Nursing Management- Cancer In Children

Nursing Diagnosis Anxiety of parents related to learning of diagnosis Risk for Infection and hemorrhage related to bone marrow suppression caused by chemotherapy and disease Disturbed Body Image related to alopecia associated with chemotherapy Imbalanced Nutrition: Less Than Body Requirements related to anemia, anorexia, nausea, vomiting, and mucosal ulceration secondary to chemotherapy or radiation Acute Pain related to diagnostic procedures, progression of the disease, and adverse effects of treatment Activity Intolerance related to fatigue that results from the disease and treatment Anxiety of child related to hospitalization and diagnostic and treatment procedures

Decreasing Parental Anxiety

Be available to the parents when they want to discuss their feelings. Offer kindness, concern, consideration, and sincerity toward the child and parents; be a source of consolation.

Contact the family's clergyman or the hospital chaplain. Obtain the services of a social worker, as appropriate, to help the family use appropriate community resources.

Offer hope that therapy will be effective and will prolong life. Have parents speak with parents of a child currently on therapy. Encourage parents to participate in activities of daily living to help them feel a part of their child's care.

Assess family dynamics and coping mechanisms and plan interventions accordingly.

Help the parents to deal with anticipatory grief. Help the parents to deal with other family members, especially siblings and grandparents, and friends.

Encourage the parents to discuss concerns about limiting their child's activities, protecting child from infection, disciplining child, and having anxieties about the illness.

Facilitate communication with the clinic nurse or clinical specialist who may interact with the child during the entire course of illness

Preventing Infection

Monitor complete blood count (CBC) as ordered. Provide adequate hydration.

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Maintain parenteral fluid administration. Offer small amounts of oral fluids if tolerated.

Observe renal function carefully.

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Measure and record urine output. Check specific gravity.

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Observe the urine for evidence of gross bleeding. Use labsticks to determine if occult urinary bleeding is present.

Protect the child from infection sources.

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Never use a rectal thermometer or drugs or enemas when caring for a neutropenic patient.

Family, friends, personnel, and other patients who have infections should not visit or care for the child. Discuss care of siblings while child is on therapy.

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Do not place a child with an infection in the room with a child with leukemia. Good hand washing is the most important way to control infection.

Observe the child closely and be alert for signs of impending infection.
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Observe broken skin or mucous membrane for signs of infection. Report fever more than 101 F (38.3 C).

Assess central line site for redness or tenderness.

Administer growth factors, such as granulocyte colony-stimulating factor, to stimulate the production of neutrophils and to decrease the incidence of severe infections in the child after intense chemotherapy.

Administer I.V. antibiotics as ordered. Administer prophylaxis Record vital signs and report changes that may indicate hemorrhage, including:
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Tachycardia. Lowered blood pressure (BP). Pallor. Diaphoresis. Increasing anxiety and restlessness.

Observe for GI bleeding and Hematemesis Move and turn the child gently because hemarthrosis may occur and may cause pain.
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Handle the child in a gentle manner. Turn the child frequently to prevent pressure ulcers. Place the child in proper body alignment, in a comfortable position. Allow the child to be out of bed in a chair if this position is more comfortable.

Avoid I.M. injections if possible. Handle catheters and drainage and suction tubes carefully to prevent mucosal bleeding. Protect the child from injury by monitoring activities and environmental hazards. Be aware of emergency procedures for control of bleeding:
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Apply local pressure carefully so as not to interfere with clot formation. Administer packed RBCs and platelets as ordered.

Promoting Acceptance of Body Changes

Prepare the patient for potential changes in body image (alopecia, weight loss, muscle wasting) and help child cope with related feelings.

Engage Child Life therapist for medical play and support.

Contact the school nurse and teacher to help them prepare for the child's return to school. Discuss the bodily changes that have occurred and that may happen in the future.

Promoting Optimal Nutrition

Provide a highly nutritious diet as tolerated by the child.

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Determine the child's food likes and dislikes. Offer frequent, small meals. Offer high-calorie, high-protein supplemental feedings. Encourage the parents to assist at mealtime. Allow the child to eat with a group at a table if his condition allows. Avoid foods high in salt while child is taking steroids.

Give careful oral hygiene; the gums and mucous membranes of the mouth may bleed easily.
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Use a soft toothbrush. If the child's mouth is bleeding or painful, clean the teeth and mouth with a moistened cotton swab or sponge-tipped swab.

Use a nonirritating rinse for the mouth (no alcohol-containing mouthwash or hydrogen peroxide).

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Apply petroleum to dry, cracked lips. Assess for mucositis and provide appropriate mouth rinse.

Be alert for nausea and vomiting.

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Administer antiemetic drugs on a round-the-clock, regular schedule (eg, serotonin antagonist, Ativan, dexamethasone).

Become knowledgeable about chemotherapeutic agents and adjust antiemetic therapy for those drugs with delayed nausea and vomiting.

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Monitor strict intake and output. Maintain parental fluid administration and assess for signs of dehydration or overhydration.

Administer antiemetic drugs for patients who receive radiation to the chest, abdomen, pelvis, or craniospinal axis.

Suggest relaxation techniques or guided imagery for patients who experience anticipatory nausea and vomiting.

Relieving Pain

Position the child for comfort. Water beds and bean bag chairs are usually helpful. Administer drugs on a preventive schedule before pain becomes intense. Continuous infusion pumps for opioid administration are used.

Manipulate the environment as necessary to increase the child's comfort and to minimize unnecessary exertion.

Prepare the child for treatment and diagnostic procedures

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Use knowledge of growth and development to prepare the child for such procedures as bone marrow aspirations, spinal taps, blood transfusions, and chemotherapy.

Provide a means for talking about the experience. Play, storytelling, or roleplaying may be helpful.

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Convey to the child an acceptance of fears and anger. Use EMLA Cream for local anesthesia at spinal tap, injection, and bone marrow sites to decrease pain.

Administer conscious sedation before procedures and monitor pulse, BP, respirations, and pulse oximetry during and after procedures.

Conserving Energy

Assess the child's energy level and space needed activities accordingly. Allow the child to rest, if necessary.

Encourage the child to lie down and rest after such diagnostic procedures as bone marrow aspirations and spinal taps.

Reducing the Child's Anxiety

Provide for continuity of care. Encourage family-centered care Facilitate play activities for the child and use opportunities to communicate through play.

Maintain some discipline, placing calm limitations on unacceptable behavior. Provide appropriate diversional activities. Encourage independence and provide opportunities that allow the child to control his environment.

Explain the diagnosis and treatment in age-appropriate terms.

Community and Home Care Considerations

Begin to develop a home care plan before the child leaves the hospital. Communicate with health care provider, hospital nurses, family, and others familiar with the case to gather information about the child's illness, treatment plan, and specific needs in the home.

Arrange schedule for blood drawing and how results will be managed. Contact the child's school and arrange a meeting with the school nurse, principal, and appropriate teachers to explain child's diagnosis, treatment, and potential time away from school.

Discuss with patient the possibility of making a visit to the classroom; explain about cancer and the adverse effects of chemotherapy to facilitate school reentry.

Collaborate with primary care provider regarding immunization schedule and the contraindication for children on immunosuppressive therapy who receive live vaccines.

Make sure that parents or caregivers can demonstrate the proper technique for care of venous access, such as dressing changes, flushing, and assessing for infection.

Family Education and Health Maintenance

Teach parents about normal CBC values and expected variations caused by therapy. Instruct parents about leukemia and adverse effects of chemotherapy. Tell parents to call the health care provider if child has a fever more than 101 F (38.3 C), bleeding, signs of infections, and exposure to chickenpox if the child has not had it. Immunosuppressed children are in danger of developing disseminated varicella and may be treated prophylactically with varicella immune globulin.

Teach parents the importance of detecting and reporting fever in the child with leukemia. A fever over 101 F may indicate overwhelming infection and impending septic shock.

Teach preventive measures, such as hand washing and isolation from children with communicable diseases.

Reinforce that parents never use a rectal thermometer