Nursing Care Child with Leukaemia 1 (1).pdf

Nursing Care Child with Leukaemia Alice Ward CNF 2017 Karen Neary 2021 Haemaology Oncology Foundation Programme Coordinator Plan Specific care –  Tumour Lysis Syndrome  Hickman Catheter  Chemotherapy and Side effects  Nausea and Vomiting  Bone Marrow De...

Nursing Care Child with Leukaemia Alice Ward CNF 2017 Karen Neary 2021 Haemaology Oncology Foundation Programme Coordinator Plan Specific care –  Tumour Lysis Syndrome  Hickman Catheter  Chemotherapy and Side effects  Nausea and Vomiting  Bone Marrow Depression  Mucositis  Parent Education and Support  Leukaemia  Leukaemia is the malignant transformation and proliferation of haematopoetic cells.  A cancer of the blood and bone marrow  Most common childhood cancer accounting for approximately 1/3 of all cancers.  Tumour Lysis Syndrome  Tumour Lysis Syndrome is an Oncology Emergency  Describes the consequences of massive cell lysis, which can arise with tumours which have a large growth fraction and extreme sensitivity to chemotherapy (ALL / Lymphomas)  Lysis is the disintegration of a cell due to the breakdown of it’s membrane  Tumour Lysis can occur either spontaneously or in response to treatment  Massive cell lysis results in the rapid release of large amounts of intracellular electrolytes (potassium, phosphorous & nucleic acid) & chemicals into the bloodstream and surrounding tissues  The resultant metabolic imbalance can quickly lead to fatal renal, cardiac and neurologic complications  TLS is a potentially fatal metabolic complication that occurs in some cancers  Biochemical abnormalities  Hyperuricaemia from tumour cell destruction  Hyperphosphataemia lymphocytes rich in phosphorus / lysis  Hyperkalaemia results from rapid cell lysis  Hypocalcaemia results from hyperphosphatemia  Occurs within 12hrs – 72 hrs after initiation of cytotoxic therapy (but may occur prior to start of treatment)  Usually occurs only after the first treatment  Main complications due to urate precipitation in the renal tubules  Nursing Assessment  Identify those at risk of TLS  Patient assessment (Weight & Height, BP, PEWS, urinary output, uninalysis, neuro status) Assess for signs of :  Hyperkalaemia - Weakness, Muscle Cramps, GI symptoms, Cardiac Arrhythmias, Paraesthesia  Hyperphosphataemia - Oliguria or anuria, Elevated Urea & Creatinine  Hyperuricaemia - N & V , elevated uric acid level, lethargy, renal insufficiency  Hypocalcaemia – Increased cardiac neuromuscular irritability, confusion, twitching, seizures Pathophysiology https://coreem.net/core/tumor-lysis-syndrome Investigations  Urea, creatinine, uric acid (urate), LDH, albumin  Electrolytes including calcium and magnesium, potassium, phosphate  CXR to out rule mediastinal mass  Renal ultrasound if a child has an abdominal mass to rule out renal infiltration or obstructive uropathy. Children with the latter are at increased risk of renal failure and may require dialysis at an early stage.  Management  Prehydrate pre induction (3 L/M2/day) to decrease uric acid concentration to increase solubility of uric acid in urine  During induction - Accurate intake / output BP 4 hourly BD weight Bloods - U/E / Urate/ Creatinine/ FBC as appropriate ECG monitor if hyperkalemic / on Calcium Infusion Management of Complications  Fluid balance If diuresis inadequate and no evidence of obstruction give Lasix as stat dose  Hyperuricaemia Fasturec (Rasburicase) in NaCl over 30 minutes daily Converts uric acid to Allantoin, which is water soluable  Hypocalcaemia ( 1.8mmol/ L) Calcium infusion in NaCl as separate infusion (if symptomatic) Cardiac monitoring – stop infusion if bradycardia Management of Complications Hyperkalaemia (> 5.4mmol / L)  Stop KCl in fluids  Salbutemol infusion , ECG monitoring  Calcium Gluconate, to counteract cardiotoxic effects  Dialysis, if oliguria /anuria/ Serum k >6.5 mmol / L Usually accompanied by - Urate > 1000mmol / L Creatinine > 500 mmol / L Urea > 50 mmol / L Phosphate > 4 mmol / L Hyperleukocytosis  WCC > 100, 000, Associated with early morbidity  Intravascular accumulation of blast cells, occupy most /or all vascular lumen +/- fibrin deposition  Leads to - leucostasis - tissue ischaemia – haemorrhage  Cerebral – confusion, somnolance, coma, headache, visual disturbance, retinal haemorrhage, +/- papilloedema  Respiratory – respiratory distress, hypoxia +/- diffuse interstitial infiltrates Hyperleucocytosis What is a Hickman Catheter?  CVAD - Central Venous Access Device  Silicone, radiopaque  Inserted under GA What is a Hickman Catheter?  TunneIled under the skin of the chest wall and inserted into the right atrium of the heart via the Internal / external Jugular vein  Dacron cuff- allows tissue to grow around it to anchor the line  Cuff also acts as a barrier to infection  Exit / entry site  Uses  Chemotherapy  Blood products/ Blood  Bone marrow transplant taking  Poor peripheral access  Intravenous antibiotics  Long term access  Intravenous fluids  TPN Types of Hickman Catheter  Single lumen- Wilms tumour (depends on stage)  Double lumen- ALL, AML, bone tumours, brain tumours and rhabdomyosarcoma.  Triple lumen- Neuroblastoma and all BMT patients. Catheter Care  Handwashing  Lines flushed once a week-  Change needlefree device Heparin sodium 10iu/ml- 2.5mls weekly  Use push-pause method for  Change dressing weekly or as flushing / positive pressure at required. last 0.5mls.  Aseptic technique  Clamp catheter over the  IV 3000 dressing/ Mepore reinforced clamping area dressing  Always ensure the line is looped. Complications  Infection – exit /entry/tunnel  Bleeding – needlefree device off / break  Occlusion  Splitting  Accidental removal  Thrombus  Ref – Supportive Care Guidelines OLCHC 2013  Chemotherapy  Routes of administration  Safe handling Personal protective equipment PPE administration / excreta  Side effects Drug specific Focus  Nausea and vomiting  Mucositis  Bone marrow depression Ref – Supportive Care Guidelines 2013 Medication Policy (OLCHC)Chapter 9 Chemotherapy Side Effects  Drug  Quality of life  Dose  Burden  Route of administration  Physical  Rate of administration  Psychological  Patient tolerance  Emotional  Short term  Psychosocial  Long term  Drug specific  Patient individual response  Nausea and Vomiting  Most adverse side effect  83% adults report nausea and vomiting  Significant problem for children  Often age related (less in young)  Incidence and severity related to emetogenic potential of drug  Anxiety and stress contribute  Anticipatory / Acute / Delayed vomiting Ref : Paediatric Cancer Handbook 2016 Supportive Care Guidelines 2013  Nausea and Vomiting  Potential to induce vomiting is a complex interaction between - the chemotherapeutic agent given - the dose - how it was administered - the child’s response (Gibson and Evans,1999)  Anticipatory Nausea/Vomiting - Complex  Results from stimulation received by the vomiting centre from the cerebral cortex and the limbic system  Classic conditioned response during which previously neutral stimuli provide the thoughts, images or reminders that become the stimulus to recall the previous experience  Physiology Higher cortical centres Chemoreceptor Trigger Zone Vomiting Centre (area prostrema, (medulla) 4th ventricle) Vomiting Reflex Labyrinths Stomach Small intestine Neuronal pathways  Anti Emetics  Goal is to minimise the direct effect of treatment  Antiemetic protocol related to emetic potential of chemotherapeutic agents administered  Combination of agents for different stimuli  Anti emetics block the pathway to the vomiting centre  Regular administration of antiemetic agents  Non pharmacological methods  Aim - facilitate the early recovery of the child If successful anti emetic therapy is achieved on first course then nausea and vomiting may be avoided subsequently  Antiemetic Action  5-HT3 receptor antagonist (Ondansetron) binds to type 3 serotonin receptor 5HT3in GIT / CNS  Corticosteroids (Dexamethazone) unknown, ? blocks prostoglandin  Benzodiazepam (Lorazepam) ? block cortical pathways to Vomiting Centre  Antihistamine (Phenergan) used for sedative effect  Aprepitant acts centrally. Give with other antiemetic medication  Special Notes No Dexamethazone for ALL / Lymphoma patients /Brain Tumour patients Ref – Paediatric Cancer Handbook 2019 Non Pharmacological Methods  Distraction  Avoid stimuli ie smells, food etc  Family education and support  Psychology/ play strategies  Prevention Easier to prevent emesis from occurring, than to control it once it has started Nursing Notes  Be aware of emetic potential of agents  Regular administration of antiemetics  No PRN prescriptions  Monitor child’s response  Be aware of side effects of antiemetic agents  Knowledge of onset and duration of emesis  Education re diet, fluids intake Nausea / Vomiting Complications  Complications -  Care –  Oesophagitis / gastritis  Education- parents / staff  Dehydration, electrolyte  Anti emetics imbalance  Electrolyte imbalance  Diminished appetite, taste  Fluid replacement alteration  Distraction -  Weight loss Play therapy  Anticipatory N/V Psychology  Bone Marrow Depression  Normally the bone marrow produces stem cells (immature cells) that develop into mature blood cells  In bone marrow depression stem cells in the bone marrow are damaged or destroyed  This results in neutropenia, thrombocytopenia and anaemia  Anaemia  Reduction in number of red blood cells RBC Signs / symptoms  Transport oxygen in Hb  Lifespan - 90-120 days  Fatigue  Rarely an acute problem  Pallor  Dizzyness Management  Headaches  Aim Hb 11-12g/dl  Tachycardia  Transfuse RCC Hb < 8  Tachypnoea Active bleeding  Dyspnoea Symptomatic  Formula Wt (kg) x 3 x desired Hb rise = amount mls  Thrombocytopenia  Platelet production suppressed  Lifespan – 8-11 days Signs / symptoms Management  Often asymptomatic  Monitor blood counts  Petechial rash  Transfuse if – active bleeding  Bruising plts < 10  Mucosal bleeding – gums, sepsis/rigors –keep >20 nose pre procedures  Prolonged menstruation  NB platelet reactions  Headache Ref - Blood Transfusion Guidelines OLCHC  Neutropenia  Reduction neutrophils (% WBC)  Absolute Neutrophil Count ANC