children with cancer nur 264 pediatrics julianna maynor, rn, msn

Children with CancerChildren with Cancer

NUR 264NUR 264

PediatricsPediatrics

Julianna Maynor, RN, MSNJulianna Maynor, RN, MSN

Developmental DifferencesDevelopmental Differences Childhood malignances arise from embryonic tissue Childhood malignances arise from embryonic tissue Environmental factors do not play as large a part in Environmental factors do not play as large a part in

childhood cancers as they do in adult cancerschildhood cancers as they do in adult cancers Diagnosis of cancer in children is usually made when Diagnosis of cancer in children is usually made when

symptoms warrant a diagnostic work-upsymptoms warrant a diagnostic work-up Few preventative strategies are known for childhood Few preventative strategies are known for childhood

cancercancer Metatstatic disease is often present at diagnosis of Metatstatic disease is often present at diagnosis of

childhood cancerschildhood cancers Childhood cancers are more responsive to treatmentChildhood cancers are more responsive to treatment Childhood cancers have a greater than 70% cure rateChildhood cancers have a greater than 70% cure rate

Cardinal Symptoms of CancerCardinal Symptoms of Cancer

Unusual mass or swellingUnusual mass or swelling Unexplained paleness and loss of energyUnexplained paleness and loss of energy Sudden tendency to bruiseSudden tendency to bruise Persistent, localized pain or limpingPersistent, localized pain or limping Prolonged, unexplained fever or illnessProlonged, unexplained fever or illness Frequent headaches, often with vomitingFrequent headaches, often with vomiting Sudden eye or vision changesSudden eye or vision changes Excessive, rapid weight lossExcessive, rapid weight loss

Diagnostic AssessmentDiagnostic Assessment

History and physical examHistory and physical exam Lab tests: CBC (decreased H&H, increased immature Lab tests: CBC (decreased H&H, increased immature

cells), chemistry (abnormal renal &liver function, cells), chemistry (abnormal renal &liver function, electrolyte balance), UA, lumbar punctureelectrolyte balance), UA, lumbar puncture

Imaging studies: x-rays, IVP, CT scans, US, nuclear Imaging studies: x-rays, IVP, CT scans, US, nuclear scan, MRIscan, MRI

BiopsyBiopsy Classification –biological characteristics of tumorClassification –biological characteristics of tumor Staging – extent of disease at time of diagnosis (higher the Staging – extent of disease at time of diagnosis (higher the

stage, poorer the prognosis) stage, poorer the prognosis)

Diagnostic AssessmentDiagnostic Assessment

Bone marrow studies: when concern for Bone marrow studies: when concern for metastasis or when primary site is blood metastasis or when primary site is blood forming organ to determine extent of forming organ to determine extent of involvement by malignant cellsinvolvement by malignant cells Aspiration – obtain marrow through needleAspiration – obtain marrow through needle Biopsy – obtain piece of bone through special Biopsy – obtain piece of bone through special

needleneedle

Cancer TreatmentCancer Treatment

Goal of treatment is to remove all malignant Goal of treatment is to remove all malignant cells from the body. Therapy may include:cells from the body. Therapy may include: SurgerySurgery ChemotherapyChemotherapy Radiation therapyRadiation therapy Bone marrow transplantBone marrow transplant Biological response modifiersBiological response modifiers

Cancer Treatment: SurgeryCancer Treatment: Surgery

Obtain biopsyObtain biopsy Aids in tumor staging by noting the presence Aids in tumor staging by noting the presence

and extent of metastasisand extent of metastasis Remove tumorRemove tumor Restore body functionRestore body function

Cancer Treatment: ChemotherapyCancer Treatment: Chemotherapy

Primary form of treatment or adjunct to Primary form of treatment or adjunct to surgery and/or radiationsurgery and/or radiation

Used for systemic cancers that cannot be Used for systemic cancers that cannot be managed by surgery or radiationmanaged by surgery or radiation

Combination of drugs – for optimum cancer Combination of drugs – for optimum cancer cell cycle destruction with minimum toxic cell cycle destruction with minimum toxic effectseffects

Cancer Treatment: ChemotherapyCancer Treatment: Chemotherapy

Use access ports to minimize multiple Use access ports to minimize multiple venipuncturesvenipunctures

Use continuous infusions over extended period Use continuous infusions over extended period via syringe pumps for decreased toxicity, such via syringe pumps for decreased toxicity, such as when intermittent dosages are givenas when intermittent dosages are given

Healthy cells are susceptible to damageHealthy cells are susceptible to damage Causes bone marrow suppression – fatigue, Causes bone marrow suppression – fatigue,

anemia, bleeding tendencies, increased risk of anemia, bleeding tendencies, increased risk of infectioninfection

Chemotherapy: Three phasesChemotherapy: Three phases

InductionInduction: Initial therapy: Initial therapy Goals: To eliminate as many cancer cells as possibleGoals: To eliminate as many cancer cells as possible To obtain a complete remissionTo obtain a complete remission

ConsolidationConsolidation: Given after remission is complete: Given after remission is complete Goal: To ensure complete eradication of diseaseGoal: To ensure complete eradication of disease

MaintenanceMaintenance: Given for several months to years : Given for several months to years after consolidation, depending on diseaseafter consolidation, depending on disease Goals: To maintain a complete remissionGoals: To maintain a complete remission To minimize late effectsTo minimize late effects To prevent drug resistance from developingTo prevent drug resistance from developing

Cancer Treatment: ChemotherapyCancer Treatment: ChemotherapyPotential ComplicationsPotential Complications

Vesicants: severe cellular damage if infiltrateVesicants: severe cellular damage if infiltrate Side effects affecting almost every body systemSide effects affecting almost every body system Anaphylaxis: cyanosis, hypotension, wheezing, Anaphylaxis: cyanosis, hypotension, wheezing,

severe uticaria. Can be fatal – discontinue drug, severe uticaria. Can be fatal – discontinue drug, flush IV with saline and monitor VSflush IV with saline and monitor VS

Hypersensitivity: rash, itching, flushing, Hypersensitivity: rash, itching, flushing, hypotension, angioedema. When administering – hypotension, angioedema. When administering – wear gown, gloves, mask, goggles to prevent any wear gown, gloves, mask, goggles to prevent any physical contact. Discard ampules and syringes in physical contact. Discard ampules and syringes in special containersspecial containers

Chemotherapy Side EffectsChemotherapy Side Effects Hematopoietic effectsHematopoietic effects

Myelosuppression (transient decrease in blood cell production)Myelosuppression (transient decrease in blood cell production) Anemia: may require blood transfusionsAnemia: may require blood transfusions ThrombocytopeniaThrombocytopenia Immunosuppression Immunosuppression Neutropenia (abnormal decrease in number of WBC)Neutropenia (abnormal decrease in number of WBC)

Gastrointestinal effectsGastrointestinal effects Stomatitis (inflammation of the oral mucosa. May be mild to Stomatitis (inflammation of the oral mucosa. May be mild to

severe and may affect the entire GI tract)severe and may affect the entire GI tract) NauseaNausea VomitingVomiting AnorexiaAnorexia

Chemotherapy Side EffectsChemotherapy Side Effects

Hepatic effectsHepatic effects Liver toxicityLiver toxicity

Renal effectsRenal effects Renal toxicityRenal toxicity Hemorrhagic cystitisHemorrhagic cystitis

Integumentary effectsIntegumentary effects Hair lossHair loss

Reproductive effectsReproductive effects SterilitySterility Delayed pubertyDelayed puberty

Cancer Treatment: Radiation Cancer Treatment: Radiation TherapyTherapy

Used to deliver a therapeutic dose of ionizing Used to deliver a therapeutic dose of ionizing radiation to a a tumor with minimal effects to radiation to a a tumor with minimal effects to the healthy surrounding tissuethe healthy surrounding tissue

Causes breaks in DNA molecules to destroy Causes breaks in DNA molecules to destroy the cancer cellsthe cancer cells

Many side effectsMany side effects Radiation pneumonitisRadiation pneumonitis Somnolence syndromeSomnolence syndrome

Cancer Treatment: Bone Marrow Cancer Treatment: Bone Marrow TransplantTransplant

Allows lethal doses of chemotherapy and radiation to Allows lethal doses of chemotherapy and radiation to be givenbe given

After chemotherapeutic agents are given, bone After chemotherapeutic agents are given, bone marrow or stem cells are transfused to patient to marrow or stem cells are transfused to patient to allow nonmalignant blood cells to functionallow nonmalignant blood cells to function

Types of bone marrow transplantTypes of bone marrow transplant Autologous: patient receives own marrowAutologous: patient receives own marrow Allogenic: patient receives donor marrow, must match as Allogenic: patient receives donor marrow, must match as

close as possibleclose as possible Syngeneic: patient receives marrow from identical twinSyngeneic: patient receives marrow from identical twin Umbilical cord blood stem cells: may use unmatched donorUmbilical cord blood stem cells: may use unmatched donor

Cancer Treatment: Biologic Cancer Treatment: Biologic Response ModifiersResponse Modifiers

Stimulate immune system to respond Stimulate immune system to respond aggressively to tumor or to attack tumor cells aggressively to tumor or to attack tumor cells with antibodieswith antibodies Monoclonal antibodies: early cancer detection, to Monoclonal antibodies: early cancer detection, to

reduce graft vs. host disease, destroy malignant reduce graft vs. host disease, destroy malignant cells from autologous bone marrow for cells from autologous bone marrow for retransplantretransplant

Immune stimulants: interferon, interleukinImmune stimulants: interferon, interleukin

Complications of Cancer TreatmentComplications of Cancer Treatment

Acute tumor lysis syndrome: Occurs when a Acute tumor lysis syndrome: Occurs when a large number of tumor cells are destroyed large number of tumor cells are destroyed quickly in response to chemotherapy or quickly in response to chemotherapy or radiation. As tumor cells die, nucleic acids radiation. As tumor cells die, nucleic acids and intracellular metabolites are released and and intracellular metabolites are released and exceed the excretory capacity of the kidneys. exceed the excretory capacity of the kidneys. Nucleic acids are converted to uric acid in the Nucleic acids are converted to uric acid in the liver and may crystallize leading to obstruction liver and may crystallize leading to obstruction of the kidneys and acute renal failure.of the kidneys and acute renal failure.


Graft versus host disease (GVHD): immune response Graft versus host disease (GVHD): immune response resulting from disparities in the match between donor resulting from disparities in the match between donor and recipient bone marrow. The donor white cells and recipient bone marrow. The donor white cells perceive the child’s body as foreign material to be perceive the child’s body as foreign material to be attacked and destroyed. Graft versus host disease is attacked and destroyed. Graft versus host disease is usually restricted to certain organs such as the skin, usually restricted to certain organs such as the skin, GI tract, liver, and other organs. The symptoms of GI tract, liver, and other organs. The symptoms of GVHD can be minimal or life-threatening and include GVHD can be minimal or life-threatening and include skin rash beginning on the hands and feet, spreading skin rash beginning on the hands and feet, spreading to other parts of the body, diarrhea, jaundice and to other parts of the body, diarrhea, jaundice and infection. These symptoms are managed with infection. These symptoms are managed with symptomatic support and immunosuppressive drugs.symptomatic support and immunosuppressive drugs.


Hypercalcemia: when large amounts of bone are destroyed by Hypercalcemia: when large amounts of bone are destroyed by treatmentstreatments

Hyperleukocytosis: increased WBC count leads to capillary Hyperleukocytosis: increased WBC count leads to capillary obstruction, micorinfarction, and organ dysfunctionobstruction, micorinfarction, and organ dysfunction

Obstructions: from space-occupying lesions, masses, tumors, Obstructions: from space-occupying lesions, masses, tumors, catheterscatheters

Overwhelming infection: sepsis, septic shock – due to protein Overwhelming infection: sepsis, septic shock – due to protein malnutrition and other dietary deficiencies and immune malnutrition and other dietary deficiencies and immune suppressionsuppression

Life-threatening hemorrhages: from DIC, thrombocytopenia, Life-threatening hemorrhages: from DIC, thrombocytopenia, leukocytosis, intracranial bleedingleukocytosis, intracranial bleeding

Death: due to high energy demands and nutrient needs of Death: due to high energy demands and nutrient needs of cancer cells – take over nutrients and O2 supply needed by cancer cells – take over nutrients and O2 supply needed by normal cells to survivenormal cells to survive

Types of Cancers in ChildrenTypes of Cancers in Children Leukemia: group of malignant diseases of the Leukemia: group of malignant diseases of the

bone marrow and lymphatic system. Normal bone marrow and lymphatic system. Normal bone marrow elements are replaced by abnormal bone marrow elements are replaced by abnormal immature lymphocytes, known as blast cells – immature lymphocytes, known as blast cells – most common form of childhood cancermost common form of childhood cancer Acute lymphocytic leukemia: accounts for 80% of Acute lymphocytic leukemia: accounts for 80% of

all childhood leukemia. Peak incidence occurs all childhood leukemia. Peak incidence occurs between the ages of two and five years old. CNS between the ages of two and five years old. CNS prophylaxis.prophylaxis.

Acute myelogenous leukemia: accounts for 15 to Acute myelogenous leukemia: accounts for 15 to 25% of all childhood leukemia. Prognosis is 25% of all childhood leukemia. Prognosis is poorer than for those with ALL.poorer than for those with ALL.

Types of Cancers in ChildrenTypes of Cancers in Children

Brain tumors: most common solid tumor. Brain tumors: most common solid tumor. Second most common form of childhood Second most common form of childhood cancer. Third leading cause of death in cancer. Third leading cause of death in children under 16 years of age. Prognosis children under 16 years of age. Prognosis varies depending upon the age of he child at varies depending upon the age of he child at diagnosis, pathology and location of the tumor.diagnosis, pathology and location of the tumor.

Astrocytoma: most common type of CNS Astrocytoma: most common type of CNS tumor in childrentumor in children

Types of Cancer in ChildrenTypes of Cancer in Children

Lymphomas: malignancy that arises from the Lymphomas: malignancy that arises from the lymphoid system. Lymphomas are the third lymphoid system. Lymphomas are the third most common type of childhood cancermost common type of childhood cancer Hodgkin’s disease: usually originates in a cervical Hodgkin’s disease: usually originates in a cervical

lymph node and spreads to other lymph node lymph node and spreads to other lymph node regions. Accounts for approximately 5% of regions. Accounts for approximately 5% of childhood malignancies.childhood malignancies.

Non-Hodgkin’s lymphoma: no single focal origin, Non-Hodgkin’s lymphoma: no single focal origin, malignant cells are rarely localized. Has a rapid malignant cells are rarely localized. Has a rapid onset and presents with widespread involvementonset and presents with widespread involvement


Neuroblastoma: nervous system tumors arising Neuroblastoma: nervous system tumors arising from adrenal gland or retroperitoneal from adrenal gland or retroperitoneal sympathetic chain (brain, adrenal medulla, sympathetic chain (brain, adrenal medulla, pelvis, mediastinum, and sympathetic ganglia)pelvis, mediastinum, and sympathetic ganglia)

Fourth most common childhood malignancyFourth most common childhood malignancy Most common malignant tumor of infancy Most common malignant tumor of infancy

“silent tumor” – poor prognosis“silent tumor” – poor prognosis


Wilm’s Tumor: most common type of renal Wilm’s Tumor: most common type of renal cancer in childrencancer in children

Usually presents as an abdominal mass.Usually presents as an abdominal mass. A large flank mass is usually found in a A large flank mass is usually found in a

healthy child by a family memberhealthy child by a family member The mass is present on one side and seldom The mass is present on one side and seldom

crossing the midline, as does neuroblastomacrossing the midline, as does neuroblastoma


Bone tumorsBone tumors Osteogenic sarcoma: tumor of the bone that usually occurs in Osteogenic sarcoma: tumor of the bone that usually occurs in

the growth metaphysis or the end of the long bonesthe growth metaphysis or the end of the long bones Ewing’s sarcoma: can present in any bone of the skeleton, but Ewing’s sarcoma: can present in any bone of the skeleton, but

is often seen in the bones of the pelvis, tibia, fibula, and femur is often seen in the bones of the pelvis, tibia, fibula, and femur


Rhabdomyosarcoma: soft tissue sarcoma Rhabdomyosarcoma: soft tissue sarcoma arising primarily from the connective tissues arising primarily from the connective tissues of the body, such as fibrous, adipose, or of the body, such as fibrous, adipose, or muscle tissue.muscle tissue. Embryonal: most common type. Usually affects Embryonal: most common type. Usually affects

infants and young children in the area of the infants and young children in the area of the genitourinary tract and the head and neck area.genitourinary tract and the head and neck area.

Alveolar: occurs in the large muscles of the trunk, Alveolar: occurs in the large muscles of the trunk, arms, and legsarms, and legs


Retinoblastoma: malignant tumor arising from Retinoblastoma: malignant tumor arising from the retina. Seen only in children. Usually the retina. Seen only in children. Usually found in infants and very young children. found in infants and very young children. Detected by presence of cat’s eye reflex Detected by presence of cat’s eye reflex instead of red reflexinstead of red reflex

Testicular tumor: most common form of Testicular tumor: most common form of cancer in males age 15 - 34cancer in males age 15 - 34

Nursing Care of Children with Nursing Care of Children with CancerCancer

Thorough AssessmentThorough Assessment HistoryHistory Manage side effects of treatmentManage side effects of treatment

InfectionInfection Hemorrhage and anemia – administer transfusions as orderedHemorrhage and anemia – administer transfusions as ordered Nausea / vomiting – administer antiemeticsNausea / vomiting – administer antiemetics Altered nutrition – monitor daily weight, strict I&OAltered nutrition – monitor daily weight, strict I&O Mucosal ulceration – offer bland, moist soft diet, sot toothbrushMucosal ulceration – offer bland, moist soft diet, sot toothbrush Neurologic problems – warn parents of somnolence syndromeNeurologic problems – warn parents of somnolence syndrome Hemorrhagic cystitis – provide adequate hydrationHemorrhagic cystitis – provide adequate hydration Alopecia Alopecia Steroid effectsSteroid effects


Nursing care during Bone Marrow TransplantationNursing care during Bone Marrow Transplantation Hospitalization 3-6 weeks, isolationHospitalization 3-6 weeks, isolation Risk of infectionRisk of infection Numerous proceduresNumerous procedures Side effects & complications of cytotoxic treatmentsSide effects & complications of cytotoxic treatments Monitor for graft vs. host disease GVHD & treatMonitor for graft vs. host disease GVHD & treat Monitor skin breakdown, wound healingMonitor skin breakdown, wound healing Sensitive & supportive attitudeSensitive & supportive attitude

Nursing Care for Children with Nursing Care for Children with CancerCancer

Prepare for proceduresPrepare for procedures IV’sIV’s Labs, imaging studiesLabs, imaging studies Bone marrow studiesBone marrow studies Lumbar punctureLumbar puncture SurgerySurgery Conscious/unconscious sedationConscious/unconscious sedation EMLA creamEMLA cream Emotional supportEmotional support


Pain ManagementPain Management OpoidsOpoids NSAIDsNSAIDs

Health promotionHealth promotion Dental careDental care ImmunizationsImmunizations NutritionNutrition School School DisciplineDiscipline Vision & hearing screeningsVision & hearing screenings


Family educationFamily education Home careHome care Referrals Referrals

Cessation of therapyCessation of therapy Assess for delayed growth, secondary Assess for delayed growth, secondary

malignancies, body system disturbancesmalignancies, body system disturbances Follow-up careFollow-up care

Questions?Questions?

children with cancer nur 264 pediatrics julianna maynor, rn, msn

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