NCLEX-RN: Pediatric Nursing

Pediatric Nursing: PEDIATRIC ONCOLOGY

Focus topic: Pediatric Nursing

The signs and symptoms of pediatric malignancy may be subtle and not easily recognized. In addition, the causal factors associated with cancer in children are not clearly defined. Current research supports the theory of a genetic cause, allowing the uncontrolled proliferation of abnormal cells from previously normal ones. Current treatment focuses on chemotherapy and radiation therapy; combinations of the two; and surgical intervention. The specialty area of pediatric oncology is becoming more prominent as the incidence increases and the etiology remains somewhat a mystery.

Pediatric Nursing: Treatment Modalities

Focus topic: Pediatric Nursing

Pediatric Nursing: Chemotherapy

Focus topic: Pediatric Nursing

Characteristics
A. Chemotherapeutic agents work on rapidly dividing cells.
B. Tumor’s location and cell type affect choice of drugs.
C. Most anti-neoplastic drugs are metabolized in the liver and excreted by the kidneys so they must be adequately functioning to prevent toxicity.

Assessment
A. Assess if more than one chemotherapeutic agent is being administered.
B. Identify potential side effects of medications (specific to medications used).

  •  GI disturbance.
  • Loss of hair.
  •  Bone marrow suppression.

C. Assess for fluid and electrolyte imbalances associated with drug therapy.
D. Assess for adequate urine output.
E. Monitor laboratory values.
F. Assess oral cavity for irritation and bleeding gums.

Implementation
A. Establish baseline data.

  •  Nutritional status.
Pediatric Nursing
  •  Oral condition.
  •  Skin condition.
  •  Degree of mobility.
  •  Psychological status.
  • Neurological condition.

B. Observe for side effects of cell breakdown.

  • Signs of acute tumor lysis syndrome (ATLS): Tumor degradation rapidly releases intracellular components causing rapid rise in uric acid, phosphate, and potassium. Kidneys are unable to clear substances quickly enough and renal failure may develop.
    a. Monitor for increasing serum potassium, phosphates, BUN and creatinine, and uric acid with corresponding decreasing serum calcium.
    b. Anticipate use of Zyloprim (allopurinol) to decrease uric acid, IV fluids with sodium bicarbonate to alkalinize the urine before chemotherapy starts.
    c. Parenteral urate oxidase, a recombinant enzyme, is able to oxidize uric acid into water-soluble product so that it can be excreted.
  •  Stone formation in urinary tract, cystitis.

C. Maintain chemotherapy flow sheet, per institutional protocols.
D. Observe for side effects on rapidly dividing cells.

  • Gastrointestinal mucosa: diarrhea, nausea, vomiting.
    a. Administer antiemetics 1 hour prior to chemotherapy.
    b. Provide mouth care with prescribed product. Use soft toothbrush.
    c. Provide frequent cold, high-calorie beverages.
  • Hair follicles: loss of hair.
    a. Prepare client for loss (i.e., suggest wig, hats, scarves).
    b. Reassure client that hair will begin to grow back 6–8 weeks after chemotherapy ends.

E. Monitor administration of common drugs according to protocol.

  • Corticosteroids: Deltasone used most frequently.
    a. Monitor side effects, which may include ravenous appetite, change in fat distribution, retention of fluid, hirsutism, occasional hypertension, growth disturbances, and psychological disturbance.
    b. Monitor serum blood glucose levels.
    c. Monitor tapering of medication if prolonged use.
  •  Purinethol (mercaptopurine; 6MP): interrupts the synthesis of purines essential to the structure and function of nucleic acids.
    a. Monitor side effects: anorexia, dermatitis, stomatitis; very little toxicity in children but the kidneys must excrete increased amount of uric acid may be hepatotoxic.
    b. Observe kidney function and possible increase in fluid intake.
  •  Trexall: folic acid antagonist (anti-metabolite) that suppresses the growth of abnormal cells enough to permit regeneration of normal cells.
    a. Monitor side effects: ulceration of oral mucosa and nausea, vomiting, diarrhea, and abdominal pain.
    b. Toxic effects: hepatitis, nephropathy, pneumonitis, osteoporosis.
    c. Observe for ulcerations. Discontinue drug temporarily at the appearance of ulcers.
    d. Observe renal function (e.g., drug is excreted through kidneys).
    e. High-dose Trexall often followed with citrovorum factor (leucovorin) rescue.
  • Cytoxan (cyclophosphamide), Ifex (ifosfamide): alkylating agents that suppress cellular proliferation; have greater effect on abnormal than normal cells.
    a. Monitor side effects: hemorrhagic cystitis, severe immunosuppression.
    b. Provide large quantities of fluids preceding and immediately following drug administration to help prevent side effects (usually three times normal maintenance).
  • Oncovin (vincristine): alkylating agent used to rapidly induce remissions.
    a. Monitor side effects: insomnia, severe constipation, peripheral neuritis or weaknesses, or syndrome of inappropriate antidiuretic hormone (SIADH).
    b. Once disease is in remission, maintain client on another less toxic drug as ordered.

F. Observe for tumor mass effects.

  •  Leukostasis (peripheral WBC > 100,000).
    a. High number blast cells causes capillary obstruction, micro-infarction, and end-organ dysfunction (primary lungs and brain).
    b. Thorough and frequent CNS and respiratory assessment necessary.
  •  Superior vena cava syndrome (obstruction to venous return from upper body due to tumor or enlarged lymph nodes).
    a. Assess swelling or discoloration of face, tachypnea, wheezing, lethargy, headache, or visual disturbances.

b. Assist with diagnostic procedures: x-ray, CT scan, MRI.
c. Maintain patent airway; support ventilation and oxygenation, CNS status, and cardiac output until tumor can be reduced.

  • Spinal cord compression arising from primary tumor or metastases.
    a. Assess motor weakness, back pain, sensory loss, respiratory compromise (high lesion).
    b. Assist with diagnosis (usually MRI).
    c. Provide pain relief, measures to assist with bowel or bladder dysfunction, ROM if motor impairment.

 

Pediatric Nursing: Radiation

Focus topic: Pediatric Nursing

Characteristics
A. Radiation affects all cells but is particularly lethal to rapidly developing cells.
B. Radiation is often utilized in conjunction with chemotherapy and surgery, or as primary therapy.
C. Radiation may be used to eradicate or shrink tumors or to relieve pressure.
D. Total body irradiation used in preparation for bone marrow transplant.
E. Side effects usually dependent on irradiated area.

Assessment
A. Assess for easy fatigability.
B. Assess fluid and electrolyte imbalances due to vomiting, diarrhea, and urinary frequency associated with radiation therapy.
C. Monitor hemoglobin and hematocrit for anemia.
D. Assess skin condition in radiated area.
E. Assess for dental caries, gum disease, and ulcerations.
F. Assess condition of hair.

Implementation
A. Treat radiation sickness.

  •  Monitor symptoms: nausea, vomiting, malaise.
  •  Offer frequent high-calorie feedings (milkshakes with extra protein and vitamins).
  •  Make food trays attractive and palatable.

B. Observe side effects of cell breakdown: signs of tumor lysis syndrome and renal compromise, rising potassium, phosphate, creatinine, and BUN; accumulation of uric acid; and stone formation in urinary tract.
C. Treat side effects of cell breakdown.

  •  Increase fluid intake if adequate renal function.
  •  Monitor intake and output.

D. Treat skin breakdown.

  •  Check client regularly for any redness or irritation at radiation site.
  • Notify physician immediately.
  •  Apply lotion to area following termination of radiation therapy.
  •  Avoid any irritation to area from clothing, soap, or weather extremes.

E. Treat bone marrow depression.

  •  Watch lab values carefully.
  •  Isolate client if absolute neutrophil count dangerously low (< 1500).
  •  Avoid injections (low platelets), bruising.
  • Administer antibiotics.
  •  Meticulous hand washing, limit contacts, keep those with any illness away from client.
  •  Remove fresh fruits and vegetables and fresh plants from the client’s room.

Surgery
A. Goal is to remove all traces of the malignancy and restore normal functioning. May be palliative or curative (if tumor is encapsulated and localized  and detected early).
B. Current trend is toward more conservative excision (e.g., resections rather than complete amputations).
C. Surgery is generally combined with chemotherapy and/or radiation in treatment of many pediatric cancers.

Biologic Response Modifiers
A. Change in reaction to tumor cells most agents are monoclonal antibodies.
B. Influence the immune response by affecting numerous cellular activities.
C. Particularly useful in T cell suppression in antirejection therapy for transplant recipients Neoral, Orthoclone OKT3 (muromonab-CD3), etc.
D. Also used to deplete T cells to reduce graft versus host disease in bone marrow transplant.
E. Some BRMs have direct antitumor effects.
F. Major categories include interferons, interleukins, and colony-stimulating factors.

Bone Marrow Transplantation
A. For cancers that do not respond to conventional therapy, but is high-risk and expensive.
B. May be considered earlier in treatment in children with acute myeloblastic leukemia (AML).
C. Marrow may be retrieved from living relative or unrelated with histocompatibility.

D. High-dose chemotherapy and total-body irradiation are given first in attempt to destroy all malignant cells, and transplanted marrow should then produce normally functioning cells.
E. Posttransplant care involves prolonged stay in protected environment to monitor marrow function and protect from infection.
F. Most serious complication is graft-versus-host disease (GVHD).
G. Child and family require extensive multidisciplinary support throughout process.

Pediatric Nursing: Malignant Diseases

Focus topic: Pediatric Nursing

Pediatric Nursing: Leukemia

Focus topic: Pediatric Nursing

Definition: The most common childhood cancer. A potentially fatal malignant disease caused by the unrestricted proliferation of leukocytes and their precursors.

Characteristics
A. Average life expectancy was 3–4 years in the 1940s, but new therapies have extended life expectancy and long term disease-free survival rates.
B. Types include acute lymphocytic leukemia, which is responsible for about 80% of all childhood cases, and chronic myelocytic leukemia (CML), which affects young adults.
C. Long-term survival in all types treated at major research centers is now around 80%, and the majority are cured.
D. The annual incidence is around 4–5 per 100,000 in Caucasian children less than 15 years old and less in black children under age 15.

Assessment
A. Obtain complete history of symptoms, previous illnesses, cancers, or therapies.
B. Assess for early manifestations, usually vague, nonspecific complaints.

  •  Bone and abdominal pain.
  •  Fever.
  •  Bruising, epistaxis.
  •  Lethargy, pallor, anorexia, or malaise.
  •  Lymph node enlargement.
  •  Night sweats.
  •  Lingering illness (usually a cold or “flu”).

C. Assess for late manifestations.

  •  Oral and rectal ulcers.
  • Hemorrhage.
  •  Infection, overwhelming sepsis.
  •  Increased intracranial pressure, ventricular enlargement.
  •  Invasion of bone, weakened periosteum.
  •  Muscle wasting, weight loss.

Treatment
A. Clinical course.

  •  Untreated: rapid deterioration and death.
  •  Treated: with chemotherapy, 90% of those treated experience at least an initial remission.

B. Initial remission usually occurs following the commencement of induction therapy, the chemotherapy lasting 4–6 weeks. The goal is complete eradication of leukemic cells.
C. Induction is followed by CNS prophylactic therapy and maintenance/intensification therapy.
D. Drugs most commonly used for induction and maintenance of remissions in acute lymphocytic leukemia.

  • Corticosteroids: Deltasone and Decadron (dexamethasone).
  •  Elspar (L-asparaginase).
  •  Adriamycin (doxorubicin).
  •  Oncovin.
  • Trexall.

E. Trexall, Cortef (hydrocortisone), and Ara C (cytarabine) administered by intrathecal injection soon after start of remission to prevent central nervous system involvement in high-risk children or those with CNS involvement.
F. Induction therapies differ with AML and CML.
G. Maintenance therapy begins after induction is completed.

Implementation
A. Counsel parents, child, and siblings.

  •  Prepare for diagnostic procedures (bone marrow aspiration, biopsy, LP, and MRI).
  •  Provide support and education throughout therapy: reinforcement of medical information, preparation for procedures.
  •  During periods of remission, encourage normal activity, support growth and development.
  •  Provide support for occurrence of complications or recurrences.
  •  Refer to parents’ support group.
  •  Provide for continuing follow-up of family.

B. Prevent infection.

  •  Meticulous hand hygiene in all contacts.
  • Avoid contact with communicable diseases.
  •  Do not give live virus immunizations while in treatment.
  •  Provide oral hygiene and frequent peri-care.
  •  Prevent and/or treat Candida oral infections.
  •  Change intravenous tubing daily, as institutional protocol; monitor IV site closely.
  •  If absolute neutrophil count is very low (< 15,000), implement “reverse isolation.”
  • Monitor fever, CBC, and vital signs closely for early signs of infection.

C. Prevent hemorrhage.

  •  Handle infants carefully.
  •  Pad beds: head, feet, and sides.
  •  Follow platelet count closely, other clotting studies.
  •  Avoid all unnecessary intramuscular and intravenous injections.
  •  Gentle tooth cleaning and oral care.
  • Monitor for GI bleeding; avoid rectal temps.
  •  Platelet transfusions if actively bleeding.

D. Promote nutrition.

  •  Administer anti-emetic 30 minutes before meals (Zofranondansetron) most effective) and as needed.
  • Use anesthetic mouthwash before meals.
  • Use only soft toothbrushes or soft swabs.
  • Offer cold liquids high in calories (Popsicles, ice cream, milkshakes), frequently and in small amounts, or any food child will eat.

E. Monitor renal status.

  •  Observe for hemorrhagic cystitis (related to Cytoxan).
  •  Monitor for acute tubular disease.
  •  Meticulous I&O daily weights.

F. Provide ongoing education and support as therapy progresses.

  •  Management of complications.
  •  Alopecia.
  •  Mood changes.
  •  Altered body image.

Pediatric Nursing: Wilms’ Tumor (Nephroblastoma)

Focus topic: Pediatric Nursing

Definition: A cancerous unilateral tumor of the kidney. The most common type of renal cancer in children; peak age of occurrence is 3 years. Multimodal therapy can give 90% cure in localized tumors (stage I or II).

Assessment
A. Evaluate family history, previous symptoms and illnesses, usual voiding patterns.
B. Carefully assess child’s abdomen (see Implementation B).
C. Assess for presence of fever or abdominal pains.
D. Assist with diagnostic evaluation; ultrasound, CT scan, blood studies, urine evaluation, bone marrow, aspiration if metastases are suspected.
E. Evaluate abdominal girth, anemia, hypertension.
F. Assess for other congenital abnormalities of genitourinary system.

Implementation
A. Avoid palpation of the tumor preoperatively. (Although tumor is generally well encapsulated, seeding is possible. If a mass is present, defer palpation of abdomen to physicians ONLY.)

B. Treatment is surgical removal of affected kidney and adrenal gland, combined with chemotherapy and possible radiation.

  • Chemotherapy is indicated for all stages of
    tumor, usually Oncovin, Dactinomycin (actinomycin D), Adriamycin, and Cytoxan from 6–15 months.
  •  Radiation may be added if tumor is large, not completely resectable, or with metastasis or recurrence.

C. Provide appropriate nursing care aimed at routine post abdominal surgery management, minimizing complications of chemotherapy and radiation therapy (as previously discussed).
D. Support growth and development of child, provide family support and appropriate referrals.

Pediatric Nursing: Hodgkin’s Disease

Focus topic: Pediatric Nursing

Definition: A malignancy of the lymph system characterized by painless enlargement of lymph nodes large, primitive, reticulum like, malignant cell. Prognosis is greatly improved due to recent staging and treatment protocols. The long-term survival rates are as high as 90% in early-stage disease; 65–75% in advanced stages.

Assessment
A. Assess age. Symptoms usually peak between 15 and 29 years of age.
B. Evaluate enlarged, painless lymph nodes (i.e., nodes are firm and movable).
C. Assess for frequent infections.
D. Assess for stage of disease (CBC, liver function tests; UA, ESR; CT scan of chest, liver, and spleen; bone scans all useful in staging).

  •  Stage I: Disease is restricted to single anatomic site or is localized in a group of lymph nodes; asymptomatic.
  •  Stage II(a): Two or three adjacent lymph nodes in the area on the same side of the diaphragm are affected.
  •  Stage II(b): Symptoms appear.
  • Stage III: Disease is widely disseminated into the lymph areas and one or more extra lymphatic sites (spleen, liver, bone marrow, or lungs).

Implementation
A. Provide symptomatic relief of the side effects of radiation and chemotherapy.

  •  Radiation and chemotherapy used in combination is usual treatment of choice.
    a. Combination drugs commonly used: Adriamycin, Blenoxane (bleomycin),Velban (vinblastine), DTIC (dacarbazine) (ABVD) regimen or Blenoxane,Etopophos (etoposide), Adriamycin, Cytoxan, Oncovin, Matulane (procarbazine), and Deltasone (prednisone) (BEACOPP).
    b. Extensive follow-up is mandatory.
  •  Radiation is used for stages I, II, and III in an effort to eradicate the disease. May be used in involved areas only or to include adjacent nodes.

B. Counsel client and family.

  •  Enlist participation of client and family in treatment plan.
  •  Provide reinforcement of medical teaching, make appropriate multidisciplinary referrals.
  • Encourage independence where possible.

C. Observe for pressure from enlargement of the lymph glands on vital organs, particularly for respiratory problems from the compression of the airway. Observe for other complications of therapy.
D. Appropriate discharge planning and teaching.

Pediatric Nursing: Brain Tumors

Focus topic: Pediatric Nursing

Definition: The second most common childhood cancer. Two-thirds of brain tumors arise in the infratentorial region of the brain compared with those in adults, which are usually supratentorial. The most common types are cerebellar astrocytoma, medulloblastoma, and brain stem glioma.

Characteristics
A. Stereotactic surgery and procedures using lasers and brain mapping have greatly increased the numbers of tumors that can be resected. Many childhood brain tumors, however, are impossible to remove, or are so situated as to cause damage if completely removed.
B. Tumors occur most frequently in the 5–7 age group.
C. Location: Most tumors occur in the posterior fossa.
D. Types most frequently seen in children:

  • 1. Astrocytoma (most common pediatric brain tumor 20% of pediatric brain tumors).
    a. Located in the cerebellum.
    b. Insidious onset and slowly progressive course.
    c. Surgical removal usually possible.
  •  Medulloblastoma (about 18% of pediatric brain tumors).
    a. Located in the cerebellum.
    b. Highly malignant, fast growing.
    c. Prognosis poor.
  •  Brain stem gliomas (about 10% of pediatric brain tumors).
    a. Surgical excision difficult. Poor long-term prognosis.
    b. Develops slowly with initial symptoms of cranial nerve palsies.
  •  Ependymoma (6% of pediatric brain tumors).
    a. Usually, a ventricular blockage, which leads to signs of increased intracranial pressure.
    b. Treated with incomplete internal compression and radiation therapy.
  • Neuroblastoma.
    a. A malignant, solid tumor primarily occurring in infants and young children.
    b. The tumor generally arises in the adrenal gland, but may originate in any part of the sympathetic chain. First symptom may be abdominal mass.
    c. Growth is by extension and invasion; prognosis is guarded.
    d. Chemotherapy (Oncovin and Cytoxan) can be successful, especially under 1 year of age. Also, autologous stem cell transplantation after high-dose chemotherapy has improved survival rates. Administering the biologic modifier 13-cis-retinoic acid (Accutane) has further increased survival rates.

Assessment
A. Assess for increased intracranial pressure.

  •  Vomiting without nausea, or projectile.
  •  Headache (especially one that awakens from sleep).
  •  Irritability/lethargy (changes in LOC).
  •  Seizures.

B. Measure OFC in children under 3 years old.
C. Neuromuscular changes (motor weakness, clumsiness, poor fine-motor control).
D. Vital signs indicative of Cushing’s triad.
E. Papilledema, cranial nerve neuropathy.

Implementation
A. Control and relieve symptoms.
B. Institute seizure precautions.
C. Frequent, thorough neurological assessment  report any changes promptly.
D. Administer postoperative care prevent postoperative complications.

  • Maintain child flat in bed on unaffected side if infratentorial procedure. Elevate head of bed with supratentorial procedure.
  • Log roll for change of position.
  • Control fever with hypothermia mattress.
  • Frequently observe vital signs until stable, every 15–30 minutes, with neurological checks. Be alert to signs of CNS infection.
  • Reinforce a wet dressing with sterile gauze.
  • Notify physician of increased wetness of dressing and test for possible cerebral spinal fluid leakage.
  •  Minimize increases in ICP: Prevent vomiting, coughing, straining with stool, keep lights dim and noise to minimum, limiting suctioning.
  •  Child may have ventricular drain in place postoperatively; handle as ordered and with aseptic technique.

E. Surgery may be followed by chemotherapy and/or radiation therapy.

  •  Radiation therapy is detrimental to brain growth and development in children less than 3 years old.
  •  Chemotherapy may be used after surgery in children under age 3, and radiation postponed.
  •  Many clinical trials are currently under way.

F. Educate and counsel family.

  •  Counsel family and child through the stages of acceptance of the disease.
  •  Instruct on the use of medications and dosage.
  •  Alert family to signs of increased intracranial pressure.
  •  Suggest the use of a wig, a hat, or a scarf to cover the child’s shaved head.
  •  Encourage return of the independence of the child.

Pediatric Nursing: Bone Tumors

Focus topic: Pediatric Nursing

Pediatric Nursing: Osteogenic Sarcoma

Focus topic: Pediatric Nursing

Definition: The most common malignant bone tumor in children, originating from osteoblasts (bone-forming cells). Occurs twice as frequently in boys as in girls, most occurring between 4 and 25 years of age. The usual location is in the metaphysis of long bones, near growth plates, especially in lower extremities.

Assessment
A. Assess for tumor. Usually located at the end of the long bones (metaphysis). Most frequently seen at the distal end of the femur or the proximal end of the tibia or humerus. Other sites include the pelvis, jaw, or phalanges.
B. Assist with diagnostic procedures; CT scan, biopsy, bone scan.
C. Assess for pain at site, swelling, and limitation of movement. Tumors are usually painless pain indicative of metastasis from other cancer, or non-cancer trauma.
D. Evaluate lungs, kidneys, thyroid; common sites of metastasis.

Implementation
A. Therapy is aimed at salvaging the limb whenever possible, limb-sparing tumor resection, followed by adjuvant irradiation and/or chemotherapy.

B. Provide postoperative care and pain relief appropriate to procedure.
C. Assist with irradiation and chemotherapy as needed.
D. Administer and monitor frequently used chemotherapy.

  •  Adriamycin (antibiotics).
  •  High-dose Trexall (antimetabolite) with citrovorum factor rescue.
  •  Ifex (alkylating agents).
  • Oncovin (plant alkaloid).
  •  Platinol (cisplatin) (synthetic agent).
  •  Etopophos (cell cycle–specific mitotic inhibitor).

E. Monitor and manage side effects of chemotherapy and irradiation.
F. Provide education and support to child and family. Involve child immediately with plan of care, therapeutic regimen, and decision making. Make appropriate referrals to community agencies, other healthcare professionals, and support groups. Educate child and family about long-term activities/ prognosis and signs of treatment complications and side effects. Support growth and development.

Pediatric Nursing: Ewing’s Sarcoma

Focus topic: Pediatric Nursing

Definition: A malignant tumor of the bone originating from myeloblasts with early metastases to lung, lymph nodes, and other bones. Occurs predominantly in individuals 4–25 years old.

Assessment
A. Assist in obtaining history of tumor development.
B. Palpate tumor. Usually located on the shaft of the long bones. Femur, tibia, and humerus are common sites. Lesions at distal ends of extremities have highest cure rate.
C. Assess for swelling and tenderness.
D. Check elevation in temperature, other signs of metastases (enlarged lymph nodes, cough, CNS symptoms).
E. Assess for side effects of therapy.

Implementation
A. Assist with diagnostic procedures; MRI, x-rays, CT scans, biopsy.
B. Treatment is generally limb-sparing surgery with adjuvant irradiation and/or chemotherapy.
C. Rarely, amputation may be necessary.
D. Encourage inclusion of child in discussions of treatment, options, risks, and prognosis.
E. Monitor for side effects of radiation.
F. Administer chemotherapy to treat tumor and prevent metastases.

  •  Adriamycin, Blenoxane.
  • Cytoxan; alternate with Ifex and Etopophos.
  •  Oncovin.

G. Treat the side effects of chemotherapy and radiation, relieve pain.
H. Listen to parents, child, and siblings as they work through denial, anger, acceptance; allow them their grieving process.
I. Promote age-appropriate activities and group discussions with peers.
J. Assist parents in avoiding over protection, promoting normal growth and development, encouraging safe activities, interactions with friends and family.

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