question

Cancer warning signs in Children

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-Unusual mass or swelling -Unexplained paleness and loss of energy -Sudden tendency to bruise -Persistent, localized pain or limping -Prolonged, unexplained fever or illness -Frequent headaches, often with vomiting -Sudden eye or vision changes -Excessive, rapid weight loss

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What is the most common form of childhood cancer?

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*Acute Lymphoblastic Leukemia* (ALL)

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Classification of Childhood Cancer

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a wide range of diseases that are classified into two broad subcategories: 1. Hematological malignancies 2. Solid tumors Within these classifications, tumors are named based on the *type of tissue* and/or *site* that the cancer develops in. ex: rhabdosarcoma = striated muscle cancer (I think, thats what Hockenberry told me)

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Tissue Classification

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All body tissues arise from one of the embryonal tissue layers: - Ectoderm - Mesoderm - Endoderm

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Where do most childhood cancers arise from?

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the *mesoderm or ectoderm* (tissues deep within the body) Conversely, most adult cancers arise from the *endoderm* (tissues exposed to the environment)

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Common Hematological Child Cancers

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*Leukemia (Blood/Marrow)* -ALL -AML *Lymphoma (lymphoid)* -Hodgkin -NHL

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Common Solid Tumor Child Cancers

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CNS tumors (brain/spine) neuroblastoma (SNS) -Usually abdomen rhabdomyosarcoma (muscle) Wilms tumor (kidney) Ewing's sarcoma (bone) osteosarcoma (bone) retinoblastoma (eye)

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Why do children have higher survival rates of cancer?

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Their bodies are generally healthy in all other aspects besides having cancer. *Highest survival rate- ALL (87%)* *Lowest survival rate- AML (54%)* ^from ppt

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Childhood vs Adult-Onset Cancers: Prevention

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Childhood- not possible Adults- 80% preventable

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Childhood vs Adult-Onset Cancers: Early Detection

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Childhood: Usually accidental, no screenings Adults: Possible with screening

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Childhood vs Adult-Onset Cancers: Stage at diagnosis

answer

Childhood: 80% metastatic Adults: Local or regional

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Childhood vs Adult-Onset Cancers: Response

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Childhood: Very chemosensitive Adults: Less chemosensitive

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Childhood vs Adult-Onset Cancers: Treatment effects

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Childhood: less acute toxicity, more longterm effects Adults: more acute toxicity, fewer long-term effects

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Childhood vs Adult-Onset Cancers: Prognosis

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Childhood: around 80% 5-year survival Adults: around 66% 5-year survival

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Characteristics of Childhood Cancer

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Usually affects deep tissues Often disseminated (metastasized) at diagnosis Sometimes related to peak growth periods No screening or early detection available Usually very responsive to therapy 80% overall cure rate

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Childhood Cancer: Patterns of Onset: Infancy and Early Childhood

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Associated with peak growth periods Neuroblastoma Wilms tumor Retinoblastoma

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Childhood Cancer: Patterns of Onset: Adolescence

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Associated with peak growth periods Hodgkin's lymphoma Osteosarcoma

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What are the reasons for improved survival rates?

answer

-The clinical trials that go on in pediatric oncology -The fact that multimodality therapy is used (chemo w/ radiation w/ surgery) -The intensive supportive care that has been developed - that allows us to push the boundaries in terms of what therapies can be used -The use of a multidisciplinary approach, including many healthcare professionals from a wide variety of subspecialties.

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What are the treatment modalities used in childhood cancers?

answer

*Chemotherapy*- primary for kids *Radiation*- not awesome for kids *Surgery*- also primary for kids *Hematopoietic stem cell transplant* *Biotherapy- monoclonal antibodies:* watch for anaphylaxis; first infusion- forming antibodies; second infusion- nope

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Leukemia- What is it?

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a group of malignancies that affect the bone marrow and lymphatic system

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How is Leukemia classified?

answer

By the type of WBCs that become neoplastic Two groups: Acute Lymphoid Leukemia (ALL) Acute Myelogenous (Myeloid) Leukemia/ Nonlymphoid (AML/ ANLL)

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Leukemia Pathophysiology

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Causes *bone marrow suppression* leading to *anemia* and *neutropenia* Causes an *increase in immature WBC production*, leading to *infiltration* of organs and tissues. *Bone Marrow infiltration->* crowding of cells that normally produce RBCs, platelets, mature WBCs -> anemia (low RBCs), neutropenia (low wbcs, increased rx for infection), thrombocytopenia (low platelets, bleeding, fibrosis) *Spleen, Liver, Lymph node* infiltration-> tissue fibrosis *CNS infiltration*-> increased ICP

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Leukemia Risk Factors

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-Most common form of childhood cancer -Caucasian boys >1yr, peak 2-6yrs - Trisomy 21 have 20x the risk of developing ALL

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Leukemia- Subjective Data

answer

Vague Anorexia, HA, fatigue

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Leukemia- Objective Data- *Early* Physical Manifestations

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Low grade fever (decreased WBCs) Pallor (decreased RBCs) Increased bruising and petechiae (decreased platelets) Listlessness Enlarged liver, lymph nodes, joints Abdominal, leg, joint pain Constipation HA Vomitting Anorexia (decreased everything) Unsteady gait

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Leukemia- Objective Data- *Late* Physical Manifestations

answer

Pain Hematuria Ulcerations in the mouth Enlarged kidneys and testicles Signs of increased ICP

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Leukemia- Laboratory Tests

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*CBC* Anemia- low blood counts Thrombocytopenia- low platelets Neutropenia- low neutrophils Leukemic Blasts- immature WBCs

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Leukemia- Diagnostics

answer

*Bone Marrow aspiration or biopsy* *CSF analysis*

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Bone Marrow aspiration or biopsy

answer

*most definitive diagnostic procedure* If leukemia is present, will show prolific quantities of immature leukemic blast cells and protein markers for the specific type of leukemia.

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Bone Marrow Aspiration/ Biopsy Nursing Management

answer

-Assist -Topical anesthetic (EMLA) applied over area 45min to 1hr prior to procedure -Unconscious sedation is induced using general anesthetic (propofol) - Specimen from posterior or anterior iliac crest or tibia is obtained *Post procedure* - Apply pressure 5-10 minutes - Assess vitals frequently - Apply pressure dressing - Monitor bleeding and for infection 24hr Educate

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Cerebrospinal fluid CSF analysis

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Lumbar Puncture Determines CNS involvement, BBB crossing, increased ICP

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Cerebrospinal fluid CSF analysis Nursing Management

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-Have child empty bladder -Child in fetal position, assist in maintaining position - Assist in procedure - Topical anesthetic or sedation w/ EMLA or sumblimaze or versed

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Survival in Pediatric Leukemia

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ALL Cure rate of >90% AML Cure rate of 60-70% Why does AML have a lower cure rate? AML- secondary infections cause lower cure rate; r/t severe neutropenia

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Leukemia Onset

answer

May be *acute or insidious*. May be diagnosed with a minor infection—a cold that won't go away --child continues to be pale, listless, irritable, febrile, and anorexic. May be diagnosed after an extended history of s/s mimicking another condition such as mononucleosis. May be discovered during a routine physical exam.

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What is the most life-threatening complication of leukemia?

answer

Infection Also, Children cured of leukemia are shown to be at great risk for developing a brain tumor.

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Treatment

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*Chemotherapy- primary treatment; systemic* Prophylactic antibiotics- very high risk for infection- septic shock, BMT- not first line, treatment if relapse; goal is to replace diseased bone marrow; very dangerous procedure; Give 3-8x chemo that you would normally give in treatment before you can give transplanted bone marrow (graph vs host)

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Chemotherapy treatment for leukemia- Chemotherapeutic Agents

answer

L- asparaginase, teniposide (VM-26), etoposide (VP-16), bleomycin, cisplatin, vincristine, cyclophosphamide Admisnistered in FOUR phases: *Induction, CNS prophylactic therapy, Intensification, Maintenance*

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Induction therapy- first phase

answer

To achieve complete remission or less than 5% of leukemic cells in the bone marrow

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CNS prophylactic therapy- leukemia

answer

prevent invasion of CNS by leukemic cells

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Intensification therapy- leukemia

answer

Destroy any remaining leukemic cells follow by a delayed intensification to prevent any resistant leukemic cells from emerging

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Maintenance Therapy- leukemia

answer

Sustaining of remission

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Nursing Considerations for Chemo- leukemia

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Control n/v with antiemetics prior to treatment Manage SE

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SEs of Chemotherapy

answer

Mucosal Ulceration Skin Breakdown Neuropathy Loss of Appetite Hemorrhage cystitis Alopecia ATI- read of interventions, pretty self explanatory!

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Chemotherapy Client Education

answer

Steroids- moon face Mood changes Look for s/s of infection, skin breakdown, nutritional deficiency Encourage hygience Avoid people w/ infectious diseases Teach self administration of meds Nutritional support Proper vascular access use Bleeding precautions and how to manage active bleeding

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Hematopoietic Stem Cell Transplant (HCST)

answer

Indicated for children who have AML during first remission and for those who have ALL after second remission involves high-dose chemo and radiation for destroy chemo cells CHild is given donor bone marrow or other stem cells, such as cord blood. Implantation may take 2-6 weeks

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HCST Nursing Actions

answer

Assists Implement protective isolation -Private, positive pressure room - 12 air exhanges/hr - HEPA filtration for incoming air - Respirator mask, gloves, gowns - No dried or fresh flowers and no potted plants Child is at increased risk for infection and bleeding until stem cells grow

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Radiation- blood

answer

Brain and Spinal Cord

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Radiation SEs

answer

Fatigue, infection

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Radiation Nursing Mgmt

answer

Encourage rest, healthy diet

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Complications of Myelosuppresion from Treatment

answer

Infection Bleeding Anemia Cardiotoxicity Delayed Growth and Development

question

Complications of Treatment- Infection

answer

Provide w/ private room w/ adequate air flow restrict visitors monitor temp and potential sites for infection administer antibiotics Monitor child's absolute neutrophil count (ANC) Adequate protein & calories *Avoid all immunizations while immune system is depressed*

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Complications of Treatment- Bleeding

answer

S/s of bleeding- *petechiae, ecchymosis, hematuria, bleeding gums, hematemesis, tarry stools* Avoid unnecesary skin punctures Use surgical aseptic technique when puncturing skin, hold pressure for 5 min *Treat nosebleed w/ cold and pressure* Administer platelets as ordered No rectal temps Meticulous oral care- avoiding gingival bleeding- *avoid astringent mouthwash* Avoid activities that lead to injury or bleeding

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Complications of Treatment- Anemia

answer

Administer blood transfusions as ordered Lots of rest periods O2 therapy IV fluid replacement Educate about high iron foods

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Complications of Treatment- Cardiotoxicity

answer

Monitor cardiac dysfunction by BP, HR, weights, cap refil, cardiac rhythm Teach: how to take pulse and BP, daily weights, educate s/s of dysfunction

question

Complications of Treatment- delayed growth and development

answer

long term effect of treatment Assess status, initiate OT and PT

question

Organ cancers

answer

Wilms' Tumor Neuroblastomas S/s vary with type and location of cancer Treatment may be combination of surgery, chemo, radiation

question

Wilms' Tumor

answer

Nephroblastoma Malignancy that occurs in *kidneys or abdomen* Most often in toddler or preschool years *Metastasis is rare* *Does not cross midline* *Most common primary malignant renal tumor rapidly growing/vascular fragile gelatinous capsule*

question

Neuroblastoma

answer

malignancy occuring in the adrenal gland, sympathetic chain of the retroperitoneal area, head, neck, pelvis, or chest Occurs before age 10, usually in *toddler* years

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RFs of Organ Cancers

answer

Some genetic predisposition- Wilms

question

Wilms Tumor S/S

answer

Nontender, firm flank mass not crossing midline healthy-appearing child avoid deep palpation Often discovered by parent May be asymptomatic or have: abdominal pain vomiting 25-30% microscopic/gross hematuria anemia Hypertension- kidneys in stress; increases BP other anomalies GU symtoms- familial type of Wilms: frequency, urgency *DO NOT PALPATE* Rupture and hemorrhage can lead to anemia, seeding of cancer cells into abdomen

question

Wilms Tumor Metastasis

answer

10% have metastatic disease at diagnosis Metastasize by hematogenous/lymphatic spread LUNG most common metastatic site Other sites: regional lymph nodes liver contralateral kidney brain bone *S/S of metastasis*: Edema if periorbital around eyes, Lymphadenopathy, Weight loss, anemia, fatigue, hepatomegaly, splenomegaly, bone pain, respiratory involvement,

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Wilms Tumor Treatment

answer

*Surgery* unilateral -complete nephrectomy bilateral -nephrectomy of more involved kidney 0partial nephrectomy of contralateral kidney *Chemotherapy* -all stages *Radiation* +/- stages III-IV for decrease in size or for palliation

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Wilms Tumor: Chemotherapy

answer

Vincristine, Doxorubicin, Cyclophosphamide, Actinomycin D PO, IV, or Local Administer antiemetics Lasts for 6-15 months

question

Wilms Tumor:Survival

answer

Overall 85-92% Unfavorable histology/metastatic disease at diagnosis 40-80% Following recurrence 10-70%

question

Neuroblastoma S/S

answer

Asymmetrical- *crosses midline* firm, nontender mass in abdomen SNS involvement if metastasized

question

Neuroblastoma Metastasis

answer

Edema if periorbital around eyes, Lymphadenopathy (cervical and supraclavicular), Weight loss, anemia, fatigue, hepatomegaly, splenomegaly, bone pain, respiratory involvement, paralysis

question

Organ Cancer Lab Studies

answer

CBC- anemia and infection Urine studies for renal suppresion Liver enzymes

question

Organ Cancer Diagnostics

answer

Chest X-ray, CT, MRI, PET scan, Single photon emission computed tomography (SPECT) scans - ask for allergies to dye or shellfish -oral contrast - sedation may be necessary

question

Neuroblastoma Treatment

answer

Surgical removal of tumor Radiation- emergency or to decrease size of spinal cord compression tumor, or for palliation Chemotherapy- main

question

Neuroblastoma Chemotherapy

answer

Cisplatin

question

Radiation for Organ Cancers

answer

Dose Calculated Divided treatments over several weeks

question

How does radiation work?

answer

affects rapidly growing cells in the body Cells that normally have a fast turnover may be affected in addition to cancer cells

question

Nursing Actions for Radiation- Organ Cancers

answer

Wear lead aprons Educate family - Do not wash marks off skin that outline targeted areas; instead wash areas with lukewarm water and hands - Avoid use of soaps, creams, lotions - Encourage loose cotton clothing - Protection from sun - Seek care for blisters, weeping, red tender skin

question

Complications of Organ Cancer Treatment

answer

*Pancytopenia* *Anorexia, NV* (chemo and radiation) *Alteration in bowel elimination* (radiation, chemo, imbalanced nutrition) *Stomatitis and Dry Mouth* *Alopecia* (chemo and radiation of head/neck)

question

Pancytopenia nursing care

answer

bone marrow depression w/ anemia, neutropenia, thrombocytopenia Report temp greater than 37.8C Monitor for infecion, mouth lesions, lung congestion, immunization status, administer meds as prescribed Avoid crowds, Avoid fresh fruits and veggies, *Administer filgrastim to promote WBC production* Avoid NSAIDS, aspirin Administer epoetin alfa subc to stimulate RBC production Administer Interleukin-11 (oprelvekin) to stimulate platelets

question

Anorexia, N/V nursing care

answer

small, frequent meals Avoid strong odors, administer antiemetics before meals

question

Alteration in bowel elimination nursing care

answer

skin care diet determine what worsens condition monitor I/O

question

Stomatitis and Dry Mouth nursing care

answer

Soft toothbrush Lubricate lips Soft, nonacidic foods Pureed or liquid diet Analgesics Dentist visit before therapy Encourage mouth washes- 1tsp salt in 1pint water or 1tsp baking soda in 1qt water

question

Alopecia nursing care

answer

Assess feelings, discuss cutting long hair Use gentle shampoos Brush hair Avoid blow dryers and curling irons Suggest wearing cotton hat or scarf Suggest wig

question

Bone Cancers

answer

May originate from all tissues involved in bone growth, including osteoid matrix, blood vessels, and cartilage *Osteosarcoma* *Ewing's Sarcoma*

question

Soft Tissue Cancers

answer

Arise from undifferentiated cells in any of the soft tissues- muscles, tendons- in connective or fibrous tissue, or in blood or lymph vessels. Can begin in any area of the body. *Rhabdomyosarcoma*

question

Osteosarcoma

answer

Usually occurs in the metaphysis of the long bones; most often in the femur Treatment usually includes amputation w/ chemotherapy Most often males during puberty- rapid bone growth

question

Ewing's Sarcoma

answer

Primitive neuroectodermal tumor (PNET) Occurs in shafts of long bones and trunk bones Treatment includes surgical biopsy, intensive radiation to site, chemotherapy No amputation necessary Prognosis depends on how quickly the disease was diagnosed and whether or not metastasis has occured Occurance: Over 4 years; Younger than 30 years

question

Rhabdomyosarcoma

answer

skeletal muscle in any part of the body- most often in head and neck; orbit of they eye frequently affected Treatment- surgical biopsy, local radiation, chemotherapy Caucasian children, younger than 5

question

Bone Cancers- Subjective Data

answer

Non-specific bone pain; often mistaken for an injury or growing pains Temporary relief of pain when extremity is flexed

question

Bone Cancers- Objective Data

answer

Weakness, swelling, decreased mvmt of extremity Palpable lymph nodes near tumor Anemia, generalized infection, unexplained weight loss

question

Rhabdomyosarcoma- Subjective Data

answer

Pain in local areas r/t compression by tumor (such as sore throat w/ tumor of nasopharynx) Absence of pain in some parts of body when tumor begins obstructing organs

question

Rhabdomyosarcoma- Objective Data

answer

Based on affected area: Orbit- Strabismus, exopthalamos, generalized swelling, color change in conjunctiva Nasopharynx- Palpable area of firm swelling, nasal stuffiness, generalized swelling, palpable lymph nodes, rhinorrhea Retroperitoneal area- Palpable mass and a urinary or intestinal obstruction

question

Bone Cancer Lab Tests

answer

Alkaline Phostphatase- elevated CBC- rule out other causes of findings

question

Diagnostics for Bone and Soft tissue Cancers

answer

Xray, CT, MRI Bone Scan Bone marrow aspiration CSF analysis

question

Treatment for Bone and Soft Tissue Cancers

answer

Chemotherapy Amytriptyline- for neuropathic pain or phantom limb pain (TCA) Localized radiation Surgery- Limb salvage and limb amputation

question

Complications from Treatment for Bone and Soft Tissue Cancers

answer

Skin desquamation with permanent hyperpigmentation and possible damage Myelosuppression

question

A 3 year old child with Wilms' tumor of the right kidney is admitted to the ped onc unit. He is to undergo a course of chemo, followed by radiation treatments to shrink the tumor before surgically removing it, along with the kidney and the adjacent adrenal gland. The child will recieve additional radiation after therapy. *Baseline assessments to be obtained?*

answer

Vitals, including temp Skin- assess for red/broken areas Mucous membranes Last dental visit Ht/wt Nutritional preferences, normal meal patterns Activity and mobility levels Fears and knowledge levels of family and child

question

When completing the child's admission assessment (wilms), what should the nurse avoid?

answer

PALPATION!

question

A primary care provider has prescribed a clear liquid diet for a child who is postop following surgical removal of a Wilms tumor. What assessment finding requires that the nurse must clarify this order?

answer

Absence of bowel sounds on second postoperative day - Indication that motility is absent- child should not eat

question

When assessing a child who has neuroblastoma of the adrenal gland, what findings indicate the child has probably developed metastasis from the primary site?

answer

Bone pain, Varying degrees of paralysis, Hepatomegaly

question

What are the manifestations/complications of anemia r/t bone marrow suppression?

answer

Fatigue and SHOB

question

What are the manifestations/complications of Neutropenia r/t bone marrow suppression?

answer

Fever and pneumonia

question

What are the manifestations/complications of thrombocytopenia r/t bone marrow suppression?

answer

Bruising and nosebleed

question

A child with leukemia is experiencing severe thrombocytopenia. What actions should the nurse take to avoid complications?

answer

Avoid injections and skin punctures, Monitor platelet counts, Avoid rectal temperatures.

question

A child with leukemia has mucosal ulcerations in his mouth and throat due to neutropenia. What actions should the nurse take?

answer

Offer soft foods, Use a soft, disposable toothbrush for oral care, Encourage gargling with warm saline mouthwash.

question

An infant diagnosed with rhabdomyosarcoma of the middle ear is to undergo a lumbar puncture. The HCP tells the nurse that the procedure will be carried out with the infant in a sitting position. WHat action should the nurse take?

answer

Restrain the infant during the procedure to prevent movement. Why? To prevent possible injury during the procedure. EMLA cream should be applied 60 minutes prior to procedure.

question

A nurse is caring for a school-age child who has suspected osteosarcoma. What lab value is likely to be elevated if diagnosis is correct?

answer

Alkaline Phosphatase Why? Made in the liver and bones.

question

A nurse in a primary care clinic is assessing a 12-year old who reports frequent pain in the L proximal anterior thigh. The HCP suspects osteosarcoma. What findings should the nurse expect if diagnosis is correct?

answer

Visible swelling in area, Pain causes child to limp at times, Lymph nodes in groin can be palpated.

question

Still need to go over...

answer

Retinoblastoma, lymphomas and CNS tumors- not in ATI or ppts sorry guys, I'm over thisssss

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