ Chemotherapy uses drugs to destroy leukemia cells either by killing the cells or by stopping them from dividing but the drug can also harm normal cells that divide rapidly Chemotherapy is delivered in several different ways: a. By mouth (as pills patient can swallow) b. Into a vein (IV) c. Through a catheter (a thin, flexible tube) ♦ The tube is placed in a large vein, often in the upper chest. A tube that stays in Place is useful for patients who need many IV treatments. The health care professional injects drugs into the catheter, rather than directly into a vein. This method avoids the need for many injections, which can cause discomfort and injure the veins and skin. d. Intrathecal chemotherapy ♦ used because many drugs given by IV or taken by mouth can't pass through the tightly packed blood vessel walls found in the brain and spinal cord. This network of blood vessels is known as the blood-brain barrier. Intrathecal chemotherapy is given in two ways: d.1. Into the spinal fluid: The doctor injects the drugs into the spinal fluid. Prepared by MCN FEU Faculty Lecturers January  FAR EASTERN UNIVERSITY INSTITUTE OF HEALTH SCIENCES AND NURSING FIRST SEMESTER – AY 2024-205 NUR 1210 – NCM 109 CARE OF THE MOTHER AND CHILD AT RISK OR WITH PROBLEM d.2. Under the scalp: Children and some adult patients receive chemotherapy through a special catheter called an Ommaya reservoir. The doctor places the catheter under the scalp. The doctor injects the drugs into the catheter. This method avoids the pain of injections into the spinal fluid. ♦ Chemotherapy is usually given in cycles. Each cycle has a treatment period followed by a rest period. There may be 1 week of chemotherapy followed by 3 weeks of rest. The 4 weeks make up one cycle. The rest period gives your body a chance to build new healthy cells. Side effects: a. Blood cells: When chemotherapy lowers the levels of healthy blood cells, you're more likely to get infections, bruise or bleed easily, and feel very weak and tired. b. Cells in hair roots: Chemotherapy may cause hair loss. If you lose your hair, it will grow back, but it may be somewhat different in color and texture. c. Cells that line the digestive tract: Chemotherapy can cause poor appetite, nausea and vomiting, diarrhea, or mouth and lip sores d. Sperm or egg cells: Some types of chemotherapy can cause infertility Children: Most children treated for leukemia appear to have normal fertility when they grow up. However, depending on the drugs and doses used and the age of the patient, some boys and girls may be infertile as adults. Adult men: Chemotherapy may damage sperm cells. Men may stop making sperm. Adult women: Chemotherapy may damage the ovaries (irregular menstrual periods or experience menopause such as hot flashes and vaginal dryness Combination Chemotherapy ♦ involves treating a patient with a number of different drugs simultaneously. The drugs differ in their mechanism and side-effects. The biggest advantage is minimizing the chances of resistance developing to any one agent. Also, the drugs can often be used at lower doses, reducing toxicity. ♦ Combined modality chemotherapy is the use of drugs with other cancer treatments, such as radiation therapy, surgery and/or hyperthermia therapy. Neoadjuvant Chemotherapy ♦ given prior to a local treatment such as surgery ♦ designed to shrink the primary tumor. ♦ also given to cancers with a high risk of micrometastatic disease. Prepared by MCN FEU Faculty Lecturers January  FAR EASTERN UNIVERSITY INSTITUTE OF HEALTH SCIENCES AND NURSING FIRST SEMESTER – AY 2024-205 NUR 1210 – NCM 109 CARE OF THE MOTHER AND CHILD AT RISK OR WITH PROBLEM Adjuvant Chemotherapy ♦ given after a local treatment (radiotherapy or surgery). ♦ can be used when there is little evidence of cancer present, but there is risk of recurrence. ♦ also useful in killing any cancerous cells that have spread to other parts of the body. Maintenance Chemotherapy ♦ a repeated low-dose treatment to prolong remission. ♦ Salvage chemotherapy or palliative chemotherapy ♦ given without curative intent, but simply to decrease tumor load and increase life expectancy The treatment of childhood ALL usually has 3 phases. 1. Induction therapy: This is the first phase of treatment. Its purpose is to kill the leukemia cells in the blood and bone marrow. ♦ Achieving a complete remission or absence of leukemia cells ♦ 3-6 weeks or 1 month ♦ The child receives a variety of chemotherapeutic agents to induce remission. 2. Sanctuary / Consolidation / Intensification therapy: ♦ This is the second phase of therapy. It begins once the leukemia is in remission. a. Preventing leukemia cells from invading or growing in the CNS b. Extended for 2-3 weeks during the phase of consolidation to combat involvement of the CNS & other vital organs. 3. Maintenance therapy: ♦ This is the third phase of treatment. Its purpose is to kill any remaining leukemia cells that may regrow and cause a relapse. ♦ Often the cancer treatments are given in lower doses than those used for induction and consolidation/intensification therapy. This is also called the continuation therapy phase. a. Administering delayed Intensive therapy b. Maintaining the original remission c. Administered for several years after diagnosis to sustain remission. ♦ Bone marrow biopsy and aspirates are done throughout all phases to see how well the leukemia is responding to treatment. C. Radiation therapy ♦ a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells or keep them from growing. Prepared by MCN FEU Faculty Lecturers January  FAR EASTERN UNIVERSITY INSTITUTE OF HEALTH SCIENCES AND NURSING FIRST SEMESTER – AY 2024-205 NUR 1210 – NCM 109 CARE OF THE MOTHER AND CHILD AT RISK OR WITH PROBLEM ♦ Radiation is aimed at the spleen, the brain, or other parts of the body where leukemia cells have collected. ♦ This type of therapy takes place 5 days a week for several weeks. The radiation treatments are given once or twice a day for a few days, usually before a stem cell transplant. There are two types of radiation therapy. a. External radiation therapy ♦ series of daily radiation exposures as patient is left alone in a room using a machine outside the body to send radiation toward the cancer. ♦ Keep skin dry, cornstarch is the only topical application allowed ♦ Avoid: strong sunlight; extremes of temperature; tight constricting clothing; strong alcohol mouthwash; fatigue; crowded places; Talcum and lotions b. Internal radiation therapy ♦ uses a radioactive substance (radium, indium, celsium) sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer. ♦ Unsealed Internal Radiation (radio-isotope/radionuclide) where source of radiation is given orally, intravenously or instilled in cavity Principles of Internal Radiation Therapy 1. Time – the shortest possible (not more than 30 minutes per shift) 2. Distance – as far as possible (can spend more time at distance of 20 feet) 3. Shielding – protection lead apron Disadvantages: 1. Radiation to the abdomen can cause nausea, vomiting, and diarrhea 2. The skin in the area being treated may become red, dry, and tender 3. Patient may lose hair in the treated area D. Cobalt Therapy ♦ A linear accelerator can be used to deliver cobalt therapy to larger tumors. ♦ Aims gamma rays at cancerous cells / malignant cells without destroying nearby healthy tissue. These rays attack cancer from several directions as cobalt ions deteriorate. Healthy cells harmed by cobalt therapy typically regenerate and return to normal. E. Stem Cell Transplant ♦ Allows treatment with high doses of drugs, radiation, or both. The high doses destroy Prepared by MCN FEU Faculty Lecturers January  FAR EASTERN UNIVERSITY INSTITUTE OF HEALTH SCIENCES AND NURSING FIRST SEMESTER – AY 2024-205 NUR 1210 – NCM 109 CARE OF THE MOTHER AND CHILD AT RISK OR WITH PROBLEM both leukemia cells and normal blood cells in the bone marrow. After high-dose chemotherapy, radiation therapy, or both healthy stem cells is delivered through a large vein. New blood cells develop from the transplanted stem cells. The new blood cells replace the ones that were destroyed by treatment. Stem cells may come from the patient or from a donor ♦ From you: An autologous stem cell transplant uses your own stem cells. Before you get the high-dose chemotherapy or radiation therapy, your stem cells are removed. The cells may be treated to kill any leukemia cells present. Your stem cells are frozen and stored. After you receive high-dose chemotherapy or radiation therapy, the stored stem cells are thawed and returned to you. ♦ From a family member or other unrelated donor: An allogeneic stem cell transplant uses healthy stem cells from a donor. Your brother, sister, or parent may be the donor. Sometimes the stem cells come from a donor who isn't related. Doctors use blood tests to learn how closely a donor's cells match your cells. ♦ From your identical twin: If you have an identical twin, a syngeneic stem cell transplant uses stem cells from your healthy twin. Stem cells come from a few sources. 1. From the blood (peripheral stem cell transplant) 2. From the bone marrow (bone marrow transplant) 3. Umbilical cord blood. Cord blood is taken from a newborn baby and stored in a freezer. (Umbilical cord blood transplant) ♦ After a stem cell transplant, you may stay in the hospital for several weeks or months. You'll be at risk for infections and bleeding because of the large doses of chemotherapy or radiation you received. In time, the transplanted stem cells will begin to produce healthy blood cells. Drug of Choice a. Vincristine –anti neoplastic b. Prednisone – anti inflammation c. L- Asparaginase – decrease the level of asparagine (an amino acid necessary for tumor growth) d. Doxorubicin – Anti neoplastic e. Methotrexate – Anti neoplastic f. Allopurinol – used to treat gout or kidney stones, and to decrease levels of uric acid During the treatment a high level of uric acid is excreted because so many cells are Prepared by MCN FEU Faculty Lecturers January  FAR EASTERN UNIVERSITY INSTITUTE OF HEALTH SCIENCES AND NURSING FIRST SEMESTER – AY 2024-205 NUR 1210 – NCM 109 CARE OF THE MOTHER AND CHILD AT RISK OR WITH PROBLEM destroyed by chemotherapy. This can lead to plugging of kidney glomeruli and loss of kidney function g. Keep child well hydrated – helps maintain safe uric acid excretion F. Targeted therapy ♦ a treatment that uses drugs or other substances that block the growth of leukemia cells to identify and block the action of an abnormal protein that stimulates the growth of leukemia cells without harming normal cells. ♦ Side effects include swelling, bloating, and sudden weight gain, anemia, nausea, vomiting, diarrhea, muscle cramps, or a rash. G. Biological Therapy ♦ Treatment that improves the body's natural defenses against the disease. ♦ Monoclonal antibody is given by IV infusion. This substance binds to the leukemia cells that kills the leukemia cells, others help the immune system destroy leukemia cells, while another kind slows the growth of leukemia cells ♦ Biological therapies commonly cause a rash or swelling where the drug is injected, headache, muscle aches, fever, or weakness. H. Nutrition and Physical Activity ♦ Right amount of calories to maintain a good weight ♦ Enough protein to keep up the strength ♦ Side effects of treatment (poor appetite, nausea, vomiting, or mouth sores) can make it hard to eat well. I. Walking, yoga, and other activities to keep patient strong and energized J. Exercise may reduce nausea and pain, help relieve stress Nursing Management 1. Monitor child for reactions to medications 2. Monitor for infections. 3. Monitor for hemorrhage. 4. Monitor for of complications. 5. Monitor for the concerns & anxiety about the diagnosis of cancer & its related treatments. 6. Monitor for emotional responses such as anger, denial & grief. 7. Monitor disruptions in family planning. Side Effects and Nursing Management 1. Nausea and vomiting Prepared by MCN FEU Faculty Lecturers January  FAR EASTERN UNIVERSITY INSTITUTE OF HEALTH SCIENCES AND NURSING FIRST SEMESTER – AY 2024-205 NUR 1210 – NCM 109 CARE OF THE MOTHER AND CHILD AT RISK OR WITH PROBLEM ♦ small frequent, high calorie, high potassium, high protein diet; foods should be easy to swallow; frequent mouth care; pleasant environment; or NGT, IV, hyper alimentation. 2. Stomatitis ♦ soft toothbrushes, frequent mouth care; oral salt mouth gargle, avoid commercial mouthwash that contain high alcohol; avoid hot drinks or food; bland foods is best. 3. Alopecia ♦ advise short hair before treatment; gentle combing, use wig or scarf when necessary; 4. Diarrhea ♦ low residue diet; increase fluids; avoid hot or cold drinks and food 5. Infections ♦ avoid uncontrolled crowds and sources of infection; balanced diet; skin care. ♦ Standard treatments involve chemotherapy and radiotherapy, bone marrow transplant I. B. OSTEOGENIC SARCOMA  a primary malignant tumour of the long bone involving rapidly growing bone tissue (mesenchymal-matrix forming cells). More commonly occur in boys characterized by the direct formation of immature bone or osteoid tissue by the tumour cells :  Osteosarcoma and in children who have had radiation for other malignancies as a later life effect.  Most common sites of occurrence are the distal femur, the proximal tibia and the proximal humerus  Osteogenic sarcoma  Metastasis is common due to high vascular system of bones. Metastasis common in the lungs, brain and other bone tissue Incidence of Osteogenic sarcoma  Most common primary malignant bone tumour  Vast majority are metastatic  More rarely Osteogenic sarcoma may arise in the soft tissue  Twice as common in males  More than 75% occur in patients younger than 20 years (with peaks at 10-14 for girls and 15-18 for boys) but a second smaller peak also occurs in the elderly Prepared by MCN FEU Faculty Lecturers January  FAR EASTERN UNIVERSITY INSTITUTE OF HEALTH SCIENCES AND NURSING FIRST SEMESTER – AY 2024-205 NUR 1210 – NCM 109 CARE OF THE MOTHER AND CHILD AT RISK OR WITH PROBLEM  Tends to occur in the: ♦ Shin (near the knee) = 19% ♦ Thigh (near the knee) = 42% ♦ Upper arm (near the shoulder) = 10% ♦ Skull and jaw = 8% ♦ Pelvis = 8% Predisposing Factors: 1. Rapid bone growth  Osteosarcoma usually develops from osteoblasts (the cells that make growing bone), it most commonly affects teens who are experiencing a growth spurt 2. Common in females 10-14 years 3. Twice as common in males between the ages of 15 – 18 years 4. Slightly higher incidence in blacks than in whites 5. Genetic predisposition  Bone dysplasias, including Paget disease, fibrous dysplasia, & retinoblastoma Precipitating Factors: 1. Radiation  especially post-radiotherapy for a solid organ tumour in childhood 2. Environmental factors a. Exposure to radiation b. Water fluoridation Clinical Manifestations 1. Patient limps 2. Muscle atrophy 3. Decreased joint range of motion 4. Pathologic fracture 5. Swelling or Mass (may be tender and warm, Increased skin vascularity over the mass) 6. Pain, particularly pain with activity 7. Dull aching unilateral bone pain for several months 8. Night pain may awaken patient from sleep 9. May be misdiagnosed associated with minor injury 10. Uncommon features  Fever  Weight loss  Night sweats  Lymphadenopathy Prepared by MCN FEU Faculty Lecturers January  FAR EASTERN UNIVERSITY INSTITUTE OF HEALTH SCIENCES AND NURSING FIRST SEMESTER – AY 2024-205 NUR 1210 – NCM 109 CARE OF THE MOTHER AND CHILD AT RISK OR WITH PROBLEM Diagnostic Examinations 1. X-rays  uses invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs onto film 2. Bone scans  a nuclear imaging method to evaluate any degenerative and/or arthritic changes in the joints  to detect bone diseases and tumors  to determine the cause of bone pain or inflammation  to rule out any infection or fractures 3. Magnetic resonance imaging (MRI)  uses a combination of large magnets, radiofrequencies, and a computer to produce detailed images of organs and structures within the body.  to rule out any associated abnormalities of the spinal cord and nerves 4. Computed tomography scan  a diagnostic imaging procedure that uses a combination of x-rays and computer technology to produce cross-sectional images (often called slices), both horizontally and vertically, of the body  shows detailed images of any part of the body, including the bones, muscles, fat, and organs Laboratory Examinations 1. Complete Blood Count (CBC)  a measurement of size, number, and maturity of different blood cells in a specific volume of blood 2. Blood tests (including blood chemistries) 3. Biopsy of the tumor The Enneking Staging System or Musculoskeletal Tumour Society Staging System: (Used for planning treatment) 1. Tumour grade (histologic grade of the tumor) I = low grade II = high grade 2. Tumour extension (anatomic location of the tumor) A = intraosseous involvement only B = intra- and extraossseous extension 3. Presence of distant metastases (III) Low-grade tumor, intracompartmental - I-A Prepared by MCN FEU Faculty Lecturers January  FAR EASTERN UNIVERSITY INSTITUTE OF HEALTH SCIENCES AND NURSING FIRST SEMESTER – AY 2024-205 NUR 1210 – NCM 109 CARE OF THE MOTHER AND CHILD AT RISK OR WITH PROBLEM Low-grade tumor, extracompartmental - I-B High-grade tumor, intracompartmental - II-A High-grade tumor, extracompartmental - II-B  Any tumor with evidence of metastasis - III Goal of Treatment 1. To slow, stop, or eliminate the cancer 2. Relieve symptoms and side Medical Management: 1. Chemotherapy  the use of medical drugs to kill cancer cells and shrink the cancer to minimize chances of the cancer coming back  may be given before (neoadjuvant) or after (adjuvant) surgery Common chemotherapy medicines include: a. Cisplatin d. Doxorubicin (Adriamycin) b. Cyclophosphamide (Cytoxan) e. High-dose methotrexate w/ Leucovorin c. Carboplatin (Paraplatin) f. Ifosfamide (Ifex) Short-term effects include: a. Anemia f. Liver damage b. Abnormal bleeding g. Bladder inflammation c. Kidney damage h. Increased risk of infection d. Risk for other cancers i. Heart and skin problems e. Hearing loss j. Menstrual irregularities 2. Radiation 3. Rehabilitation (Physical and Occupational therapy) 4. Psychosocial adapting 5. Antibiotics (to prevent and treat infections) 6. Continued follow-up care  to determine response to treatment, detect recurrent disease, and manage the side effects of treatment 7. Prosthesis fitting and training Surgical Management 1. Wide Resection  the entire malignant tumor has been surgically excised, and no microscopic evidence of tumor cells at the resection margins remains 2. Limb-Salvage/Sparing surgery  remove the tumor while saving the affected limb to preserve function Prepared by MCN FEU Faculty Lecturers January  FAR EASTERN UNIVERSITY INSTITUTE OF HEALTH SCIENCES AND NURSING FIRST SEMESTER – AY 2024-205 NUR 1210 – NCM 109 CARE OF THE MOTHER AND CHILD AT RISK OR WITH PROBLEM Complications: a. Infection c. Non-union b. Prosthetic loosening d. Local tumor recurrence 3. Rotationplasty  foot being turned around and reattached to allow the ankle joint to be used as a knee 4. Bone / Skin Grafts 5. Reconstructions 6. Amputation  usually takes at least 3 to 6 months until a young person learns to use a prosthetic leg or arm a. Autologous bone graft  bone from same individual  chin, iliac crest, fibula, ribs, mandible, skull b. Allograft (Prosthetic device)  from another human (Cadaver) 7. Physical therapy and rehabilitation for 6 to 12 months following surgery usually enable the child to walk initially with a walker or crutches and then without any assistive devices Early complications after surgery: a. Infection b. Slow healing of the surgical wound c. Metal prosthetic device or the bank bone may need to be replaced in the long term Late problems might include: a. Fracture of the bank bone b. Failure of the bank bone to heal to the child's bone (might require more surgery) Radiation therapy 1. Adjuvant chemotherapy  Postoperative chemotherapy  Mode of treatment is for about five weeks, different combination drugs are used for the treatment 2. Neo-adjuvant  Preoperative Chemotherapy  preferred especially when a limb sparing procedure is being contemplated Nursing Management Prepared by MCN FEU Faculty Lecturers January  FAR EASTERN UNIVERSITY INSTITUTE OF HEALTH SCIENCES AND NURSING FIRST SEMESTER – AY 2024-205 NUR 1210 – NCM 109 CARE OF THE MOTHER AND CHILD AT RISK OR WITH PROBLEM 1. Supportive environment 2. Comfort of client (Rest, proper ventilation, massage) 3. Fluids for hydration 4. Small frequent feeding and ice chips for nausea and vomiting 5. Balanced meal for anemia 6. Accurate Intake and output monitoring while on chemotherapy 7. Care of chemotherapeutic drugs 8. Diversional care 9. Spiritual care 10. Continued follow-up care 11. Teach patient how to use assistive devices safely and how to strengthen unaffected extremities 12. Monitor full cycles of chemotherapy 13. Monitor IV antibiotics, fever and neutropenia 14. Assist in passive ROM and consider some restrictions Complications  Pathologic fractures  Lung metastasis  Limb removal Prognosis 1. Recurrence of osteosarcoma in more than 90% of patients is located in the lung 2. A 5-year survival rate of 20% to 45% following complete resection of metastatic pulmonary lesions 3. 10% to 15% following complete resection of metastases in other sites 4. Survival rates of 60% to 80% are possible if it hasn't spread beyond the tumor, depending on the success of chemotherapy 5. Combined neoadjuvant treatment gives a cure rate of 60%–70% for patients with nonmetastatic osteosarcoma of the extremities and of about 30% for tumours of the axial skeleton 6. Osteosarcoma that has spread cannot always be treated as successfully 7. A child whose osteosarcoma is located in an arm or leg generally has a better prognosis than one whose disease involves the ribs, shoulder blades, spine, or pelvic bones 1. C. NEPHROBLASTOMA (WILMS’ TUMOR) Prepared by MCN FEU Faculty Lecturers January  FAR EASTERN UNIVERSITY INSTITUTE OF HEALTH SCIENCES AND NURSING FIRST SEMESTER – AY 2024-205 NUR 1210 – NCM 109 CARE OF THE MOTHER AND CHILD AT RISK OR WITH PROBLEM ♦ Nephroblastoma (nephro) kidney, blasto-bud, oma-tumor ♦ A malignant tumor that rises from the metanephric mesoderm cells of the upper pole of the kidney ♦ Most common intraabdominal and kidney tumor of childhood early life. ♦ a rare type of kidney cancer ♦ It causes a malignant tumor on one or both kidneys that rises from the metenephic mesoderm cells of the upper pole of the kidney; survival rate are greater than 90%. ♦ Metastatic spread by the bloodstream is most often to the lungs, regional lymph nodes, liver, bone, and, eventually, brain ♦ Discovered early in life (6 months to 5 years; peak at 3 to 4 years), although it apparently arises from an embryonic structure present in the child before birth ♦ Mass seemed to appear overnight because tumors can hemorrhage into themselves, doubling their size in a matter of hours Risk Factor: 1. People of African descent 2. Children between 3 to 3.5 years old 3. A genetic predisposition to Wilms' Tumor in individuals with aniridia (Lack of color in the iris) Clinical Manifestations: 1. Abnormally large abdomen 4. Abdominal pain 2. Blood in the urine 5. Nausea and vomiting 3. Fever for no reason 6. High blood pressure in some cases Diagnostic and Laboratory Procedures 1. CT scan or Ultra sound – reveals the primary tumor and any points of metastasis. 2. Kidney function studies – Assess function of the kidneys before surgery 3. Blood urea nitrogen 4. Bone surveys and Bone marrow aspirations – to rule out metastasis 5. Excisional biopsy – confirm histologic type Children’s Oncology Group (COG) Staging System ♦ used most often to describe the extent of spread of Wilms tumors. ♦ This system describes Wilm’s tumor stages using Roman numerals I through V Stage I (40% to 45%) ♦ Tumor was contained within one kidney and was completely removed by surgery Prepared by MCN FEU Faculty Lecturers January  FAR EASTERN UNIVERSITY INSTITUTE OF HEALTH SCIENCES AND NURSING FIRST SEMESTER – AY 2024-205 NUR 1210 – NCM 109 CARE OF THE MOTHER AND CHILD AT RISK OR WITH PROBLEM ♦ Tissue layer surrounding the kidney (the renal capsule) was not broken during surgery ♦ Cancer had not grown into blood vessels in or next to the kidney ♦ Tumor was not biopsied before surgery to remove it Stage II (20%) ♦ Tumor has grown beyond the kidney, either into nearby fatty tissue or into blood vessels in or near the kidney, but was completely removed by surgery without any apparent cancer left behind ♦ Lymph nodes do not contain cancer ♦ Tumor was not biopsied before surgery. Stage III (20% to 25%) ♦ Refers to Wilm’s tumors that may not have been completely removed. The cancer remaining after surgery is limited to the abdomen (belly). One or more of the following features may be present: a. Cancer has spread to lymph nodes (bean-sized collections of immune cells) in the abdomen or pelvis but not to more distant lymph nodes, such as those inside the chest. b. Cancer has invaded nearby vital structures so the surgeon could not remove it completely. c. Deposits of tumor (tumor implants) are found along the inner lining of the abdominal space. d. Cancer cells are found at the edge of the sample removed by surgery, indicating that some of the cancer still remains after surgery. e. Cancer cells “spilled” into the abdominal space before or during surgery. f. Tumor was removed in more than one piece – for example, the tumor was in the kidney and in the nearby adrenal gland, which was removed separately. g. A biopsy of the tumor was done before it was removed with surgery. Stage IV (10%) ♦ Cancer has spread through the blood to organs away from the kidneys such as the lungs, liver, brain, or bone, or to lymph nodes far away from the kidneys. Stage V (5%) ♦ Tumors are found in both kidneys at diagnosis. Therapeutic Management: Prepared by MCN FEU Faculty Lecturers January  FAR EASTERN UNIVERSITY INSTITUTE OF HEALTH SCIENCES AND NURSING FIRST SEMESTER – AY 2024-205 NUR 1210 – NCM 109 CARE OF THE MOTHER AND CHILD AT RISK OR WITH PROBLEM ♦ The Goal of treatment is to remove the primary (main) tumor even if the cancer has spread to distant parts of the body; The lungs are the most common site of metastasis The main types of treatment that can be used for Wilms tumor are: 1. Surgery ♦ The affected kidney & the mass are removed as soon as diagnosis has been confirmed 2. Chemotherapy ♦ Drug of choice are: a. Antinomycin D b. Vincristine c. Doxorubicin (Adriamycin) ♦ They have been proven to be effective especially if there are metastasis. ♦ Late effects may include: a. Reduced kidney function b. Heart or lung problems after receiving certain chemotherapy drugs or radiation therapy to these parts of the body c. Slowed or delayed growth and development d. Changes in sexual development and ability to have children (especially in girls) 3. Radiation Therapy 4. Biologic therapies to boost your body's own ability to fight cancer Nursing Care Management 1. All unnecessary handling of the abdomen are prohibited avoided as it can cause the disease to spread. 2. A sign “DO NOT palpate abdomen” must be placed on the chart’s cover and on the crib of the child. 3. The nurse monitors GI activity a. Bowel movements c. Vomiting b. Bowel sounds d. Distention 4. Offer play therapy to children to help them adjust from the surgery and hair loss. 5. Instruct to avoid contact sports or any other high- risk activity to prevent injury to the organ. 6. Prevent UTI with good hygiene, especially in girls 7. Prompt detection and treatment of any genitourinary signs and symptoms is mandatory. Prognosis 1. The overall 5-year survival is estimated to be approximately 90% 2. Early removal tends to promote positive outcomes Prepared by MCN FEU Faculty Lecturers January  FAR EASTERN UNIVERSITY INSTITUTE OF HEALTH SCIENCES AND NURSING FIRST SEMESTER – AY 2024-205 NUR 1210 – NCM 109 CARE OF THE MOTHER AND CHILD AT RISK OR WITH PROBLEM II. Nursing Process of a child with malignancy A. Assessment The symptoms of malignancy in children are often insidious and difficult to identify because headaches or pain at a particular body site can often be explained away by other factors, such as a sports injury or fatigue. Weight loss, however, is a symptom of some forms of childhood cancer, and unintentional weight loss is never normal in healthy children. Therefore, at every healthcare visit, plot and analyze a child’s height and weight carefully to document evidence of this important finding B. Nursing Diagnosis Nursing diagnoses established for the child with a malignancy address specific symptoms caused by the malignancy itself, side effects of therapy, or coping abilities of the child and family. Example include: Pain related to neoplastic process in bone Imbalanced nutrition , less than body requirements, related to mucositis from radiation therapy Risk for infection related to immunosuppressive effects of chemotherapy Disturbed body image related to loss of hair after radiation treatment or chemotherapy Compromised family coping, related to long-term chemotherapy regimen C. Outcome Identification and Planning When a neoplasm (abnormal growth that does not respond to normal growth-control mechanisms) is first diagnosed in their child, parents may be able to deal only with short-term outcomes and plans. They may concentrate on learning about the effect or toxic properties of a particular chemotherapeutic drug prescribed for their child, or they may ask how long the child’s surgical incision will be. Dealing with such specifics help them to control their anxiety because it prevents them from dealing with the overall picture or prognosis – that their child has a potentially life-threatening illness. Be certain the family has an overall picture of the treatment protocol. Explain measures they will need to take to make their child more comfortable during therapy such as not forcing food if their child is nauseated and playing games or reading stories while an intravenous chemotherapy agent is administered. Parents are usually eager for results of diagnostic tests. They may need support while waiting until all the findings have been assembled for an accurate assessment of staging and prognosis. Establishing a primary relationship with both the child and the parents is important so that, no matter how many hospitalizations are necessary, they know a support person is waiting to help them through this long-term illness. Be certain the child’s siblings are considered in planning care, because the treatment will be long-term, putting stress on the entire family. Parents can be expected to experience grief if they learn their child’s prognosis is poor and Prepared by MCN FEU Faculty Lecturers January  FAR EASTERN UNIVERSITY INSTITUTE OF HEALTH SCIENCES AND NURSING FIRST SEMESTER – AY 2024-205 NUR 1210 – NCM 109 CARE OF THE MOTHER AND CHILD AT RISK OR WITH PROBLEM move through stages of denial, anger, bargaining, depression, and, hopefully, acceptance. During planning, be certain to take into account their current stage of grief so planning can be successful. Organizations that may be helpful for referral are the Philippine Cancer Society, Inc. Amuma Cancer Support Group Foundation Inc.... Cancer Institute Foundation, Inc. Cancer Warriors Foundation. Philippine Society of Pediatric Oncology D. Implementation Nursing interventions for a child with cancer include supporting the child and parents from the time of diagnosis through procedures such as surgery, radiation therapy, chemotherapy, and continued health supervision. Increasingly, cancer treatment is offered on an ambulatory basis to keep hospitalization to a minimum, so many nursing interventions include teaching the parents how to give care or monitor for side effects while at home. Nursing play a critical role in ensuring that the parents are aware of signs and symptoms, and of steps to take, should the child develop emergent issues such as bleeding or fever while at home. Keep in mind that the stress of long-term treatment can put the child and family at risk for developmental or family coping problems. You can be a positive force in encouraging healthy adaptation to the demands of the child’s illness and in reassessing the situation periodically during therapy to be for certain the child is receiving appropriate stimulation for developmental growth. Providing comfort and alleviating pain are often primary concerns in oncology nursing. E. Outcome Evaluation Because cancer therapy includes long-term care, children need to be evaluated periodically to be certain projected outcomes are being met and are still current. Some examples indicating outcome achievement are: child keeps all appointments for chemotherapy treatments child maintains passing grades in school despite interruptions for therapy parents state they are able to keep anxiety at an acceptable level between clinic appointments Children with cancer need much of the same well-child maintenance care that all children do, with one exception. While they are undergoing chemotherapy, which causes a decreased immune response, they should not receive routine vaccines. The siblings in the home can receive all non-live vaccines and the entire family (including the child undergoing treatment) are encouraged to receive a yearly flu vaccine. Follow-up visits are usually anxiety filled for both the parents and the child. The child seems well, but parents may be apprehensive while a health care provider palpates the child’s abdomen or blood Prepared by MCN FEU Faculty Lecturers January  FAR EASTERN UNIVERSITY INSTITUTE OF HEALTH SCIENCES AND NURSING FIRST SEMESTER – AY 2024-205 NUR 1210 – NCM 109 CARE OF THE MOTHER AND CHILD AT RISK OR WITH PROBLEM specimens are obtained. Some parents may find the strain of returning for follow-up visits too great and miss appointments (not knowing seems better than to be told bad news). Such parents need help in understanding that initial remissions can be maintained and second remissions can be achieved so maintenance therapy must be continued. Because a child who is treated for cancer is at risk for developing long-term complications from therapy, they should have appropriate follow-up and screening according to the children’s oncology group guidelines. If a child dies, parents may feel a need to return to the healthcare agency for support. This provides an opportunity to evaluate their adjustment and refer to a social work professional if concerns are identified. Siblings should also be assessed by a provider to assure they are coping in a developmentally appropriately way with the death of a brother or sister. LEARNING RESOURCES: Silbert-Flagg, Pillitteri (2018). Maternal & child health nursing (8th ed) Philadelphia: Lippincott, Williams and Wilkins. Hockenberry/ Wilson/ Rodgers (2019). Wong’s nursing care of infants and children (2nd ed) Elsevier Singapore Prepared by MCN FEU Faculty Lecturers January