Peds Oncology

A nurse is preparing to discharge a school-aged child who has undergone splenectomy for β-thalassemia (Cooley anemia). What information should the discharge teaching include?

A high fever should be reported to the child's healthcare provider' A fever higher than 101.5° F (38.6° C) must be reported because of the increased risk of sepsis in a child without a spleen (asplenia). Contact sports are a concern in children with enlarged spleens because of the possibility of rupture; this child has had a splenectomy. A splenectomy will not cure this disorder; β-thalassemia is an inherited disorder of hemoglobin synthesis. The splenectomy was done to decrease the need for blood transfusions.

A 3-year-old child is admitted to the pediatric unit with a tentative diagnosis of Wilms tumor. The nurse obtains the child's health history from the parents. What does the child's history reveal that will help establish the diagnosis?

ABDOMINAL SWELLING Wilms tumor is a nephroblastoma that is first observed as a firm, painless intraabdominal mass located on one side of the abdomen. Periorbital edema is a sign of glomerulonephritis, not Wilms tumor. Projectile vomiting is indicative of central nervous system problems or a gastrointestinal obstruction, not Wilms tumor. A low-grade fever is a nonspecific sign of many illnesses, not necessarily Wilms tumor.

In the early stages, Wilms tumor is encapsulated.

Any disruption of the tumor capsule may precipitate metastasis. MRI CT abdominal u/s are all helpful in making the diagnosis.

A nurse is assessing a newborn with a myelomeningocele. What clinical findings prompt the nurse to suspect hydrocephalus? Select all that apply.

Bulging fontanels High-pitched crying A defect in the lumbosacral area An excessive amount of cerebrospinal fluid associated with hydrocephalus causes bulging fontanels. A shrill, high-pitched cry often accompanies progressive hydrocephalus and other neurologic problems. Hydrocephalus complicates approximately 80% of lumbosacral myelomeningoceles. Infants with hydrocephalus may or may not have low Apgar scores. Head circumference 2 cm greater than the chest circumference is expected in a newborn.

A nurse is caring for an infant with hydrocephalus after the insertion of a shunt. How should the nurse evaluate the effectiveness of the shunt?

By palpating the anterior fontanel A bulging fontanel is the most significant sign of increased intracranial pressure in an infant. Periorbital edema, the frequency of voiding, and the symmetry of the Moro reflex are not indicators of increased intracranial pressure.

When planning long-term care for a 2-year-old child with cerebral palsy (CP), what is important for the nurse to consider?

CP is not progressively degenerative. CP is a nonprogressive chronic condition and its effects are predictable. Although CI may be present in some children with CP, not all children with this disorder have CI. A variety of prenatal, perinatal, and postnatal factors contribute to the development of CP. It is estimated that the cause of CP is unknown in as many as 80% of people with the disorder.

The nurse anticipates that the family of a child with cerebral palsy is at risk for difficult parenting issues. What does the nurse conclude is the probable basis for this difficulty?

Loss of the expected healthy child All parents initially grieve over the loss of a healthy child, what could have been, and what may never be. Many families have support systems. Unrealistic expectations may be true of some, but not all, parents. Not all children with cerebral palsy are cognitively impaired; approximately 30% to 50% of children with cerebral palsy are mentally challenged.

A ventroperitoneal shunt is inserted in a 4-month-old infant with hydrocephalus. Which signs of shunt failure should the nurse teach the parents during preparations for the infant's discharge? Select all that apply.

Vomiting distended fontannels Vomiting is a sign of increased intracranial pressure in an infant; a malfunctioning shunt will produce the typical signs of hydrocephalus. Bulging fontanels indicate increased cerebrospinal fluid and increased intracranial pressure in an infant. Dehydration and sunken eyeballs are a sign of severe fluid volume deficit caused by prolonged vomiting or diarrhea; they are not associated with the projectile vomiting of increased intracranial pressure. Abdominal distention is a typical sign of gastroenteritis, not shunt failure.

Most children with spinal cord damage resulting from spina bifida can be managed successfully with

a program of intermittent straight catheterization.

Wilms tumor is a *nephroblastoma* that is first observed as a

firm, painless, intraabdominal mass located on one side of the abdomen.

Serial hematocrit readings are necessary only if

the child is in sickle cell crisis.

toddler with a RIGHT ventriculoperitoneal (VP) shunt for the treatment of hydrocephalus - postoperative positioning.

Flat on the left side with the head and back supported side-lying position on the *unaffected side* and the use of supports help *prevent pressure on the shunt*; The horizontal position prevents too-rapid drainage of cerebrospinal fluid

A 1-year-old child has a congenital cardiac malformation that causes right-to-left shunting of blood through the heart. What clinical finding should the nurse expect?

Increased hematocrit Polycythemia, reflected in an increased hematocrit reading, is a direct attempt by the body to compensate for the decrease in oxygen to all body cells caused by the mixture of oxygenated and deoxygenated circulating blood. Proteinuria is not a characteristic of heart malformations that cause right-to-left shunting of blood; nor is edema. An absence of pedal pulses is characteristic of coarctation of the aorta, an obstructive malformation.

A 3-year-old child with thalassemia (Cooley anemia) is being discharged from the hospital. What should the nurse include in the instructions to the parents?

MIN RISK FOR INFECTION Children with a chronic illness should not be exposed to the additional stress of an infection. Subsequent to frequent transfusions, the child may have iron overload. An iron-rich diet is contraindicated. Because the child is chronically anemic, the child's fluid intake should be regulated. The child should be encouraged to lead an active life during periods of well-being.

Myelomeningocele (spina bifida)

most severe form of spina bifida in which the spinal cord and meninges protrude through the spine

A shrill, high-pitched cry often accompanies

progressive hydrocephalus and other neurologic problems.

6-year-old boy is undergoing chemotherapy to treat a neuroblastoma, stage IV, and had his first chemotherapy session last week. He arrives with his mother for this week's session. How should the nurse greet the child?

"How did you feel after your last treatment?" Asking how the child felt allows the child to volunteer information first and thus feel in control; the nurse can ask validating questions later. "It's time for your next dose" is a flippant, insensitive statement. Stating that there are three more sessions is unfeeling because it reminds the child and mother that there are more sessions in the future. "Did you get sick to your stomach?" focuses the assessment on vomiting, thereby predisposing the child to think about vomiting during this treatment.

dactinomycin, doxorubicin

DNA intercalators

A young child is admitted to the pediatric unit with a diagnosis of Wilms tumor. Considering the unique needs of a child with this diagnosis, what statement should be on a sign placed by the nurse at the child's bedside?

DO NOT PALPTATE ABDOMEN Palpation increases the risk of tumor rupture and is contraindicated. There is no data to indicate that surgery is scheduled; therefore, there is no reason to maintain nothing-by-mouth (NPO) status. There is no contraindication to intravenous medication. Recording of intake and output may or may not be instituted; it is not specific to children with Wilms tumor.

A 2-year-old child is admitted to the pediatric unit with a diagnosis of thalassemia major (Cooley anemia). The parents are told that there is no cure, but the anemia can be treated with frequent blood transfusions. The father tells the nurse he is glad that there is a treatment that "fixes" his child's problem. Before responding, the nurse should recall that blood transfusions do what?

Correct the anemia, but may cause other problems Excess iron from hemolysis of the replaced red blood cells is deposited in the organs and body tissue, causing hemosiderosis. Chelation therapy is then required. With the practice of aseptic technique and screening of donated blood, hepatitis should not occur. Red blood cell replacement depends on the child's hematologic picture; the number of transfusions is not related to age. Although red blood cells are replaced, it is erroneous to compare this treatment with insulin therapy.

A 5-year-old child is being given dactinomycin and doxorubicin therapy after nephrectomy for Wilms tumor. What will the nursing care include?

Demonstraing Meticulous Oral Hygeine Oral hygiene is essential, especially during the administration of medications that have a negative effect on the oral mucosa. Although pain may be present, aspirin is avoided because doxorubicin is also being used, and a side effect of this medication is thrombocytopenia. Aspirin is contraindicated for children because it is associated with Reye syndrome. Citrus juice will aggravate stomatitis, which is a common side effect of dactinomycin. Spicy foods may aggravate the stomatitis that occurs with chemotherapy. However, usually any food that the child requests is permitted.

A nurse in the pediatric clinic is evaluating a 6-year-old child with sickle cell anemia whose spleen autoinfarcted by age 4. What is the priority nursing care at this time?

Determining parental knowledge about infection The spleen plays a role in immunity. Initially the spleen enlarges and becomes congested with accumulated sickled red blood cells; in time, fibrous material replaces the tissue in the spleen, and by age 5 the spleen is obliterated. Without a spleen the child is prone to infection, which can precipitate a sickle cell crisis. Assessing the child for jaundice is not a priority, because jaundice is an expected adaptation that is not life threatening. Abdominal assessments are important but not required frequently in this situation. Serial hematocrit readings are necessary only if the child is in sickle cell crisis. Topics

A nurse is caring for a 6-year-old child with sickle cell anemia. What is the priority nursing intervention to prevent thrombus formation?

Encouraging Fluids Dehydration, stress, infection, and electrolyte imbalance can trigger the sickling process. Red blood cells (RBCs) change to the sickle shape when deoxygenated because of polymerization of the abnormal hemoglobin. This process damages the RBC membrane, which causes the cells to become entangled in the blood vessels, depriving the tissues that are distal to the occlusion of oxygen, resulting in ischemia and infarction, which can in turn cause organ damage. The child's condition determines the activity level; although bed rest may be required during a pain episode, at other times it is not necessary. Administering oxygen will not prevent thrombus formation. Anticoagulants do not help prevent thrombus formation in sickle cell anemia.

A 7-year-old child with cerebral palsy who wears leg braces has a slight sensory loss in the lower extremities. What is the most essential information for the nurse to teach the child and parents?

Examine the skin for evidence of pressure points When sensory perception is impaired, with resultant lack of effective specific motor responses, the child will be more vulnerable to skin irritation and trauma. Although it is important for the braces to be usable and well padded, the skin must be assessed daily when there is a sensory loss. Pressure may still occur even if the braces are well padded. Although this type of shoe will facilitate balance, assessing the skin for breakdown is the priority. Although alignment of brace joints to body joints is important in facilitating joint mobility, assessment for skin breakdown takes priority.

The parents of a toddler with a right ventriculoperitoneal (VP) shunt for the treatment of hydrocephalus are taught about postoperative positioning. The nurse concludes that they understand the teaching when they state that they will place the toddler in what position?

Flat on the left side with the head and back supported The . Basing the toddler's placement in the immediate postoperative period solely on comfort is unsafe. Neck supports should not be used for toddlers because they flex the neck, which can cause airway occlusion. The prone position is contraindicated; turning the head to the side puts pressure on the shunt.

An infant with hydrocephalus has a ventriculoperitoneal shunt surgically inserted. What nursing care is essential during the first 24 hours after this procedure?

Monitoring the infant for increasing intracranial pressure The shunt may become obstructed, leading to an accumulation of cerebrospinal fluid and increased intracranial pressure. Although providing pain relief for the infant is an important part of postsurgical care, monitoring for potentially severe complications such as increased intracranial pressure takes precedence. Positioning the infant flat helps prevent complications that may result from a too-rapid reduction of intracranial fluid. The infant is positioned off the shunt to prevent pressure on the valve and incision area.

A newborn is admitted to the neonatal intensive care unit with a myelomeningocele. What is the priority nursing intervention during the first 24 hours?

Placing the infant in a prone or side-lying position A prone or side-lying position will prevent pressure on the sac; if the sac ruptures, infection may occur. Diapers should not be applied, because they may irritate or contaminate the sac. Antiinfectives are too caustic. Assessment of the area below, not at or above, the defect is essential to determination of motor, urinary, and bowel function.

What is the priority nursing intervention for an infant with a myelomeningocele before surgical correction?

Preventing trauma to the sac A meningomyelocele is thinly covered and fragile. Trauma to the sac can damage functioning neural tissue; an intact sac eliminates a potential portal of entry for microorganisms. Although minimizing infection is extremely important, it is not the priority; care of the sac is even more important, because an intact sac bars entry by microorganisms. Although observation for paralysis is an important nursing measure, it is not the priority. The extent of a meningomyelocele will influence the child's ability to control bowel and bladder function, but control is not developed until the toddler and preschool years.

A nurse is teaching a pregnant client with sickle cell anemia about the importance of taking supplemental folic acid. How does folic acid help this client?

Promotes production of hemoglobin Folic acid is needed to produce heme for hemoglobin. Supplementation with folic acid does not reduce sickling, and it will not prevent vaso-occlusive crisis. Adequate oxygenation and hydration help prevent vaso-occlusive crisis. It does not decrease cellular oxygenation need, although, through production of hemoglobin, it can improve oxygen supply.

What should the plan of care include to minimize the potential for a sickling episode in a child with sickle cell anemia?

Promoting adequate oxygenation Low oxygen tension may precipitate sickling; therefore adequate oxygenation is desirable. Oral intake of iron may contribute to iron overload. Some children with sickle cell anemia receive frequent transfusions to suppress the production of red blood cells containing the sickle hemoglobin. Hemoconcentration results in increased viscosity, which promotes thrombus formation and sickling. Quiet play is desirable during a painful episode, but it is not used routinely to prevent a crisis.

What nursing care to prevent a crisis is the same for school-aged children with sickle cell anemia and celiac disease?

Protecting the child from infection Children with both illnesses have inadequate resistance to infection. Sickling results from a low oxygen level; celiac crisis results from malnourishment and immunologic defects. Activity need not be limited in celiac disease; strenuous activity should be limited in sickle cell anemia. Documenting the color and consistency of stools is important for children with celiac disease; it is not necessary for children with sickle cell anemia. A low-carbohydrate, high-protein, low-fat diet is not particularly helpful for children with sickle cell anemia or celiac disease.

A 4-year-old child with Wilms tumor undergoes nephrectomy. What essential information should the nurse plan to teach the parents?

Recgonize the sign of a UTI Because the child now has one kidney, the parents must watch carefully for signs and symptoms of urinary tract infection (UTI) on an ongoing basis. A UTI can compromise kidney function; therefore it should be identified in the early stage and treated immediately. A kidney transplant is not necessary because the child has a functioning kidney. Sodium is usually not restricted. Fluids are not restricted; adequate fluid intake is encouraged to prevent UTI.

A healthcare provider writes prescriptions for a young child with a tentative diagnosis of Wilms tumor. Which prescription should the *nurse question*?

Renal biopsy A renal biopsy is an invasive procedure. In the early stages, Wilms tumor is encapsulated. Any disruption of the tumor capsule may precipitate metastasis. Magnetic resonance imaging, computed tomography, and abdominal ultrasound are all helpful in making the diagnosis.

Staging of Wilms Tumor

Stage I: unilateral, limited to kidney, completely resectable Stage II: unilateral, tumor extends beyond kidney but is completely resectable Stage III: unilateral, tumor has spread outside of kidney, located in abdominal cavity only, not fully removed Stage IV: unilateral with metastasis in liver, lung, bone, or brain Stage V: bilateral kidney involvement

A primary healthcare provider recommends that an adolescent with the diagnosis of osteogenic sarcoma have the affected leg amputated and then be treated with chemotherapy. The parents are concerned about what to tell their child and ask the nurse for advice. What should the nurse suggest they discuss?

The amputation and information about chemotherapy Honesty is essential in helping the adolescent accept the loss of the leg; only a brief discussion of chemotherapy is needed, because otherwise the adolescent may be overwhelmed. A theoretical discussion and detailed information will not be heard or understood during a crisis situation. The amputation is necessary; lying avoids the issue and may destroy the adolescent's trust in parents and staff.

A toddler with a repaired *myelomeningocele* has urinary incontinence and some flaccidity of the lower extremities. What should the nurse teach the parents?

The child will probably require a program of intermittent straight catheterization. Most children with spinal cord damage resulting from spina bifida can be managed successfully with a program of intermittent straight catheterization. An ileal bladder is not necessary because most of these children can be managed successfully with intermittent straight catheterization. An indwelling catheter is the least desirable approach because of the risk for recurrent urinary tract infection. Stating that the child will have to wear diapers for many years is inaccurate and may be devastating to the parents.

A nurse is performing health screenings of toddlers in a culturally diverse neighborhood. Which child should the nurse consider at risk for beta-thalassemia (Cooley anemia)?

Two-year-old child of Greek descent with a large abdomen Beta-Thalassemia is common in children who are black or of Mediterranean descent (Italian, Greek, Syrian); an enlarged abdomen may be the result of hepatomegaly or splenomegaly. Pale skin is expected in children of Irish descent; children with β-thalassemia may have bronze skin as a result of hemosiderosis if the excess iron is not chelated. Defective hemoglobin leads to damaged red blood cells and a decreased hematocrit. Asian descent is not a risk factor for β-thalassemia.

Projectile vomiting is indicative of not Wilms tumor.

central nervous system problems or a gastrointestinal obstruction,

An absence of pedal pulses is characteristic of

coarctation of the aorta, an obstructive malformation.

Polycythemia, reflected in an increased hematocrit reading, is a

direct attempt by the body to compensate for the decrease in oxygen to all body cells caused by the mixture of oxygenated and deoxygenated circulating blood.

The spleen plays a role in immunity. Initially the spleen enlarges and becomes congested with accumulated sickled red blood cells; in time,

fibrous material replaces the tissue in the spleen, and by age 5 the spleen is obliterated. Without a spleen the child is prone to infection, which can precipitate a sickle cell crisis.

Periorbital edema is a sign of

glomerulonephritis,

Excess iron from hemolysis of the replaced red blood cells is deposited in the organs and body tissue, causing .

hemosiderosis Chelation therapy is then required.

Head circumference 2 cm greater than the chest circumference

is expected in a newborn.

Hydrocephalus complicates approximately 80% of

lumbosacral myelomeningoceles

Infants with hydrocephalus

may or may not have low Apgar scores.