Chapter 29: The Child With Cancer

A nurse is teaching a client about the risk factors associated with colorectal cancer. The nurse determines that further teaching related to the colo-rectal cancer is necessary if the client identifies which of the following as an associated risk factor? A. Age younger than 50 years B. History of coloractal polyps C. Family history of colorectal cancer D. Chronic inflammatory bowel disease"

A (Colorectal cancer risk factors include age older than 50 years, a family history of the disease, colorectal polyps, and chronic inflammatory bowel disease.)

A child with lymphoma is receiving extensive radiotherapy. Which of the following is the most common side effect of this treatment? A. Malaise B. Seizures C. Neuropathy D. Lymphadenopathy

A (Malaise is the most common side effect of radiotherapy. For children, the fatigue may be especially distressing because it means they cannot keep up with their peers.)

A diagnostic workup is being performed on a 1-year-old child with suspected neuroblastoma. The nurse reviews the results of the diagnostic tests and understands that which of the following findings is most specifically related to this type of tumor? A. Elevated vanillylmandelic acid (VMA) urinary levels B. Presence of blast cells in the bone marrow C. Projectile vomiting, usually in the morning D. Postive Babinski's sign"

A (Rationale: Neuroblastoma is a solid tumor found only in children. It arises from neural crest cells that develop into the sympathetic nervous system and the adrenal medulla. Typically, the tumor compresses adjacent normal tissue and organs. Neuroblastoma cells may excrete catecholamines and their metabolites. Urine samples will indicate elevated VMA levels. The presence of blast cells in the bone marrow occurs in leukemia. Projectile vomiting occurring most often in the morning and a positive Babinski's sign are clinical manifestations of a brain tumor.)

A child with cancer has the following lab result: WBC 10,000, RBC 5, and plts of 20,000. When planning this child's care, which risk should the nurse consider most significant? A. Hemorrage B. Anemia C. Infection D. Pain

A (The lab values presented all are normal except for the platelet count. Decreases in platelet counts place the child at greatest risk for hemorrhage.)

The nurse should teach the family that which residual disabilities can occur for a child being treated for a brain tumor? (Select all that apply.) a. Ataxia b. Anorexia c. Dysphagia d. Sensory deficits e. Crania nerve palsies

ANS: A, C, D, E Even with children who are long-term survivors after treatment for a brain tumor, residual disabilities, such as short stature, cranial nerve palsies, sensory defects, motor abnormalities (especially ataxia), intellectual deficits, dysphagia, dysgraphia, and behavioral problems, may occur. Anorexia is not a residual disability.

What is the nurse's best response to a mother whose child has a diagnosis of acute lymphoblastic leukemia and is expressing guilt about not having responded sooner to her boy's symptoms?

"It is not uncommon for parents not to notice subtle changes in their children's health."

Which statement, if made by a nurse to the parents of a child with leukemia, indicates an understanding of teaching related to home care associated with the disease?

"Your son's temperature should be taken frequently."

What should the nurse recognize as symptoms of a brain tumor in a school-age child for whom she is caring? Select all that apply.

- Blurred vision - Vomiting when getting out of bed - Intermittent headache - Declining academic performance

What are favorable prognostic criteria for acute lymphoblastic leukemia? (Select all that apply.) a. Male gender b. CALLA positive c. Early pre-B cell d. 2 to 10 years of age e. Leukocyte count 750,000/mm3

ANS: B, C, D Favorable prognostic criteria for acute lymphoblastic leukemia include CALLA positive, early pre-B cell, and age 2 to 10 years. Leukocyte count less, not greater, than 50,000/mm3 and female, not male, gender are favorable prognostic criteria

What guidelines should the nurse follow when handling chemotherapeutic agents? (Select all that apply.) a. Use clean technique. b. Prepare medications in a safety cabinet. c. Wear gloves designed for handling chemotherapy. d. Wear face and eye protection when splashing is possible. e. Discard gloves and protective clothing in a special container.

ANS: B, C, D, E Safe handling of chemotherapeutic agents includes preparing medications in a safety cabinet, wearing gloves designed for handling chemotherapy, wearing face and eye protection when splashing is possible, and discarding gloves and protective clothing in a special container. Aseptic, not clean, technique should be used

Calculate the absolute neutrophil count (ANC) for the following: WBC count of 5000 mm3; neutrophils (segs) of 10%; and nonsegmented neutrophils (bands) of 12%. a. 110/mm3 b. 500/mm3 c. 1100/mm3 d. 5000/mm3

ANS: C Determine the total percentage of neutrophils ("polys," or "segs," and "bands"). Multiply white blood cell (WBC) count by percentage of neutrophils. WBC = 1000/mm3, neutrophils = 7%, and nonsegmented neutrophils (bands) = 7% Step 1: 10% + 12% = 22% Step 2: 0.22 5000 = 1100/mm3 ANC

A nurse determines that parents understood the teaching from the pediatric oncologist if the parents indicate that which test confirms the diagnosis of leukemia in children? a. Complete blood cell count (CBC) b. Lumbar puncture c. Bone marrow biopsy d. Computed tomography (CT) scan

ANS: C Feedback A A CBC may show blast cells that would raise suspicion of leukemia. It is not a confirming diagnostic study. B A lumbar puncture is done to check for central nervous system involvement in the child who has been diagnosed with leukemia. C The confirming test for leukemia is microscopic examination of bone marrow obtained by bone marrow aspiration and biopsy. D A CT scan may be done to check for bone involvement in the child with leukemia. It does not confirm a diagnosis.

Daily toothbrushing and flossing can be encouraged for the child on chemotherapy when the platelet count is above which? a. 10,000/mm3 b. 20,000/mm3 c. 30,000/mm3 d. 40,000/mm3

ANS: D Daily toothbrushing and flossing are encouraged in children with platelet counts above 40,000/mm3.

The pediatric nurse understands that the most common cancer found in children is: A. Non-hodgkin's lymphoma B. Acute lymphocytic leukemia C. Chronic lymphocytic leukemia D. Ewing's sarcoma"

B (1. No - this is not a common cancer in children 2. YES! this is the most common form of cancer found in children is acute lymphocytic leukemia. 3. No - this is not a common cancer in children 4. No - this is not a common cancer in children)

Cancer Diagnosis

CBC w/ Absolute Neutrophil Count (ANC) - This will test for degree of anemia, platelet count and competency of the immune system Concern if ANC <500 ANC = WBC x seg(neutrophils) + bands Electrolyte panel - Looks at renal and liver function in terms of toleration of chemotherapy - LDH, creatinine, Uric acid may be elevated in leukemia - Bone metastasis leads to elevated alkaline phosphatase - Renal function is monitored during tx phase Tumor markers - Metabolites or part of the cancer cells that can be detected in serum urine - EX: a-fetoprotein(serum) or catecholamine(neurobalstoma)(urine)

Neuroblastoma Therapeutic Management

Chemotherapy is main form of treatment Surgery to biopsy, debulk with the goal is to remove as much tumor as possible Radiotherapy is more for palliation or emergency management (spinal cord compression or hepatomegaly)

Quality pt Outcomes for Cancer Children

Child and family educated on disease and tx Tx admin on schedule with appropriate drug doses SE of tx managed Tx complications prevented Child and family coping skills supported Quality of life during tx maintained Child and family adjusted to chronic illness Growth and development maintained during tx General nursing care plan

Special issues with childhood survival: Secondary malignancies

Child is a risk for bone and soft tissues tumors and Nonhogkins lymphoma

Genetic Base

Chromosome 13- retinoblastoma (Rb-1 gene) that may lead to osteosarcoma Chromosome 11- nephroblastoma (Wilms' tumor) - WT1 gene

You are working with the parents of a pediatric oncology patient who has successfully responded to therapy but is now experiencing body image changes as a result of hair loss due to chemotherapy regimen. The parents are upset about this change in their child's appearance. Which response would be appropriate with regard to the parent's concern? A. As the therapy has been successful, it is important to focus on that rather than body image changes. B. Tell the parents that the child's hair will grow back soon. C. Tell the parents that the child's hair will grow back stronger and healthier. D. Acknowledge the parent's concern and focus on available options that may be used to help with body image concerns.

D

The nurse is completing a care plan for a client diagnosed with leukemia. Which independent problem should be addressed? A. Infection. B. Anemia. C. Nutrition. D. Grieving.

D (Grieving is an independent problem, and the nurse can assess and treat this problem with or without collaboration)

An example of a disease process that is based on a "two-hit" hypothesis leading to a cancer diagnosis is: A. Fanconi anemia. B. Wiskott Aldrich syndrome. C. Klinefelter syndrome. D. Retinoblastoma.

D.

In taking care of a pediatric oncology patient, which diagnostic finding would indicate a critical concern for the development of bleeding? A. Absolute neutrophil count of 1000 mm3 B. Temperature of 99.2° F C. White blood cell count 18,000 mm3 D. Platelet count 50,000 mm3

D.

Retinoblastoma Tx

Early stage needs unilateral irradiation and cryotherapy. There is an attempt to preserve useful vision in the affected eye with need to continue monitoring eye health because it can become bilateral. In bilateral disease, the attempt is to preserve useful vision in least affected eye. Advanced tumor requires enucleation (removal of eye). If enulcleation needed, then discussion surrounding child appearance post-op. Teach socket care and the use a conformer to help keep socket shape while awaiting the prosthesis. Once prosthesis in place, need teaching surrounding cleaning and what happens with accidental dislodgement. Later the child can do this task.

What is an expected physical assessment finding for an adolescent with a diagnosis of Hodgkin disease?

Enlarged, painless, firm cervical lymph nodes

Special issues with childhood survival: Adbomen

GI tract - Chronic malabsorption w/issues of weight and diarrhea Liver - fibrosis and liver affecting function Urinary system - nephritis and chronic cystitis Ovaries/ testes - Concern with infertility - Male sperm banking - EBP increasing physician/pt dialogue

Special issues with childhood survival: Head and Neck

Hormones - As the result of gland dysfunction. Follow-up needed and if found will require replacement therapy CNS - Necrosis and demylenizaion of white matter. This leads to sleepiness, lethargy, seizures. Damage to grey matter can lead to learning disabilities and chronic HA

Immune Disorders

Immunodeficient child more likely to develop various cancers like lymphoma. This can be from AIDS, after solid organ transplant, or previous cancer Virus or apoptosis allows pro-oncogens become onocogene sometimes due to lack of tumor suppressor genes

Rhabdomyosarcoma Clinical Manifestations

Initial s/s related to site of tumor/compression of adjacent organ. Organs. Symptoms initially are vague and resemble common childhood illnessess Locations of Tumor and common manifestations: - Orbit: rapid development of bilateral proptosis, ecchymosis of conjuctiva, & loss of extraocular movements - Nasopharynx: stuffy nose, pain, epitaxis, nasal obstruction, palpable nodes of neck, visible mass (late stage) - Paranasal sinuses: swelling, discharge, & sinusitis - Retroperitoneal: generally "silent tumor"; signs of obstruction, abdominal mass, & pain - Perineum: superficial mass & bowel/bladder dysfunction from tumor compression

What should the nurse teach parents about oral hygiene for the child receiving chemotherapy?

Inspect the child's mouth daily for ulcers.

Rhabdomyosarcoma

It comes from the primitive muscle cells called rhabdomyoblasts that instead of becoming striated muscle cells: they just grow out of control from embryonic meschyme cells in muscles, tendons, fascia, lymphatic or vascular tissue Most common locations: head and neck, especially orbit followed by retroperitoneal High grade tumor with potential for metastasis (so may have PET scan to determine sites

A child with a history of fever of unknown origin, excessive bruising, lymphadenopathy, anemia, and fatigue is exhibiting symptoms most suggestive of

Leukemia

Acute Leukemia Patho

Leukemia is a broad term given to a group of malignant diseases of the bone marrow and lymphatic system Unrestricted proliferation of immature WBC in the blood-forming tissues of the body Cellular destruction occurs through the process of infiltration of the immature blast saturating the bone marrow with subsequent competition for metabolic elements

Special issues with childhood survival: Chest

Lungs - Chronic pneumonia or fibrosis of the lungs Heart - restrictive cardiomyophathy

Nephroblastoma Clinical Manifestations

Painless swelling or mass within the abdomen - Mass is firm, non-tender, does not cross midline and deep within the flank (may have bilateral masses if both kidneys involved) DO NOT PALPATE Other manifestations occur secondary to compression from the mass - Hematuria - Anemia s/t hemorrhage within the tumor or persistent hematuria (pallor and lethargy) - Hypertension s/t over excretion of renin - Weight loss and fever Could metastasize → lung involvement (dyspnea, cough, SOB, CP)

What fluid is the best choice when a child with mucositis asks for something to drink?

Popsicle

Osteosarcoma Therapeutic management

Preoperative Chemotherapy Surgical resection or amputation may be needed

How is it diagnosed?

Staging - Type, severity and spread of cancer cells at the time of diagnosis - Stage 1 is best prognosis as disease limited to the primary site and highest stage of classification means extensive metastasis is present, so often leads to poor prognosis - Various tests may be needed to determine actual stage Nursing Considerations for the testing is that most are painful, so consider conscious sedation for most procedures

The nurse should base a response to a parent's question about the prognosis of acute lymphoblastic leukemia (ALL) on the knowledge that

The majority of children go into remission and remain symptom free when treatment is completed.

Hodgkin's Disease Patho

The malignancy originates in the lymphoid system and primarily involves the lymph nodes It metastasizes to non-nodal or extra-lymphatic sites especially like the spleen, liver, bone marrow, lungs, and mediastinum but it can really spread to any system Diagnosis demonstrates + Reed-Sternberg cell (large abnormal lymphocyte) from the lymph node. Differentiates it from NHL but other virus can have Reed Sternberg cells (EBV)

Non-Hodgkin Lymphoma patho

Tumors originating from malignant disorders of the lymphoreticular system. The disease can also spread to other parts of your lymphatic system. These include the lymphatic vessels, tonsils, adenoids, spleen, thymus and bone marrow

Which clinical finding is an overt sign of retinoblastoma in children?

Whitish reflex in the eye

Ewings Sarcoma

XRAY: showing an "onion skin" appearance Bone biopsy to confirm CT to look for metastasis (lung is common)

Retinoblastoma

is a congenital intraocular malignant tumor, arises from the retina may be in one or both eyes. It has hereditary component (test for RB1 gene located on chromosome 13q14).

Retinoblastoma clinical manifestations

is the presence of a whitish "glow" in the pupil, known as the cat's eye reflex, or leukocoria, which is a visualization of the tumor as the light falls on the mass.

When an adolescent with a new diagnosis of Ewing sarcoma asks the nurse about treatment, the nurse's response is based on the knowledge that (select all that apply)

- This type of tumor invades the bone. - Management includes chemotherapy, surgery, and radiation. - Affected bones such as ribs and proximal fibula may be removed to excise the tumor.

Surgery

- Used to remove all tumor or debulk, if total removal impossible - Most successful when tumor is encapsulated and has not spread - The use of surgery is declining

Bone Marrow Aspirate

- Usually done under conscious sedation - Prepare the young child as they may not be totally asleep but it should not hurt when they do the test - Educate the pt in that they will have a large band aid on their hip when they wake up - The hip will be sore but resting, initially, then playing normally will help that to go away. They need to let the nurse know if it hurts really bad as he/she can give them pain medicine - Need to monitor site for bleeding - Definitive test for leukemia and other solid tumors

Acute Leukemia Clinical Manifestations

3 main consequences (lead to bone pain) - Fatigue (for anemia) - Infection (from neutropenia) - Bleeding/eccohymosis (thrombocytopenia) Organs enlarged and eventually leads to fibrosis - Spleen, liver, and lymph glands With CNS involvement (leukemic cells infiltrate CSF) - s/sx of increase ICP - CN 7 (facial nerve), hypothalamus, and cerebrum (manifestations are related to area involved) --> difference of these is that they are not localized

Medication list

Antineoplastic agents Antibiotics: gentamycin, vancomycin, amikacin, cefipime, cefotetan, clindamycin, imipenem/cilastatin, meropenem, piperacilllin/tazobactam, and prophalyatic trimethoprim-sulfamethoxazole (Bactrim). Antifungal: nystatin, amphotericin B and caspofungin. Antiviral: acyclovir and ganciclovir. Antiemetic: ondansetron (EBP), diphenhydramine, metaclopramide, Colony stimulating factors: erythropoietin and G-CSF (filgastrin). Non-opioids: acetaminophen and ibuprofen Opioids: morphine, fentanyl, hydromorphone. Stool softeners: docusate and polyethylene glycol 3350 (Mira Lax) (EBP) Uric acid reducer: allopurinol (used in leukemia and Non-Hodgkin's Lymphoma.)

A 15-year-old has been admitted to the hospital with the diagnosis of acute lymphocytic leukemia. Which of the following signs and symptoms require the most immediate nursing intervention? A. Fatigue and Anorexia B. Fever and Petechiae C. Swollen lymph nodes in the neck and lethargy. D. Enlarged liver and spleen

B (Fever and petechiae associated with acute lymphocytic leukemia indicate a suppression of normal white blood cells and thrombocytes by the bone marrow and put the client at risk for other infections and bleeding. The nurse should initiate infection control and safety precautions to reduce these risks. Fatigue is a common symptom of leukemia due to red blood cell suppression. Although the client should be told about the need for rest and meal planning, such teaching is not the priority intervention. Swollen glands and lethargy may be uncomfortable but they do not require immediate intervention. An enlarged liver and spleen do require safety precautions that prevent injury to the abdomen; however, these precautions are not the priority.)

A preschool-aged child is to undergo several painful procedures. Which of the following techniques is most-appropriate for the nurse to use in preparing the child? A. Allow the child to practice injections on a favorite doll. B. Explain the procedure in simple terms. C. Allow a family member to explain the procedure to the child. D. Allow the child to watch an educational video.

B (Preschoolers have the cognitive ability to understand simple terms. Use of a favorite doll is contraindicated because it is ""part"" of that child and he/she might perceive the doll is experiencing pain.)

After a client is admitted to the pediatric unit with a diagnosis of acute lymphocytic leukemia, the laboratory test indicates that the client is neutropenic. The nurse should perform which of the following? a. Advise the client to rest and avoid exertion b. Prevent client exposure to infections c. Monitor the blood pressure frequently d. Observe for increased bruising

B (Rationale: Neutropenia is a decreased number of neutrophil cells in the blood which are responsible for the body's defense against infection. Rest and avoid exertion would be related to erythrocytes and oxygen carrying properties. Monitoring the blood pressure, and observing for bruising would be related to platelets and sign and symptoms of bleeding.)

A pediatric oncology patient is undergoing chemotherapy. Which observation would lead the nurse to suspect that the patient has developed sterile hemorrhagic cystitis? A. Absence of hematuria B. Presence of proteinuria C. Complaints by the patient that it burns upon urination D. Increased sensation of thirst.

B.

A nurse determines that parents understood the teaching from the pediatric oncologist if the parents indicate that which test confirms the diagnosis of leukemia in children?

Bone marrow biopsy

The nurse understands that the type of precautions needed for children receiving chemotherapy is based on which actions of chemotherapeutic agents?

Bone marrow suppression

A child being treated for Acute Lymphocytic Leukemia (ALL) has a white blood cell (WBC) count of 7,000/mm3. the nursing care plan lists risk for infection as a priority nursing diagnosis, and measures are being taken to reduce the child's exposure to infection. the nurse determines that the plan has been successful when which outcome has been met? A. child's WBC count goes up. B. child's WBC count goes down. C. child's temperature remains within normal range. D. parents demonstrate good hand washing technique."

C (In leukemia, the WBCs that are present are immature and incapable of fighting infection. increases or decreases in the number of WBCs can be related to the disease process and treatment, and not related to infection. the only value that indicates the child is infection-free is the temperature. the use of proper handwashing technique is a measure or intervention used to meet a goal. but is not a goal itself. STRATEGY: the core issue of the question is knowledge of an indicator of infection in a client who is immunosuppressed from leukemia. recall that temperature and WBC counts are frequently used as indicators of infection. recall that in leukemia the WBCs are abnormal so choose the option related to temperature.)

A child is admitted to the hospital with a diagnosis of Wilm's tumor, Stage II. Which of the following statements most accurately describes this stage? A. The tumor is less than 3 cm. in size and requires no chemotherapy. B. The tumor did not extend beyond the kidney and was completely resected. C. The tumor extended beyond the kidney but was completely resected. D. The tumor has spread into the abdominal cavity and cannot be resected.

C (The staging of Wilm's tumor is confirmed at surgery as follows: Stage I, the tumor is limited to the kidney and completely resected; stage II, the tumor extends beyond the kidney but is completely resected; stage III, residual nonhematogenous tumor is confined to the abdomen; stage IV, hematogenous metastasis has occurred with spread beyond the abdomen; and stage V, bilateral renal involvement is present at diagnosis.)

A nurse analyzes the lab values of a child with leukemia who is receiving chemotherapy. The nurse notices that the platelet count is 19,500 cell/mm3. Based on this lab value which intervention would the nurse document in her plan of care. A. Monitor closely for signs of infection. B. Temp every four hours. C. Isolation precautions D. Use a small toothbrush for mouth care"

D (Leukemia is a malignant increase in the number of leukocytes, usually at an immature stage, in the bone marrow. It affects the bone marrow, causing from decreased erythrocytes, infection from neutropenia, and bleeding from decreased platelet production. If the platelet count is les than 20,000 than bleeding precautions need to be taken.)

Chemotherapy dosage is frequently based on total body surFace area (BSA), so it is important for the nurse to do which of the following before administering chemotherapy? A. Measure abdominal girth B. Claculate BMI C. Ask the client about his/her height and weight D. Weigh and measure the client on the day of medication administration

D (To ensure that the client receives optimal doses of chemotherapy, dosing is usually based on the total Body surface area(BSA) which requires accurate height and weight before each med administration. Simply asking the client about height/weight may lead to inaccuracies in determining BSA. Calculating BMI and measuring abdominal girth does not provide the data needed.)

A preschool-age child undergoing chemotherapy experiences nausea and vomiting. Which of the following would be the best intervention to include in the child's plan of care? a. Administer tube feedings. b. Offer small, frequent meals. c. Offer fluids only between meals. d. Allow the child to choose what to eat for meals.

D (While all options can be done to encourage nutrition, allowing the preschooler choices meets two issues: nutrition and developmental tasks.)

A child with a brain tumor is undergoing radiation therapy. What should the nurse include in the discharge instructions to the child's parents? Select all that apply.

- Avoid excessive skin exposure to the sun. - Plan for adequate rest periods for the child. - A darkening of the skin receiving radiation is expected.

CT and MRI

- CT, MIR, PET and metaidobenzylguanine (MIBG) scans are being used to visualize the tumors and begin the diagnostic process - They do not hurt but the child does have to lay still

Lumbar Puncture

- Done with conscious sedation - Pt. needs to lie flat afterwards - Monitor site for bleeding or infection - It is used routinely for metastasis to the brain from leukemia and other tumors

Biopsy

- Surgical removal of tissue cells and sent to lab - Used to confirm diagnosis and stage of disease - Done under conscious sedation or as general surgery in outpatient setting - Anxiety for parents as they await diagnosis

Pediatric Differences

1. Cancer are nonepithelial or embryonic in origin 2. Occur in deep body tissue so that it is not visible or palpable until large. So cancer more advanced at time or diagnosis 3. Tumors are fast growing and healthy child can be suddenly ill in matter of weeks 4.Due to the immature functioning of the immune system as the body's major defense.. For the young child, the body fails to attack the cancer cells and therefore protect the body and there is a higher rate of cellular growth = rapid progression of cancer 5. Leukemia being the most common primary childhood cancer

What causes cancer

1. Immune disorders 2. Chromosome abnormalities 3. Genetic base

A child is undergoing remission induction therapy to treat leukemia. Allopurinol is included in the regimen. The main reason for administering allopurinol as part of the client's chemotherapy regimen is to: a. Prevent metabolic breakdown of xanthine to uric acid b. Prevent uric acid from precipitating in the ureters c. Enhance the production of uric acid to ensure adequate excretion of urine d. Ensure that the chemotherapy doesn't adversely affect the bone marrow"

A (The massive cell destruction resulting from chemotherapy may place the client at risk for developing renal calculi; adding allopurinol decreases this risk by preventing the breakdown of xanthine to uric acid. Allopurinol doesn't act in the manner described in the other options.)

The mother of a 5-year-old child asks the nurse questions regarding the importance of vigilant use of sunscreen. Which information is most important for the nurse to convey to the mother? a.) Appropriate use of sunscreen decreases the risk of skin cancer. b.) Repeated exposure to the sun causes premature aging of the skin. c.) A child's skin is delicate, and burns easily. d.) In addition to causing skin cancer, repeated sun exposure predisposes the child to other forms of cancer.

A (While all of the answer choices are correct, recommending the use of sunscreen to decrease the incidence of skin cancer (a) is the best response.)

A young child with leukemia has anorexia and severe stomatitis. What approach should the nurse suggest that the parents try? a. Relax any eating pressures. b. Firmly insist that the child eat normally. c. Serve foods that are either hot or cold. d. Provide only liquids because chewing is painful.

ANS: A A multifaceted approach is necessary for children with severe stomatitis and anorexia. First, the parents should relax eating pressures. The nurse should suggest that the parents try soft, bland foods; normal saline or bicarbonate mouthwashes; and local anesthetics. Insisting that the child eat normally is not suggested. For some children, not eating may be a way to maintain some control. This can set the child and caregiver in opposition to each other. Hot and cold foods can be painful on ulcerated mucosal membranes. Substitution of high-calorie foods that the child likes and can eat should be used.

After chemotherapy is begun for a child with acute leukemia, prophylaxis to prevent acute tumor lysis syndrome includes which therapeutic intervention? a. Hydration b. Oxygenation c. Corticosteroids d. Pain management

ANS: A Acute tumor lysis syndrome results from the release of intracellular metabolites during the initial treatment of leukemia. Hyperuricemia, hypocalcemia, hyperphosphatemia, and hyperkalemia can result. Hydration is used to reduce the metabolic consequences of the tumor lysis. Oxygenation is not helpful in preventing acute tumor lysis syndrome. Allopurinol, not corticosteroids, is indicated for pharmacologic management. Pain management may be indicated for supportive therapy of the child, but it does not prevent acute tumor lysis syndrome.

What is appropriate mouth care for a toddler with mucosal ulceration related to chemotherapy? a. Mouthwashes with plain saline b. Lemon glycerin swabs for cleansing c. Mouthwashes with hydrogen peroxide d. Swish and swallow with viscous lidocaine

ANS: A Administering mouth care is particularly difficult in infants and toddlers. A satisfactory method of cleaning the gums is to wrap a piece of gauze around a finger; soak it in saline or plain water; and swab the gums, palate, and inner cheek surfaces with the finger. Mouth rinses are best accomplished with plain water or saline because the child cannot gargle or spit out excess fluid. Avoid agents such as lemon glycerin swabs and hydrogen peroxide because of the drying effects on the mucosa. Lidocaine should be avoided in young children

A child has been diagnosed with a Wilms tumor. What should preoperative nursing care include? a. Careful bathing and handling b. Monitoring of behavioral status c. Maintenance of strict isolation d. Administration of packed red blood cells

ANS: A Careful bathing and handling are important in preventing trauma to the Wilms tumor site

Which nursing intervention should not be included in the postoperative plan of care for a child undergoing surgery for a brain tumor? a. Place the child in Trendelenburg position. b. Perform neurologic assessments. c. Assess dressings for drainage. d. Monitor temperature.

ANS: A Feedback A The child is never placed in the Trendelenburg position because it increases intracranial pressure and the risk of bleeding. B Increased intracranial pressure is a risk in the postoperative period. The nurse would assess the child's neurologic status frequently. C Hemorrhage is a risk in the postoperative period. The child's dressing would be inspected frequently for bleeding. D Temperature is monitored closely because the child is at risk for infection in the postoperative period.

The nurse notes that a child's gums bleed easily and he has bruising and petechiae on his extremities. What laboratory values are consistent with these symptoms? a. Platelet count of 19,000/mm3 b. Prothrombin time of 11 to 15 seconds c. Hematocrit of 34 d. Leukocyte count of 14,000/mm3

ANS: A Feedback A The normal platelet count is 150,000 to 400,000/mm3. This finding is very low, indicating an increased bleeding potential. The child should be monitored closely for signs of bleeding. B The prothrombin time of 11 to 15 seconds is within normal limits. C The normal hematocrit is 35 to 45 and, although this finding is low, it would not create the symptoms presented. D This value indicates the probable presence of infection, but it is not a reflection of bleeding tendency.

What are the most common clinical manifestations of brain tumors in children? a. Headaches and vomiting b. Blurred vision and ataxia c. Hydrocephalus and clumsy gait d. Fever and poor fine motor control

ANS: A Headaches, especially on awakening, and vomiting that is not related to feeding are the most common clinical manifestations of brain tumors in children. Diplopia (double vision), not blurred vision, can be a presenting sign of brainstem glioma. Ataxia is a clinical manifestation of brain tumors, but headaches and vomiting are the most common. Hydrocephalus can be a presenting sign in infants when the sutures have not closed. Children at this age are usually not walking steadily. Poor fine motor coordination may be a presenting sign of astrocytoma, but headaches and vomiting are the most common presenting signs of brain tumors

An adolescent is scheduled for a leg amputation in 2 days for treatment of osteosarcoma. What approach should the nurse implement? a. Answer questions with straightforward honesty. b. Avoid discussing the seriousness of the condition. c. Explain that although the amputation is difficult, it will cure the cancer. d. Help the adolescent accept the amputation as better than a long course of chemotherapy.

ANS: A Honesty is essential to gain the child's cooperation and trust. The diagnosis of cancer should not be disguised with falsehoods. The adolescent should be prepared for the surgery so there is time for reflection about the diagnosis and subsequent treatment. This allows questions to be answered. To accept the need for radical surgery, the child must be aware of the lack of alternatives for treatment. Amputation is necessary, but it will not guarantee a cure. Chemotherapy is an integral part of the therapy with surgery. The child should be informed of the need for chemotherapy and its side effects before surgery

One pediatric oncologic emergency is acute tumor lysis syndrome. Symptoms that this may be occurring include what? a. Muscle cramps and tetany b. Respiratory distress and cyanosis c. Thrombocytopenia and sepsis d. Upper extremity edema and neck vein distension

ANS: A Risk factors for development of tumor lysis syndrome include a high white blood cell count at diagnosis, large tumor burden, sensitivity to chemotherapy, and high proliferative rate. In addition to the described metabolic abnormalities, children may develop a spectrum of clinical symptoms, including flank pain, lethargy, nausea and vomiting, muscle cramps, pruritus, tetany, and seizures. Respiratory distress and cyanosis occur with hyperleukocytosis. Thrombocytopenia and sepsis occur with disseminated intravascular coagulation. Upper extremity edema and neck vein distention occur with superior vena cava syndrome

A parent of a hospitalized child on chemotherapy asks the nurse if a sibling of the hospitalized child should receive the varicella vaccination. The nurse should give which response? a. The sibling can get a varicella vaccination. b. The sibling should not get a varicella vaccination. c. The sibling should wait until the child is finished with chemotherapy. d. The sibling should get varicella-zoster immune globulin if exposed to chickenpox.

ANS: A Siblings and other family members can receive the live measles, mumps, and rubella vaccine and the varicella vaccine without risk to the child who is immunosuppressed

As part of the diagnostic evaluation of a child with cancer, biopsies are important for staging. What statement explains what staging means? a. Extent of the disease at the time of diagnosis b. Rate normal cells are being replaced by cancer cells c. Biologic characteristics of the tumor or lymph nodes d. Abnormal, unrestricted growth of cancer cells producing organ damage

ANS: A Staging is a description of the extent of the disease at the time of diagnosis. Staging criteria exist for most tumors. The stage usually relates directly to the prognosis; the higher the stage, the poorer the prognosis. The rate that normal cells are being replaced by cancer cells is not a definition of staging. Classification of the tumor refers to the biologic characteristics of the tumor or lymph nodes. Abnormal, unrestricted growth of cancer cells producing organ damage describes how cancer cells grow and can cause damage to an organ

The nurse should expect to care for which age of child if the admitting diagnosis is retinoblastoma? a. Infant or toddler b. Preschool- or school-age child c. School-age or adolescent child d. Adolescent

ANS: A The average age of the child at the time of diagnosis is 2 years, and bilateral and hereditary disease is diagnosed earlier than unilateral and nonhereditary disease.

In teaching parents how to minimize or prevent bleeding episodes when the child is myelosuppressed, the nurse includes what information? a. Meticulous mouth care is essential to avoid mucositis. b. Rectal temperatures are necessary to monitor for infection. c. Intramuscular injections are preferred to intravenous ones. d. Platelet transfusions are given to maintain a count greater than 50,000/mm3.

ANS: A The decrease in blood platelets secondary to the myelosuppression of chemotherapy can cause an increase in bleeding. The child and family are taught how to perform good oral hygiene to minimize gingival bleeding and mucositis. Rectal temperatures are avoided to minimize the risk of ulceration. Hygiene is also emphasized. Intramuscular injections are avoided because of the risk of bleeding into the muscle and of infection. Platelet transfusions are usually not given unless there is active bleeding or the platelet count is less than 10,000/mm3. The use of platelets when not necessary can contribute to antibody formation and increased destruction of platelets when transfused.

A child with cancer being treated with chemotherapy is receiving a platelet transfusion. The nurse understands that the transfused platelets should survive the body for how many days? a. 1 to 3 days b. 4 to 6 days c. 7 to 9 days d. 10 to 12 days

ANS: A Transfused platelets generally survive in the body for 1 to 3 days. The peak effect is reached in about 1 hour and decreased by half in 24 hours

A child is receiving vincristine (Oncovin). The nurse should monitor for which side effect of this medication? a. Diarrhea b. Photosensitivity c. Constipation d. Ototoxicity

ANS: A Vincristine, and to a lesser extent vinblastine, can cause various neurotoxic effects. One of the more common neurotoxic effects is severe constipation caused from decreased bowel innervation.

What strategies should the nurse implement to increase nutritional intake for the child receiving chemotherapy? (Select all that apply.) a. Allow the child any food tolerated. b. Fortify foods with nutritious supplements. c. Allow the child to be involved in food selection. d. Encourage the parents to place pressure on the importance of eating. e. Encourage the child to eat favorite foods during infusion of chemotherapy medications.

ANS: A, B, C To increase nutritional intake for the child receiving chemotherapy, the nurse should allow the child any food tolerated, fortify foods with nutritious supplements, and allow the child to be involved in food selection. The parents should be encouraged to reduce pressure placed on eating. Some children develop aversions to certain foods if they are eaten during chemotherapy. It is best to refrain from offering the child's favorite foods while the child is receiving chemotherapy.

A child on chemotherapy has developed rectal ulcers. What interventions should the nurse teach to the child and parents to relieve the discomfort of rectal ulcers? (Select all that apply.) a. Warm sitz baths b. Use of stool softeners c. Record bowel movements d. Use of an opioid for discomfort e. Occlusive ointment applied to the area

ANS: A, B, C, E If rectal ulcers develop, meticulous toilet hygiene, warm sitz baths after each bowel movement, and an occlusive ointment applied to the ulcerated area promote healing; the use of stool softeners is necessary to prevent further discomfort. Parents should record bowel movements because the child may voluntarily avoid defecation to prevent discomfort. Opioids would cause increased constipation.

What should the nurse recognize as symptoms of a brain tumor in a school-age child for whom she is caring? (Select all that apply.) a. Blurred vision b. Increased head circumference c. Vomiting when getting out of bed d. Intermittent headache e. Declining academic performance

ANS: A, C, D, E Feedback Correct Visual changes such as nystagmus, diplopia, and strabismus are manifestations of a brain tumor. The change in position on awakening causes an increase in intracranial pressure, which is manifested as vomiting. Vomiting on awakening is considered a hallmark symptom of a brain tumor. Increased intracranial pressure resulting from a brain tumor is manifested as a headache. School-age children may exhibit declining academic performance, fatigue, personality changes, and symptoms of vague, intermittent headache. Other symptoms may include seizures or focal neurologic deficits. Incorrect Manifestations of brain tumors vary with tumor location and the child's age and development. Infants with brain tumors may have increased head circumference with a bulging fontanel. School-age children have closed fontanels and therefore their head circumferences do not increase with brain tumors.

The nurse is precepting a new graduate nurse at an ambulatory pediatric hematology and oncology clinic. What cardinal signs of cancer in children should the nurse make the new nurse aware of? (Select all that apply.) a. Sudden tendency to bruise easily b. Transitory, generalized pain c. Frequent headaches d. Excessive, rapid weight gain e. Gradual, steady fever f. Unexplained loss of energy

ANS: A, C, F The cardinal signs of cancer in children include a sudden tendency to bruise easily; frequent headaches, often with vomiting; and an unexplained loss of energy. Other cardinal signs include persistent, localized pain; excessive, rapid weight loss; and a prolonged, unexplained fever.

The nurse is caring for a 6-year-old child with acute lymphoblastic leukemia (ALL). The parent states, "My child has a low platelet count, and we are being discharged this afternoon. What do I need to do at home?" What statement is most appropriate for the nurse to make? a. "You should give your child aspirin instead of acetaminophen for fever or pain." b. "Your child should avoid contact sports or activities that could cause bleeding." c. "You should feed your child a bland, soft, moist diet for the next week." d. "Your child should avoid large groups of people for the next week."

ANS: B A child with a low platelet count needs to avoid activities that could cause bleeding such as playing contact sports, climbing trees, using playground equipment, or bike riding. The child should be given acetaminophen, not aspirin, for fever or pain; the child does not need to be on a soft, bland diet or avoid large groups of people because of the low platelet count

A child with osteosarcoma is experiencing phantom limb pain after an amputation. What prescribed medication is effective for short-term phantom pain relief? a. Phenytoin (Dilantin) b. Gabapentin (Neurontin) c. Valproic Acid (Depakote) d. Phenobarbital (Phenobarbital)

ANS: B A recent Cochrane review reported that various medications have been used for phantom limb pain but complete pain relief has been unsuccessful. Morphine, gabapentin, and ketamine are effective for short-term pain relief.

Essential postoperative nursing management of a child after removal of a brain tumor includes which nursing care? a. Turning and positioning every 2 hours b. Measuring all fluid intake and output c. Changing the dressing when it becomes soiled d. Using maximum lighting to ensure accurate observations

ANS: B After brain surgery, cerebral edema is a risk. Careful monitoring is essential. All fluids, including intravenous antibiotics, are included in the intake. Turning and positioning depend on the surgical procedure. When large tumors are removed, the child is usually not positioned on the operative side. The dressing is not changed. It is reinforced with gauze after the amount of drainage is marked and estimated. A quiet, dimly lit environment is optimum to decrease stimulation and relieve discomfort such as headaches.

An adolescent will receive a bone marrow transplant (BMT). The nurse should explain that the bone marrow will be administered by which method? a. Bone grafting b. Intravenous infusion c. Bone marrow injection d. Intraabdominal infusion

ANS: B Bone marrow from a donor is infused intravenously, and the transfused stem cells migrate to the recipient's marrow and repopulate it.

A child, age 10 years, has a neuroblastoma and is in the hospital for additional chemotherapy treatments. What laboratory values are most likely this child's? a. White blood cell count, 17,000/mm3; hemoglobin, 15 g/dl b. White blood cell count, 3,000/mm3; hemoglobin, 11.5 g/dl c. Platelets, 450,000/mm3; hemoglobin, 12 g/dl d. White blood cell count, 10,000/mm3; platelets, 175,000/mm3

ANS: B Chemotherapy is the mainstay of therapy for extensive local or disseminated neuroblastoma. The drugs of choice are vincristine, doxorubicin, cyclophosphamide, cisplatin, etoposide, ifosfamide, and carboplatin. These cause immunosuppression, so the laboratory values will indicate a low white blood cell count and hemoglobin.

The nurse is collecting a 24-hour urine sample on a child with suspected diagnosis of neuroblastoma. What finding in the urine is expected with neuroblastomas? a. Ketones b. Catecholamines c. Red blood cells d. Excessive white blood cells

ANS: B Neuroblastomas, particularly those arising on the adrenal glands or from a sympathetic chain, excrete the catecholamines epinephrine and norepinephrine. Urinary excretion of catecholamines is detected in approximately 95% of children with adrenal or sympathetic tumors.

The nurse is caring for a child receiving chemotherapy for leukemia. The child's granulocyte count is 600/mm3 and platelet count is 45,000/mm3. What oral care should the nurse recommend for this child? a. Rinsing mouth with water b. Daily toothbrushing and flossing c. Lemon glycerin swabs for cleansing d. Wiping teeth with moistened gauze or Toothettes

ANS: B Oral care is essential for children receiving chemotherapy to prevent infections and other complications. When the child's granulocyte count is above 500/mm3 and platelet count is above 40,000/mm3, daily brushing and flossing are recommended. Rinsing the mouth with water is not effective for oral hygiene. Lemon glycerin swabs are avoided because they have a drying effect on the mucous membranes, and the lemon may irritate eroded tissue and decay the child's teeth. Wiping teeth with moistened gauze or Toothettes is recommended when the child's granulocyte count is below 500/mm3 and platelet count is below 40,000/mm3

What childhood cancer may demonstrate patterns of inheritance that suggest a familial basis? a. Leukemia b. Retinoblastoma c. Rhabdomyosarcoma d. Osteogenic sarcoma

ANS: B Retinoblastoma is an example of a pediatric cancer that demonstrates inheritance. The absence of the retinoblastoma gene allows for abnormal cell growth and the development of retinoblastoma. Chromosome abnormalities are present in many malignancies. They do not indicate a familial pattern of inheritance. The Philadelphia chromosome is observed in almost all individuals with chronic myelogenous leukemia. There is no evidence of a familial pattern of inheritance for rhabdomyosarcoma or osteogenic sarcoma cancers

A 5-year-old child is being prepared for surgery to remove a brain tumor. Preparation for surgery should be based on which information? a. Removal of the tumor will stop the various signs and symptoms. b. Usually the postoperative dressing covers the entire scalp. c. He is not old enough to be concerned about his head being shaved. d. He is not old enough to understand the significance of the brain.

ANS: B The child should be told what he will look and feel like after surgery. This includes the anticipated size of the dressing. The nurse can demonstrate on a doll the expected size and shape of the dressing. Some of the symptoms may be alleviated by removal of the tumor, but postsurgical headaches and cerebellar symptoms such as ataxia may be aggravated. Children should be prepared for the loss of their hair, and it should be removed in a sensitive, positive manner if the child is awake. Children at this age have poorly defined body boundaries and little knowledge of internal organs. Intrusive experiences are frightening, especially those that disrupt the integrity of the skin.

A school-age child with leukemia experienced severe nausea and vomiting when receiving chemotherapy for the first time. What is the most appropriate nursing action to prevent or minimize these reactions with subsequent treatments? a. Administer the chemotherapy between meals. b. Give an antiemetic before chemotherapy begins. c. Have the child bring favorite foods for snacks. d. Keep the child NPO (nothing by mouth) until nausea and vomiting subside.

ANS: B The most beneficial regimen to minimize nausea and vomiting associated with chemotherapy is to administer a 5-hydroxytryptamine-3 receptor antagonist (e.g., ondansetron) before the chemotherapy is begun. The goal is to prevent anticipatory signs and symptoms. The child will experience nausea with chemotherapy whether or not food is present in the stomach. Because some children develop aversions to foods eaten during chemotherapy, refraining from offering favorite foods is advised. Keeping the child NPO until nausea and vomiting subside will help with this episode, but the child will have discomfort and be at risk for dehydration.

A parent tells the nurse that 80% of children with the same type of leukemia as his son's have a 5-year survival. He believes that because another child on the same protocol as his son has just died, his son now has a better chance of success. What is the best response by the nurse? a. "It is sad for the other family but good news for your child." b. "Each child has an 80% likelihood of 5-year survival." c. "The data suggest that 20% of the children in the clinic will die. There are still many hurdles for your son." d. "You should avoid the grieving family because you will be benefiting from their loss."

ANS: B This is a common misconception for parents. The success data are based on numerous factors, including the effectiveness of the protocol and the child's response. These are aggregate data that apply to each child and do not depend on the success or failure in other children. The failure of one child in a protocol does not improve the success rate for other children. Although the son does face more hurdles, these are aggregate data, not specific to the clinic. It may be difficult for this family to be supportive given their concerns about their child. Families usually form support groups in pediatric oncology settings, and support during bereavement is common.

The nurse is administering an intravenous chemotherapeutic agent to a child with leukemia. The child suddenly begins to wheeze and have severe urticaria. What nursing action is most appropriate to initiate? a. Recheck the rate of drug infusion. b. Stop the drug infusion immediately. c. Observe the child closely for next 10 minutes. d. Explain to the child that this is an expected side effect.

ANS: B When an allergic reaction is suspected, the drug is immediately discontinued. Any drug in the line should be withdrawn, and a normal saline infusion begun to keep the line open. The intravenous infusion is stopped to minimize the amount of drug that infuses. The infusion rate can be confirmed at a later time. Observation of the child for 10 minutes is essential, but it is done after the infusion is stopped. These signs are indicative of an allergic reaction, not an expected response.

The mother of an infant tells the nurse that sometimes there is a whitish "glow" in the pupil of his eye. The nurse should suspect which condition? a. Brain tumor b. Retinoblastoma c. Neuroblastoma d. Rhabdomyosarcoma

ANS: B When the nurse examines the eye, the light will reflect off of the tumor, giving the eye a whitish appearance. This is called a cat's eye reflex. Brain tumors are not usually visible. Neuroblastoma usually arises from the adrenal medulla and sympathetic nervous system. The most common presentation sites are in the abdomen, head, neck, or pelvis. Supraorbital ecchymosis may be present with distant metastasis. Rhabdomyosarcoma is a soft tissue tumor that derives from skeletal muscle undifferentiated cells.

Chemotherapeutic agents are classified according to what feature? a. Side effects b. Effectiveness c. Mechanism of action d. Route of administration

ANS: C Chemotherapeutic agents are classified according to mechanism of action. For example, antimetabolites resemble essential metabolic elements needed for growth but are different enough to block further deoxyribonucleic acid (DNA) synthesis. Although the side effect profiles may be similar for drugs within a classification, they are not the basis for classification. Most chemotherapeutic regimens contain combinations of drugs. The effectiveness of any one drug is relative to the cancer type, combination therapy, and protocol for administration. The route of administration is determined by the pharmacodynamics and pharmacokinetics of each drug.

The nurse is caring for a child with retinoblastoma that was treated with an enucleation. What interventions should the nurse plan for care of an eye socket after enucleation? (Select all that apply.) a. Clean the prosthesis. b. Change the eye pad daily. c. Keep the opposite eye covered initially. d. Irrigate the socket daily with a prescribed solution. e. Apply a prescribed antibiotic ointment after irrigation.

ANS: B, D, E Care of the socket is minimal and easily accomplished. The wound itself is clean and has little or no drainage. If an antibiotic ointment is prescribed, it is applied in a thin line on the surface of the tissues of the socket. To cleanse the site, an irrigating solution may be ordered and is instilled daily or more frequently if necessary before application of the antibiotic ointment. The dressing consists of an eye pad changed daily. The prosthesis is not placed until the socket has healed. The opposite eye is not covered

A child with a brain tumor is undergoing radiation therapy. What should the nurse include in the discharge instructions to the child's parents? (Select all that apply.) a. Apply over-the-counter creams to the area daily. b. Avoid excessive skin exposure to the sun. c. Use a washcloth when cleaning the area receiving radiation. d. Plan for adequate rest periods for the child. e. A darkening of the skin receiving radiation is expected.

ANS: B, D, E Feedback Correct: Children receiving cranial radiation are particularly affected by fatigue and an increased need for sleep during and shortly after completion of the course of radiation. Skin damage can include changes in pigmentation (darkening), redness, peeling, and increased sensitivity. Incorrect: Extra care must be taken to avoid excessive skin exposure to heat, sunlight, friction (such as rubbing with a towel or washcloth), and creams or moisturizers. Only topical creams and moisturizers prescribed by the radiation oncologist should be applied to the radiated skin.

What chemotherapeutic agent can cause an anaphylactic reaction? a. Prednisone (Deltasone) b. Vincristine (Oncovin) c. L-Asparaginase (Elspar) d. Methotrexate (Trexall)

ANS: C A potentially fatal complication is anaphylaxis, especially from L-asparaginase, bleomycin, cisplatin, and etoposide (VP-16).

What type of chemotherapeutic agent alters the function of cells by replacing a hydrogen atom of a molecule? a. Plant alkaloids b. Antimetabolites c. Alkylating agents d. Antitumor antibiotics

ANS: C Alkylating agents replace a hydrogen atom with an alkyl group. The irreversible combination of alkyl groups with nucleotide chains, particularly deoxyribonucleic acid (DNA), causes unbalanced growth of unaffected cell constituents so that the cell eventually dies. Plant alkaloids arrest the cell in metaphase by binding to proteins needed for spindle formation. Antimetabolites resemble essential metabolic elements needed for growth but are different enough to block further DNA synthesis. Antitumor antibiotics are natural substances that interfere with cell division by reacting with DNA in such a way as to prevent further replication of DNA and transcription of ribonucleic acid (RNA).

The nurse is preparing a child for possible alopecia from chemotherapy. What information should the nurse include? a. Wearing hats or scarves is preferable to a wig. b. Expose head to sunlight to stimulate hair regrowth. c. Hair may have a slightly different color or texture when it regrows. d. Regrowth of hair usually begins 12 months after chemotherapy ends.

ANS: C Alopecia is a side effect of certain chemotherapeutic agents and cranial irradiation. When the hair regrows, it may be of a different color or texture. Children should choose the head covering they prefer. A wig should be selected similar to the child's own hairstyle and color before the hair loss. The head should be protected from sunlight to avoid sunburn. The hair usually grows back within 3 to 6 months after the cessation of treatment.

A child with leukemia is receiving intrathecal chemotherapy to prevent which condition? a. Infection b. Brain tumor c. Central nervous system (CNS) disease d. Drug side effects

ANS: C Children with leukemia are at risk for invasion of the CNS with leukemic cells. CNS prophylactic therapy is indicated. Intrathecal chemotherapy does not prevent infection or drug side effects. A brain tumor in a child with leukemia would be a second tumor, and additional appropriate therapy would be indicated.

Children with non-Hodgkin lymphoma are at risk for complications resulting from tumor lysis syndrome (TLS). The nurse should assess for: a. Liver failure b. CNS deficit c. Kidney failure d. Respiratory distress

ANS: C Feedback A TLS is related to intracellular electrolytes overloading the kidney as a response to the rapid lysis of tumor cells. This does not affect the liver. B TLS does not affect the CNS. C In TLS, the tumor's intracellular contents are dumped into the child's extracellular fluid as the tumor cells are lysed in response to chemotherapy. Because of the large volume of these cells, their intracellular electrolytes overload the kidneys and, if not monitored, can cause kidney failure. D TLS does not affect the lungs and cause respiratory distress.

The nurse should base a response to a parent's question about the prognosis of acute leukemia (ALL) on the knowledge that: a. Leukemia is a fatal disease, although chemotherapy provides increasingly longer periods of remission. b. Research to find a cure for childhood cancers is very active. c. The majority of children go into remission and remain symptom free when treatment is completed. d. It usually takes several months of chemotherapy to achieve a remission.

ANS: C Feedback A With the majority of children surviving 5 years or longer, it is inappropriate to refer to leukemia as a fatal disease. B This statement is true, but it does not address the parent's concern. C Children diagnosed with the most common form of leukemia, ALL, can almost always achieve remission, with a 5-year disease-free survival rate approaching 85%. D About 95% of children achieve remission within the first month of chemotherapy. If a significant number of blast cells are still present in the bone marrow after a month of chemotherapy, a new and stronger regimen is begun.

Nursing care of the child with myelosuppression from leukemia or chemotherapeutic agents should include which therapeutic intervention? a. Restrict oral fluids. b. Institute strict isolation. c. Use good hand-washing technique. d. Give immunizations appropriate for age.

ANS: C Good hand washing minimizes the exposure to infectious organisms and decreases the chance of infection spread. Oral fluids are encouraged if the child is able to drink. If possible, the intravenous route is not used because of the increased risk of infection from parenteral fluid administration. Strict isolation is not indicated. When the child is immunocompromised, the vaccines are not effective. If necessary, the appropriate immunoglobulin is administered

What description identifies the pathophysiology of leukemia? a. Increased blood viscosity b. Abnormal stimulation of the first stage of coagulation process c. Unrestricted proliferation of immature white blood cells (WBCs) d. Thrombocytopenia from an excessive destruction of platelets

ANS: C Leukemia is a group of malignant disorders of the bone marrow and lymphatic system. It is defined as an unrestricted proliferation of immature WBCs in the blood-forming tissues of the body. Increased blood viscosity may result secondary to the increased number of WBCs. The coagulation process is unaffected by leukemia. Thrombocytopenia may occur secondary to the overproduction of WBCs in the bone marrow.

Hematopoietic stem cell transplantation (HSCT) is the standard treatment for a child in his or her first remission with what cancer?

Acute myeloblastic leukemia (AML)

What statement related to clinical trials developed for pediatric cancers is most accurate? a. Are accessible only in major pediatric centers b. Do not require consent for standard therapy c. Provide the best available therapy compared with an expected improvement d. Are standardized to provide the same treatment to all children with the disease

ANS: C Most clinical trials have a control group in which the patients receive the best available therapy currently known. The experimental group(s) receives treatment that is thought to be even better. The protocol outlines the therapy plan. Protocols are developed for many pediatric cancers. They can be accessed by pediatric oncologists throughout the United States. Consent is always required in treatment of children, especially for research protocols. The protocol is designed to optimize therapy for children based on disease type and stage

What is an important priority in dealing with the child suspected of having Wilms tumor? a. Intervening to minimize bleeding b. Monitoring temperature for infection c. Ensuring the abdomen is protected from palpation d. Teaching parents how to manage the parenteral nutrition

ANS: C Wilms tumor, or nephroblastoma, is the most common malignant renal and intraabdominal tumor of childhood. The abdomen is protected, and palpation is avoided. Careful handling and bathing are essential to prevent trauma to the tumor site. Before chemotherapy, the child is not myelosuppressed. Bleeding is not usually a risk. Infection is a concern after surgery and during chemotherapy, not before surgery. Parenteral therapy is not indicated before surgery

What is a common clinical manifestation of Hodgkin disease? a. Petechiae b. Bone and joint pain c. Painful, enlarged lymph nodes d. Nontender enlargement of lymph nodes

ANS: D Asymptomatic, enlarged cervical or supraclavicular lymphadenopathy is the most common presentation of Hodgkin disease. Petechiae are usually associated with leukemia. Bone and joint pain are not likely in Hodgkin disease. The enlarged nodes are rarely painful

What pain management approach is most effective for a child who is having a bone marrow test? a. Relaxation techniques b. Administration of an opioid c. EMLA cream applied over site d. Conscious or unconscious sedation

ANS: D Children need explanations before each procedure that is being done to them. Effective pharmacologic and nonpharmacologic measures should be used to minimize pain associated with procedures. For bone marrow aspiration, conscious or unconscious sedation should be used. Relaxation, opioids, and EMLA can be used to augment the sedation

What side effect commonly occurs with corticosteroid (prednisone) therapy? a. Alopecia b. Anorexia c. Nausea and vomiting d. Susceptibility to infection

ANS: D Corticosteroids have immunosuppressive effects. Children who are taking prednisone are susceptible to infections. Hair loss is not a side effect of corticosteroid therapy. Children taking corticosteroids have increased appetites. Gastric irritation, not nausea and vomiting, is a potential side effect. The medicine should be given with food

What chemotherapeutic agent is classified as an antitumor antibiotic? a. Cisplatin (Platinol AQ) b. Vincristine (Oncovin) c. Methotrexate (Texall) d. Daunorubicin (Cerubidine)

ANS: D Daunorubicin is an antitumor antibiotic. Cisplatin is classified as an alkylating agent. Vincristine is a plant alkaloid. Methotrexate is an antimetabolite

Which statement, if made by a nurse to the parents of a child with leukemia, indicates an understanding of teaching related to home care associated with the disease? a. "Your son's blood pressure must be taken daily while he is on chemotherapy." b. "Limit your son's fluid intake just in case he has central nervous system involvement." c. "Your son must receive all of his immunizations in a timely manner." d. "Your son's temperature should be taken frequently."

ANS: D Feedback A The child's temperature must be taken daily because of the risk for infection, but it is not necessary to take a blood pressure daily. B Fluid is never withheld as a precaution against increased intracranial pressure. If a child had confirmed CNS involvement with increased intracranial pressure, this intervention might be more appropriate. C Children who are immunosuppressed should not receive any live virus vaccines. D An elevated temperature may be the only sign of an infection in an immunosuppressed child. Parents should be instructed to monitor their child's temperature as often as necessary.

A child has an absolute neutrophil count (ANC) of 500/mm3. The nurse should expect to be administering which prescribed treatment? a. Platelets b. Packed red blood cells c. Zofran (ondansetron) d. G-CSF (Neupogen) daily

ANS: D G-CSF (filgrastim [Neupogen], pegfilgrastim [Neulasta]) directs granulocyte development and can decrease the duration of neutropenia following immunosuppressive therapy. G-CSF is discontinued when the ANC surpasses 10,000/mm3.

What specific gravity of the urine is desired so that hemorrhagic cystitis is prevented? a. 1.035 b. 1.030 c. 1.025 d. 1.005

ANS: D Sterile hemorrhagic cystitis is a side effect of chemical irritation to the bladder from chemotherapy or radiotherapy. It can be prevented by a liberal oral or parenteral fluid intake (at least one and a half times the recommended daily fluid requirement). The urine should be dilute so 1.005 is the expected specific gravity

Postoperative positioning for a child who has had a medulloblastoma brain tumor (infratentorial) removed should be which? a. Trendelenburg b. Head of bed elevated above heart level c. Flat on operative side with pillows behind the head d. Flat, on either side with pillows behind the back

ANS: D The child with an infratentorial procedure is usually positioned flat and on either side. Pillows should be placed against the child's back, not head, to maintain the desired position. The Trendelenburg position is contraindicated in both infratentorial and supratentorial surgeries because it increases intracranial pressure and the risk of hemorrhage.

The parents of a child with cancer tell the nurse that a bone marrow transplant (BMT) may be necessary. What information should the nurse recognize as important when discussing this with the family? a. BMT should be done at the time of diagnosis. b. Parents and siblings of the child have a 25% chance of being a suitable donor. c. If BMT fails, chemotherapy or radiotherapy will need to be continued. d. Finding a suitable donor involves matching antigens from the human leukocyte antigen (HLA) system.

ANS: D The most successful BMTs come from suitable HLA-matched donors. The timing of a BMT depends on the disease process involved. It usually follows intensive high-dose chemotherapy or radiotherapy. Usually, parents only share approximately 50% of the genetic material with their children. A one in four chance exists that two siblings will have two identical haplotypes and will be identically matched at the HLA loci. The decision to continue chemotherapy or radiotherapy if BMT fails is not appropriate to discuss with the parents when planning the BMT. That decision will be made later.

What immunization should not be given to a child receiving chemotherapy for cancer? a. Tetanus vaccine b. Inactivated poliovirus vaccine c. Diphtheria, pertussis, tetanus (DPT) d. Measles, mumps, rubella (MMR)

ANS: D The vaccine used for MMR is a live virus and can cause serious disease in immunocompromised children. The tetanus vaccine, inactivated poliovirus vaccine, and DPT are not live vaccines and can be given to immunosuppressed children. The immune response is likely to be suboptimum, so delaying vaccination is usually recommended

Total-body irradiation is indicated for what reason? a. Palliative care b. Lymphoma therapy c. Definitive therapy for leukemia d. Preparation for bone marrow transplant

ANS: D Total-body irradiation is used as part of the destruction of the child's immune system necessary for a bone marrow transplant. The child is at great risk for complications because there is no supportive therapy until engraftment of the donor marrow takes place. Irradiation for palliative care is done selectively. The area that is causing pain or potential obstruction is irradiated. Lymphoma and leukemia are treated through a combination of modalities. Total-body irradiation is not indicated.

Rhabdomyosarcoma therapeutic management

All rhadomyosarcomas are high-grade tumors with the potential for metastases Complete removal of the primary tumor is advocated whenever possible Tumors are treated with chemotherapy and sometimes radiation

Brain tumor clinical manifestations

Are r/t their location and size: (een via CT scan or MRI) and can be a result of increased ICP Most common - Headache - especially upon awaking - Vomiting - not related to feeding Other changes - Neuromuscular changes like ataxia and muscle-weakness to paralysis - Behavioral and personality changes - Cranial nerve neuropathy nystagmus, visual disturbance, difficulty with swallowing - Vital sign disturbance (↑BP, ↓ HR & RR) - Other signs infant can have cranial enlargement with tense/bulging fontanel, papilledema, and seizures

Brain Tumor Post-operative Care

Assessment (VS) Temperature measurement is particularly important b/c of hyperthermia from surgery in the hypothalamus or brainstem and from certain types of general anesthesia Assess drainage-circle soiled area to monitor for signs of continuous bleeding - Colorless drainage may be CSF leaking → Report IMMEDIATELY - Foul smelling odor from dressing may indicate infection → Report finding and obtain a culture Turning as allowed - Prevent pressure against the operative side also if tumor is large then patient not placed on operative side to prevent shift of the brain leading to further trauma. Neurologic checks to monitor for signs of increased ICP NPO until gag reflex returns (loss is common with infratentorial craniotomy) Monitor I and O for concerns related to DI and SIADH. Pain management may have opioid if necessary to treat pain Low stimulation, HOB elevated, and other comfort measures Support Family - Ultimately, promote return to optimum functioning. May need consult to OT and PT with durable medical equipment.

A child with acute myeloblastic leukemia is scheduled to have a bone marrow transplant (BMT). The donor is the child's own umbilical cord blood that had been previously harvested and banked. This type of BMT is termed

Autologous

A 9-year old child with leukemia is in remission and has returned to school. The school nurse calls the mother of the child and tells the mother that a classmate has just been diagnosed with chickenpox. The mother immediately calls the clinic nurse because the leukemic child has never had chickenpox. The appropriate response by the clinic nurse to the mother is: A. There is no need to be concerned. B. Bring the child into the clinic for a vaccine. C. Keep the child out of school for 2 week period. D. Monitor the child for an elevated temperature, and call the clinic if this happens.

B (Rationale: immunocompromised children are unable to fight varicella adequately. Chickenpox can be deadly to the them. If the child who has not had chickenpox is exposed to someone with varicella, the child should receive varicella zoster immune globulin within 96hrs of exposure. Options 1,3,4, are incorrect because they do nothing to minimize the chances of developing the disease.)

Brain tumor patho

Brain tumors in general are a neoplasm arising from a cell in the cranium and can include glial cells, nerve cells, neuroepithelium, cranial nerves, blood vessels, pineal glands, and hypophyisis Majority are infratentorial (posterior brain) - s/s of increased ICP frequent

A school-age child is being seen in the oncology clinic for possible Hodgkin's disease. During the course of the nursing assessment, which findings would be expected? Select all that apply. a) fever. b) painless cervical nodes. c) painful cervical nodes. d) poor appetite. e) complaints of night sweats"

B, D (Painless cervical nodes are a hallmark sign of HD. In addition to this, night sweats also are characteristic. Fever, poor appetite, and painful cervical nodes are more characteristic of infection.")

A pediatric patient has been diagnosed with leukemia and presents with a white blood cell (WBC) count of 80,000 mm3. Which statement if provided by a nursing student indicates that additional teaching is needed with regard to pathophysiological mechanisms of leukemia? A. The increase in WBC provides protection against bacterial infections. B. Although the WBC count is elevated, there are increased blast cells which help to protect the patient against infection. C. The amount of white blood cells is greatly increased, which affords protection against viral infections. D. Increases in white blood cells are expected but associated with a low leukocyte count.

B.

A client is admitted to the hospital for a colon resection and in preparation for surgery the physician orders neomycin. The nurse understands the main reason why this antibiotic is especially useful before colon surgery is because it: A. Will not affect the kidneys B. Acts systemically without delay C. Has limited absorption from the GI tract. D. Is effective against many different organisms

C (Because neomycin is limited absorption form the GI tract, it exerts it antibiotic effect on the intestinal mucosa. In preparation of GI surgery, the level of microbial organisms will be reduced.)

Chromosome abnormalities

Cancer genome project - Down-syndrome: leukemia - Chromosome 11 and 12 translocation: Ewing's sarcoma - Philadelphia chromosone translocation between 9 and 22 leads to chronic myelogenous leukemia

Osteosarcoma

Cancer originating in the bone (osteoid tissue). Cells look like normal bone cells, but the bone tissue is not as strong as normal bone tissue Possible mutation in tumor suppressor gene TP53

A pediatric oncology patient has been discharged home following a course of chemotherapy. Which information should be included as part of discharge planning with regard to health promotion? A. No further treatments are needed and the patient can resume routine health assessments as developmentally appropriate. B. There are no restrictions based on activity and/or contacts with friends and family members. C. Certain restrictions will be in place related to immunizations that can be administered. D. The patient should limit fluid intake for several months in order to prevent overhydration from occurring.

C.

Administration of colony stimulating agents for the pediatric oncology patient are used to: A.decrease nausea. B. shrink tumor size. C. increase bone marrow response. D. decrease production of stem cells.

C.

Which finding if observed would warrant intervention regarding the administration of an antiemetic in a chemotherapy protocol for a pediatric patient? A.Providing the medication on a scheduled basis regardless of the patient's clinical symptoms. B. Administering the medication via the parenteral route prior to infusion of chemotherapy protocol. C. Providing medication with sips of water following clinical symptoms of nausea and/or vomiting. D.Administering 30 to 60 minutes prior to initiation of therapy.

C.

Treatment: Radiotherapy

Can be used for curative purposes or relief of symptoms by shrinking tumor. It is usually done in conjunction with chemo/surgery It has a cytotoxic effect by damaging pyrimidine bases or cause single/double strand breaks. It is done daily over 2-7 weeks Immediate effects are localized to area being irradiated and skin site may be tender, warm, and swollen tx includes no lotion, wash daily with small amount of soap, and if desquamation occurs notify practitioner for care Radiation sickness is the anorexia and N/V that occurs most with GI irradiation. Antiemetic ~ 30min prior to procedure may help, this is the same for chemotherapy. Malaise is the other common SE due to radiation to the thyroid gland. Sterility and other concerns with full body irradiation.

Ewings Sarcoma Therapeutic Management

Chemo/high dose radiation Limb sparing surgery or amputation (RARE)

Nephroblastoma Therapeutic Management

Combined tx w/ surgery chemotherapy Surgery: - Unilateral tumor: resection of tumor to possible nephrectomy and adjacent adrenal gland - Bilateral tumor bilateral nephrectomy (will require RRT post-operatively) with an attempt to salvage least affected (to provide some renal function) Considerations: - may need chemotherapy pre-op and post-op to shrink tumors or radiating post-operative late stage Educate pt/parents on preotection of the remaining kidney no contact sports and s/s of UTI due to need for prompt tx

A pediatric oncology patient has developed a nose bleed. Which finding would account for this occurrence? A. Increased white blood cell count B. Increased neutrophils C. Decreased hemoglobin and hematocrit D. Decreased platelet count

D

A 4-year-old has a right nephrectomy to remove a Wilms tumor. The nurse knows that it is essential to: A. Request a low-salt diet B. Restrict fluids C. Educate the family regarding renal transplants D. Prevent urinary tract infections

D (Because the child has only one remaining kidney, it is important to prevent urinary tract infections. Answers A, B, and C are not necessary, so they are incorrect.)

Non-Hodgkin Lymphoma Clinical Manifestations

Depend on anatomical site and extent of involvement - Systemic: low grade fever, anorexia with weight loss, nausea, fatigue, nigh sweats, and pruritus Painless enlargement of lymph nodes Most common: enlarged, firm, non-tender, moveable nodes in the cervical/supraclavicular Lymphoid tumors compressing various organs may cause interstitial or airway obstruction (nonproductive cough), cranial nerve palsy, or spinal paralysis, and retroperitoneal (abdominal pain/full feeling with minimal intake) Mets to the bone marrow or CNS may produce signs of leukemia Labs demonstrate increased LDH and uric acid, CT will show masses

Special issues with childhood survival: Bone

Disrupts bone growth and leads to asymmetry, fractures, scoliosis, and kyphosis. Especially a concern during growth spurts

What is an appropriate nursing action before surgery when caring for a child diagnosed with a Wilms' tumor?

Do not palpate the abdomen.

Osteosarcoma Diagnostics

Grows on top of the bone→"star" appearance on scans Bone biopsy needed to rule out trauma/infection

While completing an assessment on a 6-month-old infant, which finding should the nurse recognize as a symptom of a brain tumor in an infant?

Increased head circumference

A child with non-Hodgkin lymphoma will be starting chemotherapy. What intervention is initiated before chemotherapy to prevent tumor lysis syndrome?

Intravenous (IV) hydration containing sodium bicarbonate

Children with non-Hodgkin lymphoma are at risk for complications resulting from tumor lysis syndrome (TLS). The nurse should assess for

Kidney failure

Neuroblastoma Clinical Manifestations

Last test: urine/blood for catecholamine produced by the cells Depends on location and stage of the disease Abdominal: firm, non-tender, irregular mass in the abdomen that crosses the midline (do not palpate), urinary frequency or retention Distant metastasis: supraorbital echomyosis, periorbital edema, and proptosis (exophalmos), lymphadenopathy, hepatomegaly, and skeletal pain, pallor, weakness, irritability, anorexia, and weight loss Neurologic impairment, respiratory obstruction from a thoracic mass, or varying degrees of paralysis from compression of the spinal cord

Nephroblastoma (Wilms tumor) patho

Malignant renal and intra-abdominal tumor of childhood arises from undifferentiated metanephrogenic blastoma (responsible for renal/genital development). Metastasis can occur through he blood Thing Good day, Wilms, old CHAP C: chromosome 11 deletion of tumor suppressor gene H: hemi hypertrophy A: age at presentation 2-4 year olds P: palpable flank mass

Ewings Sarcoma

Malignant small, round cell tumor that grows in the bones or in the tissue around bones - often in legs, pelvis, ribs, arms, or spine (long bones) Possible alteration in STAG2 and TP53 gene

Neuroblastoma patho

Most common extracranial solid tumor of child Tumors originate from embryonic neural crest cells (neural blasts) that normally give rise to the adrenal medulla and the SNS → therefore, majority of the tumors arise from the adrenal glad or retroperitoneal sympathetic chain Diagnosis usually is made after metastasis has occurred

Hodgkins Disease Clinical Manifestations

Most common finding is enlarged, firm, non-tender moveable nodes in the supraclavicular or cervical area Mediastinal lymphadenophaty may cause a persistent, nonproductive cough Enlarged retroperitoneal nodes may produce unexplained abdominal pain Systemic symptoms: low-grade or intermittent fever (Pel-Ebstein disease), anorexia nausea, weight loss, night sweats, and pruritus Look at lab values, high values amy indicate metastases

Non-Hodgkin Lymphoma Therapeutic Management

Multi-agent chemotherapeutic regiments are administered for 6-24 months Aggressive approach: radiotherapy and chemotherapy

NHL different from Hodgkin's in several respects:

NHL is usually diffuse rather than nodular The cell type is evenly split between B-cell and T-cell lineages Dissemination occurs earlier, more often, and more rapidly due to undifferentiated cell type

Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity 18. The nurse is aware that an abdominal mass found in a 10-month-old infant corresponds with which childhood cancer?

Neuroblastoma

What is the most appropriate nursing action when the nurse notes a reddened area on the forearm of a neutropenic child with leukemia?

Notify the physician.

Which nursing intervention should not be included in the postoperative plan of care for a child undergoing surgery for a brain tumor?

Place the child in Trendelenburg position.

The nurse notes that a child's gums bleed easily and he has bruising and petechiae on his extremities. What laboratory values are consistent with these symptoms?

Platelet count of 19,000/mm3

Hodgkins Therapeutic Mangement

Radiotherapy is the main tx Chemotherapy is used for stage IV only Major concern of combination tx is serious late effects (long-term considerations) Follow-up care after remission is very important to detect relapse and second malignancies

What is a priority nursing diagnosis for the 4-year-old child newly diagnosed with leukemia?

Risk for Infection related to immunosuppressed state

Nursing Diangosis

Risk for injury/medication safety Chemotherapy and N/V fluid/electrolyte balance Neutropenia: risk for infection Anemia: activity intoelerance Thrombocytopenia: risk for bleeding Chemotherapy and radiotherapy: altered comfort, N/V and imbalance nutrition < body requirements Surgery/steroids: altered body image Hemorrhagic cystitis: impaired urinary elimination Disease process: pain (acute/chronic) Disease process: pain (acute/chronic) Family considerations: interrupted family process, ineffective coping, anticipatory grieving

Brain tumor therapeutic management

Surgery - total removal/debulking of tumor with goal of minimal residual neurologic damange Radiotherapy - Used to treat most tumors to reduce tumor burden before surgical removal and for palliative symptom management Chemotherapy - Can be used in combination with surgery and/or radiation Establish baseline to compare preoperative and postoperative changes is essential -Long term SE: infection, seizures requiring tx, neurological deficits, hydrocephalus (requires VP shut), and potentially endocrine (DI vs SIADH)

Treatment: Chemotherapy

This is the primary form of treatment for most of the pediatric cancers. Protocols- combinations used to maximize lethal impact at the different stages of cellular mitosis. They allow for optimum cell-cycle destruction with minimum toxic effects and decreased resistance by the cancer cells. - VAC -vincristine (plant alkaloid that arrest cells in the metaphase of mitosis), - doxorubicin (antibiotic that reacts with DNA and prevents replication), - cyclophosphamide (an alkylating agent causes unbalanced growth leading to cell death by replacing a H+ ion with alkyl group). - Another common agent is methotrexate (antimetabolites resemble metabolic elements needed for cell growth but are altered in structure to inhibit further synthesis of DNA/RNA). Needs to be given via a central line; this lessens the chance of skin or tissue damage from infiltration/extravasation. Understanding drug action and side effects are important (see notes). This allows the nurse to anticipate pt. symptoms because almost all drugs show no selective cytotoxicity for malignant cells, it affects all cells with high rate of proliferation such as bone marrow, hair, skin, and epithelial cells of the GI tract. Leads to the SE needing more nursing care than the cancer.

Bone marrow/stem cell transplants

Treatment of choice from some cancer, like leukemia. Need a good human leukocyte antigen (HLA) match Pt. undergoes total body irradiation and intensive chemo to kill all cancer cells and all bone marrow cells Then the transplant takes place there is a considerable wait for engraftment The use of cord blood for hematopoietic stem cell is on the rise. As well as autologous (pt's own marrow collected from disease free tissues)

Acute Leukemia Therapeutic Management

Use of IV chemotherapeutic agents with tx divided into phases to achieve remission CNS prophylactic therapy - Children with leukemia are at an increased risk for invasion of the CNS by the leukemic cells - Radiation is sometimes used for resistant CNS disease or testicular relapse Bone marrow transplantation can be done if relapse occurs - NOT recommended for children at ALL during the first remission b/c of the excellent results possible with chemo

Biotherapy

Using remodeled monoclonal antibodies to target cancer cells only. Important b/c this can potentially limit SE of therapy - EX: rituximab used to treat non-Hodgkins lymphoma

Role of prevention

With knowledge of risk factors, this may aid in prevention of adult cancers only. Known carcinogens in children are radiation and several drugs given to the mother during pregnancy May be focused on teaching smoking prevention and exposure to sunlight for lung and skin cancer Adolescent teaching - Females: self breast exams, yearly pap smear, and now receiving the HPV vaccine -Males: testicular self exams Neuroblastomas may have connection with Fetal alcohol syndrome, cigarette or marijuana smoking by parents

Assessing the child with cancer

You need a complete history including: presenting illness, previous illnesses, family history of cancer, present state of health of immediate family, developmental milestones, and any psychosocial or family concerns You need to include the information in a review of systmes Physical exam and document any abnormalities

Retinoblastoma Nursing care

knowledge deficit related to testing and care also ineffective family coping as the nurse supports family - guilt of transmission of gene. Need to teach that the entire family needs to have regular eye care and for those at risk for 2nd tumor continued follow-up. May include genetic counseling