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52 Cards in this Set
- Front
- Back
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Common Presenting Symptoms of Malignancy
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• Anemia- children often don’t get enough iron
• Bleeding – blood in urine, bruising, petechia • Cachexia – wasting look, malnourished • Infection- lymph, could be repeated due to poor immune system • Mass • Neurologic Symptoms – brain tumor, spinal tumor (sudden bed wetting, vision changes, headaches, incontinence) |
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Practice Question: An ANC (absolute neutrophil count) below what level is cause for most concern?
A: 500 B: 1000 C: 1500 D: 2000 |
A: 500
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Practice Question: What is acceptable for a patient who is neutropenic?
A: Live flowers in the room B: Eating raw fruits and vegetables C: Using rectal medication for nausea D: Playing with the family dog |
D: Playing with the family dog (pets are okay except for birds)
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General Diagnostic Tests-Labs for malignancy
CBC with differential |
• Complete blood count with differential
– Red Blood Cells – Platelets – White Blood Cells • % of all 5 types of white blood cells • *Absolute neutrophil count (ANC) – Segmented (mature) + bands (immature) – (neuts + bands) x (wbc x 10) » Neutrophils are also called polys or segs » < 500 is very low and increases infection risk, abnormal is under 1500, also depends on how long the patient was below that blood count to assess risk for infection |
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General Diagnostic Tests-Labs
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• Complete metabolic panel
• Renal function tests (BUN, creatnine) • Liver function tests • Urinalysis • Special tests – Alpha-fetoprotein – VMA or HVA – Elevated catecholamines |
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Specific Diagnostic Tests
• Biopsy - identifies, classifies, and stages |
– T = tumor characteristic
– N = lymph node involvement – M = metastasis – S = extent of disease |
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• Bone Marrow Aspiration
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– Iliac crest (most common), sternum - to diagnose and monitor treatment
– Diagnosis and monitoring of effectiveness of therapy |
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Practice Question: Which medication is given to increase the white blood cell count?
A: Zofran B: Epogen C: Neupogen |
C: Neupogen
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Adverse Effects of Chemotherapy
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• Bone marrow suppression 7-10 days after chemo – when symptoms start, platelets, RBC’s and WBC’s all suppressed
• Nausea, vomiting – Assess fluid/electrolytes – Prophylactic, scheduled, individualized antiemetics must be given on a schedule before they are nauseous and before radiation and chemo • Malnutrition – High protein, high calorie foods – May need NG or G-tube feedings • Constipation, diarrhea • Susceptibility to infection – first sign is increased heart rate, even before a fever |
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Chemotherapy Medications
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– G-CSF -stimulates granulocyte production
• Neupogen – SC or IV, daily for up to 14 days, until ANC is >10,000, make sure to monitor labs – Not given within 48 hours of chemotherapy because it destroys it – Erythropoietin -stimulates erythrocyte production, hypertension is a serious side effect • Epogen and Procrit – SC or IV, three times a week – Dose adjusted based on labs |
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Chemotherapy
• Stomatitis, change in taste |
– Soft sponge toothbrush
– Mouth care before/after meals – No viscous lidocaine in small children – Normal saline or plain water mouth rinse |
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Chemotherapy
Rectal Ulcers |
– No rectal temperatures or medications
– Warm, sitz bath for rectal ulceration – Meticulous cleaning of area |
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Chemotherapy
• Hemorrhagic cystitis |
– Caused by chemotherapy or radiation, have to flush the kidneys (increased fluids)
– fluid > 1.5 times normal maintenance rate – Encourage frequent voiding to get the chemo out of the bladder |
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What to avoid during chemotherapy
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– Aspirin, NSAIDS due to risk of bleeding
– Live virus vaccines – immune suppressed, can get the disease, siblings should not have them either within a month of chemo, regular vaccines are usually fine, only one you can give is immunoglobulin for chicken pox – Vitamins with folic acid |
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Care of the Neutropenic Child
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• IV care – meticulous, make sure tubes are changed when they should be, always be thinking about septic shock (decrease BP, increase pulse)
• Frequent vitals • Tachycardia + low blood pressure worrisome • Subtle changes -early signs of impending shock • Timely administration of antibiotics • Screen visitors • Pets, plants (no birds or reptiles) • No live vaccines – 1 month for siblings • Meticulous mouth care, hygiene • Oral, axillary temperatures only • No rectal meds or temps • High protein, high calorie diet |
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Care of the Thrombocytopenic Child
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• Watch for signs of bleeding (below 150,000 is below normal but below 10-20,000 is of very high extreme)
• Watch for increased bruising • Avoid activities that could cause injury – Signs above bed • Use a soft bristle toothbrush • Be careful when shaving |
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Radiation Therapy with Children
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• Frightening
– Have to be alone in the room – Tour the department, dry run – Use child friendly facility – Pictures, talk to children who’ve done it – Anesthesia if very young or can’t lie still • Radiation area – Preserve skin markings |
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Side Effects of Radiation Therapy
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• Immediate side effects
– Fatigue – biggest thing that happens, also affects bones and can increase risk for fracture – Anorexia, nausea, vomiting • Schedule anti-emetics prior to the procedure • OK to use in young children for this indication because you know it’s not because of an infection |
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Nursing Care - Radiation
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• No cream/lotion to irradiated areas because there is metal in creams that can distort the radiation beams
• Meticulous mouth and skin care • Adequate nutrition – high protein diet, fluid intake • Antiemetics and antispasmodics • Head covering • Preserve skin markings • Sunscreen – for up to six months after due to increased sensitivity |
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Practice question: What types of cells replace normal, functioning cells in leukemia?
A: platelets B: stem cells C: RBC’s D: WBC’s |
D: WBC’s – leukemia is the over production of WBC’s, overproduction replaces RBC’s, they don’t work and can’t fight off infection properly, can have up to 100k and 10k is normal, children with too many are worse off than those with too few, too many can clog up the blood, bone and joint pain could mean it’s metastasized already
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Leukemia - Pathophysiology
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• Overproduction of abnormal white blood cells
– Immature, abnormally functioning blast cells – Fill the bone marrow with abnormal white cells • Spill into the blood and replace normal WBCs • Suppress normal cell formation in bone marrow |
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Leukemia Symptoms
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• Stem from bone marrow suppression
– Anemia – Infection • WBC count can be >100,000 • ANC < 500 is more common – Bleeding, bruising • <100,000 is common – Bone, joint pain |
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Leukemia - Diagnosis
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• History – usually age 2-5, often white boys, mother’s had intrauterine infection, previous radiation
• Physical exam • Peripheral blood smear • Bone marrow aspiration – definitive test • Lumbar puncture to see if it’s in the CSF |
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Leukemia Types
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• ALL-Acute Leukemia – most common
– Immature lymphocytes, 75% cure rate • AML-Acute Leukemia – Immature myelocytes – usually older children, 50% cure rate – Chronic • CML-Chronic Leukemia – often in adults, can live a long time without chemo |
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Leukemia - Management
Cranial irradiation |
• Cranial irradiation – real problem for small children because the brain is still growing and developing, damages some of the brain, don’t usually use under age of 3 unless high risk or already have CNS involvement
– High risk patients only – For proven CNS involvement |
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Practice question: The nurse knows to avoid which portion of the abdominal assessment of the child with Wilm’s tumor.
A: Inspection B: Auscultation C: Palpation |
C: Palpation – it might spread
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Leukocoria is seen in which pediatric tumor?
A: Rhabdomyosarcoma B: Neuroblastoma C: Hodgekin’s Disease D: Retinoblastoma |
D: Retinoblastoma – Leukocoria is an opaque retina – yellow or white instead of red
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Which virus has been associated with Hodgekin’s Disease?
A: Respiratory Syncytial Virus B: Epstein Barre Virus C: Hepatitis B Virus D: Cytomegalovirus |
B: Epstein Barre Virus - mono
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Bone Marrow Transplant - indications
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• Induction failures
• Relapses within one year of completion of therapy • High risk presentation |
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Brain Tumor
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• Most common solid tumor
• Malignant or benign • Symptoms – Based on location, size and child’s age (if fontanel is not closed may not see symptoms for quite some time) • Headache upon arising • Vomiting unrelated to feeding Early signs are usually neurologic |
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Brain Tumor
• Diagnosis • Treatment • Nursing Care • Complications |
• Diagnosis
• Treatment – Surgery - second – Radiation – to shrink the tumor first – Chemotherapy - third • Nursing Care • Complications – hydrocephalus, increase pressure, changes in mental status |
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Neuroblastoma
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• 2nd most common malignant tumor
– Median age 22-months, rare after 10-yrs – Originates from nerve tissue (brain, spine, adrenal glands – monitor BP) – 60% with metastasis at diagnosis |
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Neuroblastoma Symptoms
‘The Great Masquerader’ can mimic other cancers |
• Pain – from organs being compressed by the tumor
• Abdominal mass – Firm, non-tender, irregular, crosses midline • Cerebral mass – Ecchymosis – Periorbital edema, exophthalmos • Diagnosis based on tumor or bone marrow and catecholamines in the urine or blood |
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Neuroblastoma Management
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• Surgery
– Staged, can cure early stages • Radiation – Shrinks advanced tumor for removal in surgery – Used urgently for spinal cord compression – Palliative care for bone, brain metastases • Chemotherapy – For local and disseminated disease |
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Neuroblastoma Prognosis
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• The younger the child, the better (less than a year)
• Can have spontaneous regression • 90% disease free at 5 years – Low grade tumor – Young at presentation |
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Lymphoma
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• 3rd most common malignant tumor
• Lymph system malignancy – Hodgkin’s Disease (adults get this too), most common in adolescents • Age 5-15 • Previous EBV infection, sibling with Hodgkin’s Disease • Lymph nodes closer to the surface 75% 20 year survival rate – Non-Hodgkin Lymphoma (younger kids) • Prior to puberty • B-cell or T-cell lymphomas, nodes more deep |
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Hodgkin’s Disease
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B lymphs go awry and grow in lymph nodes in the vessels
• Originates in lymphatic system, most common in adolescents – Lymph nodes and vessels • Staging, 1-4 – Determined by spread, where, how much – Presence of extranodal disease – Number of sites of lymph node involvement • Classification – Asymptomatic – B-symptomatic |
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Hodgkin’s Disease
Diagnostic Evaluation |
• Lymph node biopsy
– Essential for diagnosis and staging – Reed-Sternberg cells • Marker of Hodgkin Disease • CT scan – Neck – Chest – Abdomen – Pelvis • Gallium and bone scan – To detect metastases |
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Hodgkin’s Disease
• Manifestations |
– Painless lymph node enlargement – most common
• Cervical or supraclavicular most common • Inguinal, axillary or chest – Fever – Weight loss – Night sweats |
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Hodgkin’s Disease Management
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• Radiation
• Chemotherapy – Significant problem with late effect 2nd cancers • After splenectomy – Prophylactic antibiotics • Penicillin VK bid until 5-years-old or older – Pneumococcal, Meningococcal, Influenza vaccines • Survival – 75% at 20 years |
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Non-Hodgkin’s Lymphoma
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worse prognosis but not terrible
• Solid tumors of lymph system – Diffuse, rather than nodular • B-cell and T-cell mutations • Earlier, more rapid dissemination of deep lymph tissue • Aggressively spreads, very responsive to treatment – Needs CNS prophylaxis • Chemotherapy alone usually |
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Rhabdomyosarcoma
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• Malignancy of skeletal muscle (bone, muscle, cartilage or fat but arises from skeletal muscle)
• Common sites – can be found pretty much everywhere – Head and neck – GU tract – Orbit of the eye • Maternal risk factors – Marijuana, cocaine use and x-ray exposure |
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Rhabdomyosarcoma
• Manifestations • Diagnosis • Management |
• Manifestations
– Related to site and compressed structures • Diagnosis – Radiographic studies to isolate the tumor – Bone marrow aspirate for metastatsis • Management – Surgery, chemotherapy, radiation – Often has already metastasized |
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Retinoblastoma
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• Originates in the retina
– 75% -unilateral – 90% -no family history – Hereditary type, usually bilateral • 95% cured – > 90% retain vision in at least one eye – 80% with 20/20 vision post treatment |
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Retinoblastoma
• Symptoms • Diagnosis • Treatment |
• Symptoms
– Leukocoria • ‘Cat’s Eye’ – Abnormal red reflex – Fixed strabismus – Parent often finds it • Red eye in pictures in only one eye • Diagnosis – Opthalmological exam under anesthesia • Treatment – Ocular chemotherapy – Systemic chemotherapy – *Radiation – Enucleation • Advanced tumors |
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Enucleation
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• Prepare the parent to see the child
• Lids, lashes, tear glands intact, lid closed – Eye patch applied, ball placed in socket – Encourage child to see socket right away • Care – Irrigation, then antibiotic to socket – Daily eye patch change – Prosthesis soaked in warm water to clean – Eye protection for the good eye |
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Wilm’s Tumor-Nephroblastoma
• Manifestations • Diagnosis |
• Manifestations
– Abdominal mass • Firm, non–tender, confined to one side, do not palpate because it could rupture, found on the kidney – Anemia – Pallor, weight loss – Hematuria, hypertension because of excess rennin secreted by the tumor • Diagnosis – US, chest/abdominal CT, urinalysis |
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Wilm’s Tumor Management
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• Surgery and chemotherapy, with radiation
• Surgery – Affected kidney, tumor, adrenal gland removed – Bilateral involvement remove the worst one and try to preserve the one that isn’t affected as badly |
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Wilm’s Tumor Nursing Considerations
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• “Do Not Palpate Abdomen” if it ruptures it can spread to the abdomen
• Careful handling of child • Post-nephrectomy – Decreased urine output – Increased blood pressure – Flank pain on non-operative side – Pulmonary complications – Unexplained weight gain |
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Bone Tumors
• Osteosarcoma |
• Osteosarcoma
– Metaphysis of bones – Symptoms • Pain • Limp • Mass – 10-25 yrs – Increased risk with history of hereditary retinoblastoma |
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Bone Tumors
• Ewing’s Sarcoma |
– Diaphysis of long bones
– Symptoms • Pain • Mass • Fractures – 5-20 yrs – 80%-Caucasians |
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Bone Tumors
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– Plain x-rays, bone scan, MRI
– Serum alkaline phosphatase – Tumor biopsy for identification • Surgery – Limb salvaging or limb amputation • Chemotherapy – Pre-surgery to shrink the tumor – Post-surgery to treat or prevent metastasis • Radiation – Ewing’s |
