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By Jeanie Ward
Iron Deficiency Anemia
Reduction in the number of RBC’s caused by: Decreased iron intake Blood loss Increased internal demands during
growth periods
Iron Deficiency Anemia
Manifestations: Pallor; Pale mucus membranes Enlarged spleen and heart Poor muscle tone with decreased activity Fatigue
Diagnosis low hemoglobin (<11g/100mL) Low hematocrit (<33%) RBC are small and hypochromic Serum iron levels are low ( 30μg/mL)
Iron Deficiency Anemia
Treatment Oral iron supplements Ascorbic acid (vitamin C) Diet high in iron
Iron-fortified formula or supplements Limit cow’s milk to 24oz/day for children
>12 months Increase age-appropriate iron-rich foods
Definition
A group of genetic disorders characterized by production of elongated, crescent shaped erythrocytes, or abnormal form of hemoglobin, designated as sickle hemoglobin (HbS) in the place of the normal hemoglobin.
Etiology and Pathophysiology
Autosomal recessive inherited disease
Occurs almost exclusively among African Americans
Defect of beta chain of hemoglobin
Disease usually not apparent until 6 months of age – fetal hemoglobin contains a gamma, not a beta chain. Hemoglobin changes from fetal form to adult of HgbA at that time.
Normal vs Sickle Hemoglobin
Disc-shaped Soft (like bag of
jelly) Easily flows
through small blood vessels
Lives for 120 days
Sickle-shaped Hard (like piece
of wood) Often get stuck
in small blood vessels
Lives for 20 days or less
Genetics
Both Parents Have Sickle Cell Trait
25% will have Sickle cell Disease
25% will be normal
50% will have the Trait
What causes the cell to sickle?
Low Oxygen tension (less than 60%-70%)
Low blood pH (acidosis)
Increased blood viscosity (dehydration, fever, hypoxia)
Result of Sickling ProcessThe sickled RBC’s do not move freely through
the microcirculation.
Blockage in vessel / blood flow halts
Tissue distal to the blockage becomes ischemic
Acute pain, cell destruction, tissue death
Assessment
General Manifestations Chronic anemia (Hgb. 6-9 g/dl.), pallor,
weakness. Unable to do physical activities because of lack of stamina
Fatigue, malaise Anorexia Jaundice Possible delayed sexual maturation Marked susceptibility to sepsis Possible growth retardation – with long
bones disproportionately long.
Types of Sickle Cell Crisis
Vaso-Occlusive Crisis
Occurs from the pooling of many of the new sickled cells in vessels with resulting tissue hypoxia
May last from one day to several weeks
Manifestations of Vaso-Occlusive Crisis
Bone Pain Most outstanding symptom Mainly in the bones of the extremities
and joints, but can occur anywhere Abdominal and back pain is common Related to necrosis of bone tissue Parents may notice this with refusal to
move an extremity, crying out with joint movement or joint touched.
Hand and foot SyndromeDactylitis
Painful swelling of the hands and /or feet.
May be the first symptom of crisis
Warmth in affected areas.
Fever
Cerebrovascular accident
Vaso-occlusion in the brain results in cerebral infarction which causes variable degreesof neurologic damage
Hemiplegia Aphasia Seizures Vision changes Headaches Alterations in level of consciousness
Acute Chest Syndrome Blockage of blood vesselsin the chest leads to Pneumonia and acute chest syndrome
Chest pains Fever, cough Dyspnea, retractions
Leading cause of death in SCD.
Priapism
Persistent painful erection of the penis occurring when penile blood flow is obstructed.
Hepatomegaly
Enlarged liver with jaundice and hepatic coma.
related to damage to the kidneys
Hematuria
Aplastic Crisis
Diminished RBC production resulting in severe anemia
Manifested by: Malaise, lethargy Headache Pallor fainting
Aplastic Crisis Profound anemia- low RBC
count is lifelong. The average RBC life is down to an average of 10-20 days in SCA.
Jaundice, elevated bilirubin Reticulocytosis Bone marrow producing 3-4
times more RBC’s than normal
Acute Sequestration Crisis
Sickled cells become trapped in the spleen obstructing blood flow with pooling and enlargement of the spleen.
Leads to shock and hypovolemia
Circulatory collapse and death can occur in less than 30 minutes
Spleen Function
Acts as a filter against foreign organisms that infect the bloodstream.
Filters out old RBC’s from the bloodstream and recycles them
Minor Role: Manufacturers RBC’s toward end of fetal
life and after birth, taken over by bone marrow.Acts as a blood reservoir.
Spleen in the Infant
Soft, purplish-red organ that lies under the diaphragm on the left side of the abdominal cavity
Filters old blood and clears bacteria
Teach Parents How to Measure Spleen
A tongue depressor can be used to measure and track spleen size
Place tip on left nipple and make mark where the spleen tip is felt
Treatment for Sequestration Crisis
Intravenous fluids
Blood transfusion
Spleen removal
Effects of Chronic Crisis States on the Child’s Body
Spleen – more susceptible to infection. Gradual fibrosis and scarring with reduction in spleen activity. Asplenia.
Liver – enlarged, firm, tender Brain – single episode of sickling CVA,
seizures Heart – enlarges and murmurs develop Lungs – pulmonary edema and stasis Kidneys – hematuria, unable to concentrate
urine Bone Infarcts – hands and feet swell.
Effects of Chronic Crisis States on the Child’s Body
Eyes – bleeds in retina.
Leg Ulcers Are seen in 10-15% of older
children May start as simple insect bite
or cut that does not heal With poor circulation develops
into leg ulcer Treated with dressings, leg
elevation and elastic stockings.
Diagnostic Tests
CBC – low hgb and hct
Hemoglobin electrophoresis – used to determine type of hemoglobin. When you pass an electric charge through a solution of hemoglobin, distinct hemoglobins move different distances, depending on their composition. This technique differentiates between normal hemoglobin (A), Sickle hemoglobin (S).
Goals in Care
The is NO CURE for the disease
Treat the Symptoms Relieve the pain
Provide oxygenation
Adequate hydration
Pain Management
Give analgesics as ordered Schedule nursing care to allow for
optimal rest Position joints with pillows Application of warmth Promote circulation through passive
ROM
Oxygenation
Assess Oxygen saturation- pulse oximetry. Should be 95% or >.
Administer Oxygen for short period of time to keep saturation levels up.
Bedrest to minimize energy expenditure and oxygen consumption
Administer blood transfusions
What are Complications associated with frequent blood
transfusions?
Allergic reaction
Circulatory overload
Iron Overload Give Desferal, an iron-chelating agent,
to decrease the iron levels
Oxygenation
Prevent infection, dehydration Avoid emotional stress, overfatigue Avoid prolonged exposure to heat
and cold Avoid low oxygen environment
Hydration/ Electrolyte Replacement
Encourage fluid intake, at least the minimum amount of fluid required daily for that child’s weight. (1-2x maintenance)
Record I & O. Monitor electrolyte balance Give parents written instructions on
specific amount of daily intake needed. Assess signs of dehydration (decreased
urination, thirst) Teach parents measures to prevent
dehydration such as avoiding heat / stress.
Prevent Infection
With the spleen damaged, has greater chance of getting sepsis.
Avoid know sources of infection Assess Vital Signs and report elevated
temperatures. Treat with Ibuprofen, NOT ASA.
Place on prophylactic antibiotics such as Penicillin VK 250 mg twice a day, through age 5 yrs
Prevent Infection Immunizations
Hepatitis B series Recipient of blood and blood products.
Pneumococcal Pneumovax for now at age 24 months
and 5 years, with an improved vaccine coming on the market soon for administration to infants.
Meningococcal vaccine H. influenzae vaccine
Child / Parent Teaching Assess baseline knowledge and teach
accordingly: Causes of disease and consequences, genetic
counseling Situations that cause sickling Signs of developing crisis, infection, When to call the doctor
Keep in school, promote normal g&d as much as possible
Allow for decreased endurance - let the child set his or her own pace during strenuous exercise, and to take rest breaks when fatigue
Explain some complications: CVA, anemia, swollen spleen, liver problems
Support child and family
Critical Thinking
Which of the following nursing diagnoses should receive priority during a vaso-occlusive crisis in a 14 year old with sickle cell anemia?A. Alteration in comfortB. Ineffective individual copingC. Decreased cardiac outputD. Ineffective airway clearance
Critical Thinking
Which of these instructions should the parents of a child who has recovered from a sickle cell crisis receive?A Isolate child from known sources of
infectionB Avoid contact with all childrenC Restrict child’s intake during the nightD Reinforce the basics of trait
transmission
Hemophilia
A group of bleeding disorders in which there is a deficiency of one of the factors necessary for coagulation of the blood. Hemophilia A – most common bleeding
disorder. Deficiency of factor VIII.
Hemophilia is an hereditary condition in which the mother may pass the defect to her male child.
With deficiency of coagulation factor VIII, blood does not coagulate as it should.
Do Hemophiliacs bleed more Profusely than people without Hemophilia?
The blood of a person with hemophilia does not clot normally. He does not bleed more profusely or more quickly than other people; however, he bleeds for a longer time.
Answer:
Hemophiliacs bleed mainly from minor cuts
True or False
False This is a myth. External wounds are usually not
serious.
Far more important is internal bleeding (hemorrhaging). These hemorrhages are in joints, especially knees, ankles and elbows; and into tissues and muscles.
When bleeding occurs in a vital organ, especially the brain, a hemophiliac's life is in danger.
What Causes a Bleeding Episode? Bleeding is often caused by minor injury - a bump or a
slight twist of a joint. However, many hemorrhages, especially among severe hemophiliacs, happen for no apparent reason. This is even truer in joints that have bled often in the past. The more a joint has bled, the easier it bleeds again with no external cause.
Even hemorrhages in the brain often have no apparent cause. Brain hemorrhages are the leading cause of death from bleeding in hemophilia. Therefore it is important to recognize the symptoms of a brain hemorrhage very quickly.
Related to the deficiency of AHF
Interviewing the Child with Hemophilia – Subjective Data
Recent traumas and measures used to stop bleeding
Length of time pressure was applied before bleeding subsided
Was swelling increased after surface bleeding subsided
Did swelling and stiffness occur without apparent trauma
Assessment
Prolonged bleeding anywhere from or in the body.
Often diagnosed when infant is circumcised
Bleeding in the mouth from a cut, bitten tongue or loss of a tooth (especially in children)
Assessment Surface bruising - Bleeding from trauma into
soft tissues and muscles (the ileopsoas muscle around the hip, calf, forearm, upper arm, achilles tendon, buttocks, retroperitoneal.
Hematuria
Hemarthrosis - bleeding into joints (knees, elbows, ankles, shoulders, hips, wrists in descending order of frequency)
How to Assess Bleeding in a Joint
The first sign is a feeling of tightness in the joint but no real pain. The joint feels a little puffy to the touch.
As the hours pass, the joint becomes hot to the touch. Fully flexing or extending the joint becomes painful. Weight bearing becomes difficult. By this time, the joint is visibly swollen.
As the bleeding continues and the swelling increases, all movement in the joint is lost. The joint becomes fixed in a slightly flexed position in an attempt to relieve the interior pressure in the joint. Pain at this point can be excruciating.
The bleeding slows after several days when the joint is so full of blood that the pressure inside the joint cavity is equal to the pressure inside the broken blood vessels. Slowly, the bleeding stops and the long process of absorbing the blood in the joint cavity begins.
Assessment CNS bleeding - Major cause of death Signs and Symptoms of CNS bleeds
Persistent or increasing headache Repeated vomiting Sleepiness or a change in normal behavior Sudden weakness or clumsiness of an arm or leg Stiffness of the neck or complaints of pain with neck
movement Complaints of seeing double The development of crossed eyes Poor balance when walking, a lack of coordination Convulsions or seizures
Assessment of Child
Hemarthrosis
Bleeding in the mouth
Surface bruising
Diagnostic Tests
DNA testing for the trait Blood Tests
1. Partial Thromboplastin Time (PTT) – Prolonged
2. Bleeding time – Prolonged > 2 hrs.
3. Platelet count and Prothrombin time – Normal
4. Low levels of Factor VIII
Goals
Prevent and control Bleeding
Prevent crippling effects / Decrease pain
Child/ Parent Teaching
Interventions to Prevent or Control Bleeding
The basic treatment to stop or prevent bleeding in people with hemophilia A is:
Give Factor VIII replacement therapy
via IV.
These concentrates come from two sources: human plasma (a component of blood), Fresh whole
blood, fresh or frozen plasma may be used. a genetically engineered (artificial) Factor VIII blood
product made by DNA technology.
In both cases, the Factor VIII protein is nearly identical to the protein which is lacking in the blood of hemophiliacs. After an infusion of the concentrate, all the proteins needed for clotting are in place. A hemophiliac's blood becomes "normal", at least for a few hours. This allows the time for a clot to form at the site of the damaged blood vessel.
Unfortunately, the replacement of the missing clotting factors is not permanent. Half of the clotting factor activity which was infused is removed by the body every 24 hours. This means that within 3 days almost none is left. The hemophiliac's blood is again unable to clot normally.
•They are very concentrated. A small amount contains enough Factor VIII to control bleeding, even in major surgery. Thus, they are very effective. •They are convenient. The concentrates can be stored in a home refrigerator for up to a year or kept at room temperature for 3 to 6 months. •They are easy to mix. Five to 10 ml. of sterile water is added to the powdered concentrate. One minute later the mixture is ready to be infused. •They are quick to infuse. From beginning to end, the infusion takes about 15 to 20 minutes. •They are very safe. Hepatitis is rarely, if ever, transmitted by the concentrates made from human plasma and the concentrates made by genetic engineering are even safer because they are not made from human plasma, which can carry blood-borne infections.
Advantages of Factor VIII concentrate
Additional Interventions to Prevent and Control Bleeding
Administration of DDAVP (desmopressin acetate) nasal spray used to stimiulate release of factor VIII. Used with mild hemophilia
Apply local pressure for 10-15 minutes Elevate joint above level of heart Apply cold compresses to promote
vasoconstriction Prophylactic administration of factor VIII
What is prophylactic vs. on-demand therapy?
In prophylaxis therapy, hemophiliacs receive factor concentrates several times a week to prevent bleeding. The goal is to keep the levels of Factor VIII or IX in the blood high enough that bleeding does not happen. This therapy is common with children.
On-demand therapy is the infusion of factor concentrates immediately after the beginning of a bleed. The goal is to stop the bleeding quickly, before any damage is done to the joint or muscle.
Research has shown that prophylaxis therapy gives children the best chance to reach adulthood without damage to their joints.
Interventions to Prevent Crippling effects / Decrease Pain
During bleeding episode—elevate joint and immobilize
ROM after acute episode Exercise unaffected joints and
muscles. Give analgesics before Physical therapy. Do NOT give Aspirin.
Watch diet/ weight – excessive weight stresses the joints
What is the crippling Effect of Repeated bleeds into a Joint?
Bleeding in joints, especially knees, ankles and elbows can lead to: loss of range of motion muscle loss destruction of the joints themselves
Child / Parent Teaching
Measures to prevent injury/ providing a safe environment
Early recognition of bleeding episodes
Keep current on immunizations Hepatitis B – because recipient of blood
and blood products
Child / Parent Teaching
How to administer factor VIII. Children often learn how to infuse
themselves at the age of eight or ten. Then, the hemophiliac is able to treat himself at home, at school, at camp or on vacation.
Critical Thinking
A 12 year old hemophiliac child has been admitted to the hospital for hemarthrosis. Which of these expected outcomes should receive priority in the child’s care?A. Family will receive genetic counselingB. Child will participate in appropriate
activities for present conditionC. Child and family will seek support from
National Hemophilia FoundationD. Maximum function of the joint will be
restored
Review
Following administration of factor VIII to a nine year old child admitted to the hospital with hemarthrosis, the nurse’s next action would be to: A. Elevate and immobilize the
affected jointB. Institute passive range of motion to the affected joint during the acute phaseC. Apply warm compresses to the affected jointD. Apply pressure to the area as needed
Leading cause of death from disease in children
Almost all childhood cancers involve blood or blood-forming tissues
CancerCancer
Types and Incidence of Cancers
Leukemia
Brain Tumors
Lymphomas
Neuroblastoma
Wilms
Rhabdomyosarcoma
Retinoblastoma
Othes
Brain tumors – second leading cause of death from childhood cancer. Most are cerebellar and brain stem tumors
Lymphomas Non-Hodgkins lymphomas—one-third present with a
mass in the neck or mediastinal area. Also have dyspnea, wheezing, abdominal mass or pain and lymphadenopathy.
Hodgkin’s disease – arises in single lymph node with painless nodal enlargement, followed by extension to adjacent nodes and into spleen, liver, lungs, bone marrow.
Neuroblastoma – malignant tumor arising from sympathetic NS ganglion cells outside the cranium and and can arise from anywhere along the sympathetic nervous system chain. Can also occur in retroperitoneal area, pelvis, neck.
Childhood Cancers
Wilms Tumor – solid tumor of kidney.
Rhabdomyosarcoma—malignant tumor of the striated muscle cells. occur in muscles around eye, head, neck,
extremities, GU system. Retinoblastoma – intraocular malignancy of the
retina of eye. Usually unilateral. If bilateral , hereditary. First sign is white pupil.
Others – osteogenic sarcoma/ Ewings sarcoma – tumor of bones of the trunk. Often seen in adolescence growth spurt. Found in distal femur, proximal tibia.
Intrauterine carcinogens
Physical carcinogens
Viruses
Immune defects
Genetics Discovered
gene for leukemia on chromosome 22
Theories of Etiology
C = continual unexplained weight lossH = headaches with vomiting (early morning)I = increased swelling of pain in jointsL = lump or massD = development of whitish appearance in
pupilR = recurrent or persistent fevers, night
sweatsE = excessive bruising or bleedingN = noticeable paleness or tiredness
Warning Signs of Childhood Cancer
Biopsy Blood Tests
CBC Uric Acid
Bone Marrow Aspiration PET, SPECT MRI, CT, ultrasound
Diagnostic Tests
Radiation therapy
Chemotherapy
Surgery
Bone Marrow and Stem cell transplantation
Interventions
Radiation Therapy
Changes the DNA component ofChanges the DNA component of a cell nucleus a cell nucleus The cell cannot replicate which The cell cannot replicate which Inhibits further cell division and growthInhibits further cell division and growth
Radiation sickness- anorexia, nausea, vomiting Treated with antiemetics (Zofran or Anzimet).
Cool cloth to forehead, provide distraction, accurate I&O.
Fatigue allow for naps an rest periods (coordinate
care), encourage parent to cuddle in bed with child, pillow, blankets, favorite toys
Skin reactions –erythema, tenderness
Effects of Radiation Therapy
Bone marrow suppression – anemia, neutropenia, thrombocytopenia May be on reverse isolation
Mucositis- inflammation of mucus membranes mainly the mouth
Offer soft foods, and cold foods. Frequent mouth care. Lidocaine oral to
swish in mouth (older child)
Long term – depends on part of body receiving radiation
There are several categories of antineoplastic drugs used in treating childhood cancers.
Scheduled at set times and days and by different predetermined routes.
May remain in hospital for few days at first, then later report on specific day for therapy.
Children and Parents must be taught about what to do and not to do during therapy.
Chemotherapy
Bone Marrow Suppression – neutropenia, anemia, thrombocytopenia Place in reverse isolation, keep anyone
exposed to a virus away from patient. Monitor temperature Should not receive live-virus vaccines
Bleeding Tendency (thrombocytopenia) Apply pressure to puncture site No contact sports Check urine and stool for blood Give stool softeners. WHY? Soft objects in mouth
Side effects and Toxic Reactions to Chemotherapy
Malaise and fatigue Encourage video games, movies, etc Allow visits from friends
Nausea, vomiting, diarrhea, anorexia Give anti-emetics Small frequent meals Monitor for dehydration
Altered mucous membranes Stomatitis Rectal ulcerations
Renal involvement Uric acid levels rise as a result of breakdown of
cells. The renal tubules causing renal failure. If kidney affected/damaged- chemo drugs will
not be excreted as usual and may limit drugs given.
Body Image changes Alopecia
Pain
Side effects of chemotherapy
Know OSHA guidelines for administering antineoplastic agents
Confirm all measurements and calculations
Double-check ordered dosages Obtain complete blood count within 48
hours of chemotherapy administration Note white blood cell and platelet levels
before chemotherapy begins Know side effects of chemotherapeutic
agents and ways to alleviate these effects
Nursing Responsibilities Related to Chemotherapy
Ensure patency of IV tubing by checking for blood return
Ensure needle placement for implantable infusion device
Give vesicants (agents that can cause tissue necrosis) only through a fresh IV site
Have emergency drugs available
Nursing Responsibilities Related to Chemotherapy (Cont’d)
Chemotherapy Bone marrow
suppression Alopecia Malaise/fatigue Nausea Vomiting Anorexia Stomatitis
Radiation side effects Skin reactions Fatigue Bone marrow
suppression Nausea Vomiting Anorexia Mucositis
Review of Common Side Effects of
Chemotherapy and Radiation
CurativeRemove the tumor and
cancerous tissue
PalliativeRelieve complications due to
the cancer
Surgery
The goal of therapy is to administer a lethal dose of chemotherapy and radiation therapy that will kill the cancer and then re-supply the body with bone marrow and stem cells to reconstitute immunologic function.
Healthy bone marrow or stem cells are infused into the bloodstream and migrate to the marrow space to replenish the patient’s immunologic function and help kill remaining cancer cells.
Bone Marrow and Stem Cell Transplantation
Syngeneic bone marrow comes from identical twin
Allogeneic bone marrow comes from matched sibling (one in
four chances) or someone who is histocompatible.
Autologous own bone marrow. May be harvested at time of
remission in preparation for relapse or when bone marrow is free of malignant cells. Also being used so toxic doses of chemotherapy and radiation can be administered and the bone marrow rescued.
Types of Transplantations
First --All potential donors are typed for HLA (human leukocyte antigen) compatibility.
Collection of bone marrow is a surgical procedure. The donor undergoes anesthesia for aspiration of the
bone marrow The bone marrow is then processed and frozen
When patient ready - it is infused into the recipient.
Procedure
Where is the most common site for bone marrow aspiration in children?
Iliac crest
1. Graft-Versus-Host Disease (GVHD) – potentially lethal immunologic response of donor T cells against the tissue of the recipient. Signs and symptoms – rash, malaise, high
fever, diarrhea, liver and spleen enlargement. Because there is no cure, prevention is
essential. Careful tissue typing, irradiation of blood products which helps to inactivate mature T lymphocytes.
2. Rejection of the transplant
Side effects of Transplantation
CNS – cognitive disorders, seizures, headaches, coordination problems
Bone – asymmetric growth of bones, easy fractures, scoliosis, kyphosis
CV – cardiomyopathy (pericardial thickening) , pericardial damage
Respiratory – pneumonitis, pulmonary fibrosis GI – enteritis, bleeding, hepatic fibrosis Urinary – hemorrhagic cystitis, reflux Endocrine – decrease in growth, thyroid and
gonadal dysfunction Reproductive – decrease sperm Dental - caries Secondary malignancies
Post Therapeutic Disabilities
What is the most common form of childhood cancer?a. leukemiab. brain tumorsc. lymphomad.osteosarcoma
Ask Yourself?
Leukemia
A malignancy of the blood forming tissues/ bone marrow in which normal bone marrow is replaced by malignant immature WBC’s.
The WBC's are produced so rapidly that immature cells (blast cells) are released into the circulation.
These blast cells are nonfunctional, can't fight infection, and are formed continuously without respect to the body's needs
The blasts cells then invade other organs and interfere with metabolism / function. The production of red blood cells and platelets decreases leading to anemia and thrombocytopenia.
Pathophysiology of Leukemias
Leukemia
Bone marrow Depression results in:1. Decrease in mature WBC’s - fever2. Decrease RBC’s, Anemia- pallor, lethargy, anorexia3. Decreased Platelets/ thrombocytopenia- bleeding4. Increase cell metabolism which deprives cells of
nutrients 5. Enlargement of organs infiltrated with blast cells
results in: Bone pain Spleenomegaly. Hepatomegaly, Nephromegaly Lymphadenopathy CNS infiltration – increased ICP
Signs & Symptoms
Diagnostic Tests History and Physical
Blood Work Leukocytes are > 10,000 Platelet count, Hgb and Hct low Blast cells appear (where they normally don’t)
Bone Marrow Aspiration Used to identify the type of WBC involved,
therefore, type of leukemia
X-rays of long bones Show lesions caused by invasion of abnormal
cells
Lumbar Puncture – blast cells in the CSF
A combination of antineoplastic drugs are given for about a month
A different combination is given for about 2-3 years
Advantages of using a combination of drugs: Decrease resistance to one drug Lessening of severe side effects of massive
doses of one drug Breakdown of the tumor cell cycle at multiple
sites
Chemotherapy
1. Remission induction- most intense treatment. Large doses of antineoplastic drug administered in an effort to destroy as many proliferating cells as possible. Lasts 4-6 wks. About 95% respond.
2. Consolidation- method of destroying leukemic cells in the CNS- for children who have CNS involvement or are high risk. Given Intrathecal.
3. Remission maintenance- drugs given at specific intervals. If remain in remission for 3 yrs, treatment is discontinued. Approx 80% of children who sustain remission for 2-3 yrs continue to remain in remission and appear to be cured.
Chemotherapy Phases
Administration of Chemotherapy
When is intrathecal administration of chemotherapeutic medications
required?
Intrathecal chemotherapy is instilled in to the spinal canal for
cancers that have metastasized to the brain
Bypass the blood brain barrier
What is the rationale for the use of cranial radiation in addition to chemotherapy?
What is the rationale for the use of cranial radiation in addition to chemotherapy?
Prevent infection (neutropenia, anemia) Pain Relief Nausea and vomiting Mouth discomfort-mucositis / stomatitis Fatigue Alopecia Prevent blood loss-platelet low- nose bleed most
common kind of bleed Support child and family Assist with referrals to social services, home
health agency, chaplain
Nursing Care
Community Resource Candlelighters Childhood Cancer Foundation® (CCCF)
is a national non-profit membership organization whose mission is to educate, support, serve, and advocate for families of children with cancer, survivors of childhood cancer, and the professionals who care for them.
http://www.candlelighters.org/ American Cancer Society Make a wish Foundation Leukemia Society Church and Schools
Nursing Care
Caused by the breakdown (lysis) of malignant cells which release intracellular contents into the blood.
Intracellular electrolytes overload the kidneys and can lead to kidney failure.
Further severe electrolyte imbalances cause metabolic acidosis, hyperkalemia, increase uric acid levels, hypocalcemia and cardiac arrythmias.
Treat with IV fluids, electrolyte replacement, allopurinol.
Tumor Lysis Syndrome
An embryonic tumor of the kidney.
Cause is unknown
Originates from immature renoblast cells
Tumor is vascular
Etiology and Pathophysiology
Palpable abdominal mass Firm and smooth
**The abdomen should not be palpated once the diagnosis is made. Avoid palpating the tumor mass during assessment because of the risk of rupturing the protective capsule. Excessive manipulation can cause seeding of the tumor and spread of cancerous cells
Abdominal distention Fever Fatigue Late signs
Anemia Hematuria, dysuria Hypertension
Assessment
Abdominal ultrasound
CT, MRI
Biopsy
Diagnostic Tests
Nephrectomy and removal of lymph nodes
Post-op chemotherapy and / or radiation therapy
CT every 6 months for 3 years
Chest x-ray every 3 months for 3 years
Interventions
Pre-op Sign on bed ”Do Not Palpate Abdomen” Child / Parent teaching
Post-op Monitor kidney function, Strict I & O Monitor vital signs—B/P and temperature Monitor GI function– assess bowel sounds and
stool production NG tube to drainage. Measure abdominal girth.
Nursing Care
Clinical manifestations
Treatment sequence How does this treatment differ
from osteosarcoma?
Why is metastases more of a concern with this cancer?
Ewing’s Sarcoma
Clinical manifestations-
Treatment sequence-
Chemotherapeutic agents (VAC)
Rabdomyosarcoma
Clinical manifestations
Treatment sequence
Why is the sequence of treatment important?
Osteosarcoma
Pre-operative nursing goals for the child diagnosed with cancer- Disturbed sensory perception Anticipatory grieving Risk for infection
Post-operative nursing goals- Risk for infection Impaired skin integrity Impaired adjustment- disturbed body image Pain
Review of Nursing Care:
What is the rationale for treating some cancers with chemotherapy prior to removal of the tumor?
What specific teaching should the nurse include as priority regarding chemotherapy?
What lab values does the nurse monitor carefully in the client undergoing chemotherapy?
Review of Nursing Care:
What are the priority psychosocial needs of the child/family diagnosed with cancer
What are nursing interventions to assist with stressors that influence the child/family’s response to the diagnosis and treatment of cancer.
Review of Nursing Care:
Caring for a child who is dying can be one of the hardest tasks in nursing
Children under 3 Have no understanding of own impending death May perceive family anxiety, sadness
Preschool to 5 years More afraid of separation from parents than of
thought of dying. Greatest fear is separation. Envision death as temporary, and have little of
adults’ fear of it Think of it as a long sleep, not a final process.
Nightmares increase. May feel pain / illness is a punishment for
misdeeds or thoughts May ask questions about death In long term illness – may simulate adult
response with depression, withdrawal, fearfulness, anxiety
Understanding of Death
School Age 5-9 Begin to understand that death is
permanent May think it is something that only happens
to adults Become aware of what is happening to them
when their disorder has a fatal prognosis. Concerns center around fear of pain, fear of
being left alone and leaving parents and friends.
May associate death with sleep and may be afraid to go to sleep without someone near them.
May associate death with darkness—want light left on in room
Adolescent, older school age By age 10 have an adults concept of death,
realizing that it is inevitable, universal, and irreversible. Have more understanding than adults realize.
Understand that death is the cessation of life. Emotional outbursts may reflect anger View death as fearsome and fascinating
(increase in adolescent suicide). May feel immune to death and deny symptoms
for longer than usual because they believe it is impossible that anything serious could happen to them.
Some adolescents consider themselves alienated from their peers and unable to communicate with their parents for emotional support feeling alone in their struggle.
Understanding Death
1. Elicit child's understanding of death before discussing
2. Encourage children to express feelings in own way through play, drawings, or verbalization to promote free expression.
3. Provide a safe, acceptable outlet for expressions of feelings
4. Structure care of child to allow child choices and participation in process within constraints of physical condition
5. Help child maintain independence and control; normal ADL as much as possible (set realistic goals)
6. Realize that they will go through the stages of dying: denial, bargaining, anger, depression, acceptance
Nursing Care Child
1. Spend time with family to listen, answer questions, and provide information. Discuss issues with parents before discussing with child.
2. Provide opportunities for family to express their emotions and deal with their feelings. Parental reactions: continuum of grief process and usually depend on previous experiences with loss, intellectualization.
3. Reactions may depend on relationship with child and circumstances of illness or injury
4. Reactions depend on degree of guilt felt by parents-help them sort out
Nursing Care Parents
5. Assist parents in expressing fears, concerns, grief to enable them to appropriately support child
6. Assist parents to understand sibling' possible reactions to terminally ill child· Guilt- believing they caused the problem or
illness· Jealousy- wanting equal attention from
parents· Anger- feelings of being left behind
7. Support, enhance parent-child communication, enhance parents' ability to support child
8. Refer to parent, family support groups- not alone, help focus, open communication, provide information
Nurse needs to care for self.
Care of the caregiver is imperative if the nurse is to provide physical and psychosocial care for families at such a difficult time.
Caring for dying children and their families can be stressful and emotionally demanding.
Nursing Care Nurse