The Child with Cancer

Childhood Cancers
“…communication
promotes understanding
and clarity;
with understanding, fear
diminishes;
in the absence of fear,
hope emerges; and in the
presence of hope, anything
is possible” (Stovall, 1995)
Childhood Cancer
C- continual unexplained weight loss, fatigue malaise
H- headaches with vomiting (early morning)
I- increased edema or pain in joints
L- lump or mass, persistent lymphadenopathy
D- development of whitish appearance in pupil of the eye
R- recurrent or persistent fevers, night sweats
E- excessive bruising or bleeding
N- noticeable pallor
Childhood Cancer & Treatment
Chemotherapy
Surgery
Radiation
Stem Cell Transplantation
Steroid Therapy
Biologic Agents
Complementary and Alternative Medical (CAM)
Chemotherapy: Antinoeplastic agents
Titrated to specific formula- closely correlated with
cardiac output and blood flow to kidneys and liver
Highly specialized nurses- The Association of Pediatric
Hematology/Oncology Nurses
Administration routes:
Oral
Intravenously (large bore catheter)
Intramuscularly
Subcutaneously
Intrathecally
Chemotherapy:
side effects/ nursing interventions
Bone Marrow GI and GU Integumentary
Suppression Changes
Neutropenia Nausea/vomiting Hair loss
Anemia Stomatitis Hyperpigmentation
Thrombocytopenia Anorexia of skin
Renal damage Hypersensitivity to
sunlight
Chemotherapy
Nursing Interventions:
Protection of the patient:
Isolation- what specific type?
Exposure to sun, chemicals, skin irritants
Nutritional needs:
Prevent nausea & vomiting
Types of foods to meet metabolic requirements
Temperatures/textures/acid-base
Fluid balance
Intake and output
Integumentary
Self image
Chemotherapy
Nursing Interventions:
When administering chemotherapy, the nurse should
observe for an anaphylactic reaction for 20 minutes
and stop the medication if one is suspected.
Chemotherapy is associated with both general and
specific adverse effects, therefore close monitoring for
them is important.
Assessing for signs of infusion infiltration and
irritation
?? ! !
NCLEX Question
Which of the following statements is correct about
the rate of cell growth in relation to chemotherapy?
A. Faster growing cells are less susceptible to
chemotherapy.
B. Non-dividing cells are more susceptible to
chemotherapy
C. Faster growing cells are more susceptible to
chemotherapy
D. Slower growing cells are more susceptible to
chemotherapy
Radiation Therapy
Purpose
Palliative- prevent growth, reduce tumor size, pain relief
Eradicate or kill a tumor
Side effects similar to chemotherapy: Sub-acute & Late
Somulence syndrome
Fever
Irritability
Ataxia
Anorexia
Dysphasia
?? ! !
NCLEX Question
Nausea and vomiting are common
adverse effects of radiation and
chemotherapy. When should a nurse
administer antiemetics?
A. 30 minutes before the initiation of
therapy.
B. With the administration of therapy.
C. Immediately after nausea begins.
D. When therapy is completed
Surgical treatment for cancer
Purpose
Confirm diagnosis
Debulking or resecting
Removal of tumor as adjunct to chemotherapy/radiation
Nursing Interventions
How does the nurse prepare the patient for surgery?
What interventions apply specifically to the family?
Hematopoietic Stem Cell and
Bone Marrow Transplantation :
Conditioning- eradicate disease with high-dose
chemo/radiation therapy
Infusion- implantation of stem cells or bone marrow
Increase in patient’s WBC, RBC, and platelets signal
success!
Complications
GI disturbances
Graft-Versus-Host Disease (GVHD)
 Maintain patient on anti-rejection medications
 Prednisone

 Cyclosporine

 Tacrolimus
Graft-Versus-Host Disease (GVHD)
Potentially lethal immunologic response of donor T cells
against the tissue of the recipient.
Prevention: Careful tissue typing, irradiation of blood
products to inactivate mature T lymphocytes.
Signs & Symptoms
rash, malaise, high fever, diarrhea, liver and spleen
enlargement
Treatment
Maintain patient on anti-rejection medications
 Prednisone
 Cyclosporine
 Tacrolimus
Complementary /Alternative
Medical Therapies (CAM)
Risks-vs- benefits
Qualification of practitioner
Delay or interfere with conventional
treatment
Costs
Contraindications
?? ! !
NCLEX Question
Which of the following would be inappropriate
when administering chemotherapy to a child?
A. Monitoring the child for both general and
specific adverse effects
B. Observing the child for 10 minutes to note
for signs of anaphylaxis
C. Administering medication through a free-
flowing intravenous line
D. Assessing for signs of infusion infiltration
and irritation
Acute Lymphatic
Leukemia-
ALL
What signs and symptoms would lead to the
diagnosis of leukemia?
Fever
Pallor
Overt signs of bleeding
Lethargy or malaise
Anrexia
Large joint or bone pain
Petechiae, frank bleeding
Enlarged liver or spleen, changes in lymph nodes
Neurologic changes
Lab values for a diagnosis of
leukemia: examination of CBC with at
least 25% blasts confirm the diagnosis
Normal Leukemia
Leukocytes < 10,000 Leukocytes> 10,000
Platelets 20-100,000
Hemoglobin 7-11
Further diagnostic findings:
Bone marrow aspiration- iliac crest (why this
site?)
How does the nurse prepare the
child/family for this procedure?
What are the nurse responsibilities for this
procedure?
Treatment and Plan of Care: (p 1274-1280)
Chemotherapy: three phases
Induction phase
Consolidation
Delayed intensification
Remission and maintenance
Nursing Care for a Child Undergoing
Chemotherapy: review
Myelosupression- protect from injury
Infection/sepsis (neutropenia)- protect
from infection
Renal damage
GI disturbances
Metabolic emergencies
Intrathecal Medication
Chemotherapy instilled
into spinal canal
Assess and monitor for
placement of
intrathecal catheter
and assess neuro
checks
Treatment of Tumor Causing
Cancers
Cranial Radiation
Head and neck tumors are more
sensitive to radiation than
chemotherapy.
When would chemotherapy become
an adjunct to radiation therapy?
Tumor Lysis Syndrome:
What causes tumor lysis syndrome?
What are signs and symptoms of
this complications
What nursing interventions apply to
treatment?
Other Cancers of
Childhood
Clinical manifestations of Neuroblastoma
Smooth, hard, non-tender along sympathetic
nervous system
Frequent location is abdomen
Neck and facial edema from vena cava
syndrome
Increased ICP
Limp if metastasis to bone
Pancytopenia
Nursing Management
Assess by observation and inspection (not
palpation)
Document bowel and bladder function
Record height & weight, observe gait
Chemotherapy, radiation, surgery
Teach parents S&S of infection. Why?
?? ! !
NCLEX Question
Which of the following laboratory values is
expected for a client just diagnosed with
chronic lymphocytic leukemia?
A. Elevated sedimentation rate
B. Uncontrolled proliferation of
granulocytes
C. Thrombocytopenia and increased
lymphocytes
D. Elevated aspartate aminotransferase and
alanine aminotransferase levels
?? ! !
NCLEX Question
Which of the following foods
should a client with leukemia
avoid?
A. White bread
B. Carrot sticks
C. Stewed apples
D. Medium rare steak
?? ! !
NCLEX Question
A client with leukemia has
neutropenia. Which of the
following functions must be
frequently assessed?
A. Blood pressure
B. Bowel sounds
C. Heart sounds
D. Breath sounds
?? ! !
NCLEX Question
What are the three most important prognostic
factors in determining long-term survival for
children with acute leukemia?
A. Histologic type of disease, initial platelet
count, and type of treatment
B. Type of treatment and client’s sex
C. Histologic type of disease, initial WBC
count, and client’s age at diagnosis
D. Progression of illness, WBC at the time of
diagnosis, and client’s age at the time of
diagnosis.
?? ! !
NCLEX Question
Which of the following complications are
three main consequences of leukemia?
A. Bone deformities, spherocytosis, and
infection.
B. Anemia, infection, and bleeding
tendencies
C. Lymphocytopoiesis, growth delays, and
hirsutism
D. Polycythemia, decreased clotting time,
and infection
?? ! !
NCLEX Question
A child is seen in the pediatrician’s office
for complaints of bone and joint pain.
Which of the following other assessment
findings may suggest leukemia?
A. Abdominal pain
B. Increased activity level
C. Increased appetite
D. Petechiae
?? ! !
NCLEX Question
Which of the following immunizations
should not be given to a 4-month-old
sibling of a client with leukemia?
A. Diphtheria and tetanus and pertussis
(DPT) vaccine.
B. Hepatitis B vaccine
C. Haemophilus influenzae type b
vaccines (Hib)
D. Oral poliovirus vaccine (OPV)
?? ! !
NCLEX Question
Which of the following tests in
performed on a client with leukemia
before initiation of therapy to evaluate
the child’s ability to metabolize
chemotherapeutic agents?
A. Lumbar puncture
B. Liver function studies
C. Complete blood count (CBC)
D. Peripheral blood smear
?? ! !
NCLEX Question
Which of the following is the reason to
perform a spinal tap on a client newly
diagnosed with leukemia?
A. To rule out meningitis
B. To decrease intracranial pressure
C. To aid in classification of the leukemia
D. To assess for central nervous system
infiltration
Osteosarcoma
Osteosarcoma- most common
primary bone malignancy in children
Goal of treatment- remove tumor and prevent spread of
disease
Biopsy Chemo Surgery Chemo
(radiation=palliative pain control)
Promote self esteem
Side effects of chemotherapy
Amputation of extremity
Separation from friends and family
Ewing Sarcoma- second most common bone
tumor associated with children
Pain, soft tissue swelling
Anorexia, fever, malaise with metastasis
Diagnosis same as osteosarcoma
Management
Chemo
Surgery (decrease tumor bulk)
Radiation
Rhabdomyosarcoma
Pathophysiology and Manifestations
Most common soft tissue malignancy
Divided by young (<10 yrs) and older
(adolescents) in location
60% have positive prognosis
Soft to hard, nontender mass (depends
on location)
In pelvic tumors, may disrupt organ
function
Diagnosis and Treatment
CT, BM aspiration and biopsy
Renal function and liver function tests
Treated with chemo, surgery and
radiation
Nephroblastoma- Wilm’s Tumor
Soft renal tumor - one or both kidneys
Metastasis or seeding spread by palpation
Nephrectomy treatment of Wilm’s tumor
Nephroblastoma- Wilm’s Tumor
The most common sign of Wilms’ tumor is
a painless, palpable abdominal mass,
sometimes accompanied by an increase in
abdominal girth.
Microscopic hematuria may be present.
Nursing treatment of Wilms’ tumor:
Pain management
Frequent reposition
Noninvasive and pharmacologic pain interventions
Prevent circulatory overload
Weigh daily
I&O, urine for specific gravity
Prevent infection
Hand washing
Protective isolation
Homecare needs
?? ! !
NCLEX Question
A child is diagnosed with Wilms’
tumor. During assessment, the
nurse in charge expects to detect:
A. Gross hematuria
B. Dysuria
C. Nausea and vomiting
D. An abdominal mass
?? ! !
NCLEX Question
David, age 15 months, is recovering
from surgery to remove Wilms’
tumor. Which findings best indicates
that the child is free from pain? 
A. Decreased appetite
B. Increased heart rate
C. Decreased urine output
D. Increased interest in play
Retinoblastoma
Retinoblastoma- rare malignant tumor of the
neural retina
“cat’s eye” reflex seen as a white light in the
pupil is the most common “leukocoria”
May have strabismus of involved eye
Red painful eye is late symptom
Staging based on extent of disease
Nursing care of the child/family with a
malignant disease: (p905-915)
Initial focus on support of family members
Nurses facilitate the educational process to allay
fears of unknown
Encourage family members to verbalize fears and
questions
Postoperative care if indicated
Community resources (through the discharge
planner, case worker)
Death and Dying:
Understanding of death according to developmental age:
< 3 years- no understanding/concept of death
3-5 years- afraid of separation from parents
5-9 years- understand death is permanent, irreversible
and sad. Concerns for fear of pain, being left alone and
leaving parents and friends.
Age 10> have adult’s concept of death
Nursing Care and Grief
Child- encourage child to express
feelings, allow choices, help maintain
independence

Family- listen, answer questions, provide

information, encourage expression of
feelings and fears
Nursing Care for the Nurse
Providing physical and psychosocial support for the
patient and family places additional stressors on
the staff and nurses
 Caring for dying children and their families is
emotionally demanding.
Grief counseling plays an important role for both
family and staff
?? ! !
NCLEX Question
The community nurse is conducting a health
promotion program at a local school and is
discussing the risk factors associated with
cancer. Which of the following, if identified
by the client as a risk factor, indicates a need
for further instructions?
A. Viral factors
B. Stress
C. Low-fat and high-fiber diets
D. Exposure to radiation
?? ! !
NCLEX Question
The client with cancer is receiving
chemotherapy and develops
thrombocytopenia. The nurse identifies
which intervention as the highest priority
in the nursing plan of care?
A. Ambulation three times a day
B. Monitoring temperature
C. Monitoring the platelet count
D. Monitoring for pathological factors