Hematologic-Oncology

1
Hematologic-Oncology
2
Common Hematologic Disorders in Children

• Iron-Deficiency Anemia
• Sickle Cell Anemia
• Beta-ThalasemiaMajor (Cooleys anemia)
• Hemophilia A
• Von Willebrands Disease
• ITP (Immune Thrombocytopenic Pupura)

3
Common Heme-Oncology Diseases in Children

• Acute Lymphocytic Leukemia
• Hodgkins Disease
• Non-Hodgkins Lymphoma
• Retinoblastoma
• Neuroblastoma
• Nephroblastoma
• Osteogenic Sarcoma
• Ewings Sarcoma

4
Complete Blood Count

• WBC
• RBC
• Hgb
• Hct
• Platelet

5
CBC with Differential

• WBC
• Neutrophils- phagocytosis
• Lymphocytes T and B cell
• Monoocytes phagocytosis, antigen
• Eosophils- allergen
• Basophils-inflammatory
• RBC
• MCV- volume
• MCH
• MCHC
• RCW- width
• Hgb
• Hct
• Platelet
• MPV

6
PT, PTT

• The prothrombin time (PT) test measures how long
  it takes for a clot to form in a sample of blood.
  
• Prothrombin is one of several clotting factors
  that are produced by the liver.
• The PT test evaluates the integrated function of
  these factors and the bodys ability to produce a
  clot in a reasonable amount of time.
• Because the reagents used to perform the PT test
  vary from one laboratory to another and even
  within the same laboratory over time, the normal
  values also will fluctuate.

7
Other Labs

• Sed Rate (ESR)
• Iron
• TIBC (Transferrin)
• Ferritin
• Bilirubin

8
Pediatric Laboratory Normal Values Children age
2-12 Years

• RBC 3.89-4.96
• HgB 10.2-13.4
• Hct 31.7-39.3
• Sed 1-8
• WBC 5,400-11,000

• Platelets 206,000-403,000
• Fe 20-105
• Ferritin 47-110
• TIBC 240-508
• PT 10-11 sec
• PTT 42-54 sec
• Bilirubin- less than 11.7

9
Anemias

• )

• Types in Children

• Reduction of
• number of red blood cells
• the quantity of hemoglobin
• the volume of packed red

• Iron-Deficiency Anemia
• Sickle Cell Anemia
• Beta-ThalasemiaMajor (Cooleys anemia

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Iron-Deficiency Anemia

• The most common hematologic disorder of infancy
  and childhood
• 9 months- 2 years, adolescence
• A nutrient deficiency of inadequate dietary iron
• Prevention iron fortified products

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Children at Risk

• low birth weight infants
• infants born to mothers with iron deficiency
  anemia
• infants born with GI defects
• chronic blood loss in older children

12
Pathophysiology

• Dietary Fe is bloodstream binds to transferrin
  (TIBC) and is delivered to RBC in bone marrow,
  combines with other cells to make Hgb
• Unused dietary Fe is stored in intestinal
  epithelial cells as ferritin

13
Diagnosis

• Low RBCs
• Low HGB
• Mild ( lt 10.2), Moderate (8-9), Severe (lt 7)
• Low HCT
• Low Iron
• High Transferrin (TIBC)
• Low Ferritin

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Symptoms

• Low Hgblow O2 tissue perfusion
• Hgb of 10.2 or less
• May seem asymptomatic, not noticed by caregiver
• Pallor/Pale mucous membranes (low hgb, not enough
  red color to skin)
• Poor muscle tone, decreased activity
• Fatigue
• Increased HR, RR
• Hgb lt 9
• Above plus irritability, lack of interest in play

15
History

• Dietary history usually shows abnormally high
  milk intake gt 32 oz day in toddler
• Ask parents specific questions
• Begin the dietary history at the time the child
  awoke yesterday include all activities and
  exactly what the child ate

16
Management

• Iron-fortified formula
• Limit cows milk to 24-32 oz/day for children gt12
  months
• Increase age-appropriate iron-rich foods and Vit
  C
• Fe supplements- Ferrous Sulfate

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Nursing Considerations
18
Nursing Considerations

• Manage side effects of Ferrous Sulfate
• Nausea,
• Anorexia
• Constipation
• Abdominal distress
• Black stools.
• Give on an empty stomach if possible
• Monitor bowel movements and suggest increased
  fluid and fiber.

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Nursing Considerations

• Monitor development, sleep, and activity/fatigue
  patterns.
• Monitor hemoglobin to measure effectiveness of
  therapy.
• Instruct families to keep Ferrous Sulfate locked
  and out of reach of children poisoning is a
  serious risk.

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Sickle Cell Anemia

• Autosomal recessive disorder, African Americans
• Characterized by abnormal hemoglobin (HbS)
• Clinical manifestations caused by obstructions
  due to the sickled RBCs and destruction of
  sickled and normal RBCs

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Sickle Cell Anemia

• Symptoms may not appear until 6 months of age
• Mortality rate children lt 3 yo is 15-35
• Diagnosis
• Amniocentesis, CVS, Newborn Screen

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Signs Symptoms

• Initially fever anemia at 6 mos
• Pallor
• Fatigue
• SOB
• Irritability
• Jaundice

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Diagnosis

• Moderately low Hcb and Hct
• Normal Iron, TIBC, Ferritin
• Elevated Billirubin

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3 Sequalea of SCA

• Vaso-Occlusive Crisis
• Acute Chest Syndrome
• Splenic Sequestration

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Vaso-occlusive crisis

• Severe, sudden onset of sickling where many new
  sickled cells pool in a vessel and cause pain and
  tissue hypoxia
• Caused by infection, dehydration, anxiety, cold
• Most common from hypoxia secondary to rapidly
  destroyed RBC
• Lasts for hours to weeks

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Vaso-occlusive Crisis

• Early Signs pallor, tachycardia, fever
• Late Signs acute abdominal, back, extremity pain

• First Crisis in infants
• Dactylitis (hand foot syndrome)
• swelling of hands and feet
• joints may be warm swollen

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Management

• Pain relief
• Adequate hydration
• Adequate oxygenation

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Pain

• Assess pain every 1-2h or more frequently
• Use pain scale appropriate for age
• Non-pharmacological pain methods
• AROUND THE CLOCK PAIN MEDS
• Tylenol for mild pain
• Narcotics for mod-severe pain

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Prevent Occlusion

• Push PO fluids
• IV hydration 1.5 to 2 times normal rate
• Risk for fluid overload

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Altered Tissue Perfusion and Prevent Further
Sickling

• Administer oxygen to maintain saturation of 95
  or higher
• Pulse oximetry
• Semi-fowlers position
• Administer PRBCs

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Acute Chest Syndrome

• Sickle contents break off
• Bilateral pulmonary involvement
• Causes chest infection, embolism

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Nursing Considerations

• Know the symptoms
• Chest pain
• Fever
• Cough
• Wheeze
• Tachypnea

• Analgesics
• Oxygen
• Hydration Incentive spirometry,
• Antibiotics
• PRBC

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Splenic Sequestration

• Sickled cells block the spleen
• pooled blood in spleen and/or liver and enlarges
• Pooled blood leads to a decrease in circulating
  volume hypovolemic shock
• CVA gt coma

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Nursing Considerations

• Know the Symptoms
• Irritability
• Pale
• Tachycardia
• Pain to LUQ
• Enlarged Spleen

• Life Threatening- get child to ED a.s.a.p.!
• PRBC
• Remove spleen

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Risk for Infection r/t Chronic Immunosuppression

• Administer PCN everyday
• Up-to-date vaccines
• Educate parents
• s/s infection respiratory distress
• possible triggers
• treat pain immediately
• adequate fluids

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Beta-ThalasemiaMajor (Cooleys anemia)

• Hereditary anemia due to abnormal synthesis of
  hemoglobin
• Life long disorder
• Mediterranean descent
• Life threatening symptoms

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Diagnosis

• Low RBCs
• Extremely low Hgb lt 5
• Increased serum iron

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Symptoms

• Facial anomalies
• Frontal bossing (prominent and protruding
  forehead)
• Maxillary prominence
• Wide-set eyes with a flattened nose
• Bronze skin color (Greenish yellow skin tone)
• Growth and maturation retardation

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Management

• RBC transfusions q2-4 weeks to get Hgb to 10-12
• Iron Chelation therapy
• Desferal (deferoxamine) SQ
• Splenectomy
• Cure bone marrow stem cell transplant
• Estimated 70 do not find a suitable donor

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Nursing Considerations

• Observe for complications of transfusion- iron
  overload
• Supporting the child and family in dealing with a
  chronic life-threatening illness
• Monitor Growth and Development
• Refer the family for genetic counseling.

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Compare and Contrast
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Bleeding Disorders

• Hemophilia A
• Von Willebrands Disease
• ITP (Immune Thrombocytopenic Pupura)

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Clotting

• Host of factors
• Platelets aggregation at site of injury
• Tested by coagulation time (PT/PTT)

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Hemophilia A

• Hereditary blood coagulation deficiency (factor
  8)
• Ability to clot is slower
• X-linked recessive (white, males)

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Symptoms

• Vary according to concentration of factor 8
• Soft tissue bleeding and painful hemorrhage into
  joints
• Severe bleeding may occur in GI tract, peritoneum
  or CNS

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Interviewing the Child with HemophiliaSubjective
Data

• Recent traumas and measures used to stop bleeding
• Length of time pressure was applied before
  bleeding subsided
• Whether swelling increased after surface bleeding
  subsided
• Whether swelling and stiffness occurred without
  apparent trauma

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Diagnosis

• Above History
• Suspected by Labs
• Platelet level Normal
• PTT Prolonged (elevated number) gt 60
• Confirmed by genetic testing for missing factor

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Management of Bleeding

• Acute therapy
• Bleeding must be controlled by IV administration
  of factor 8
• After trauma, surgery
• Pressure to laceration
• Prophylactic therapy
• Children age 1-2 receive PO factor 8 replacement
  on a regular schedule if frequently symptomatic
• prior to surgery, dental work

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Parental Education

• Primary Goal Injury Prevention
• Promote oral hygiene, up to date immunizations
• No aspirin
• Avoid activities that induce bleeding
• Provide activities for normal GD
• Administration of factor replacement prn

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Von Willebrands Disease

• Most commonly inherited bleeding disorder,
  autosomal dominant (Males and Females)
• Lacks production of VWF
• Platelets are normal in number
• Inability of platelets to aggregate
• Varying degrees of disease
• VWF is deficient to defective

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Diagnosis

• Platelets is normal
• PT/PTT is normal
• Confirmed by genetic testing for VWF

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Signs Symptoms

• Can be so mild that disease is undiagnosed
• Epitaxis
• Prolonged bleeding from cuts
• Excessive bleeding following surgery

• Bleeding from gums

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Management

• Prophylactic therapy -Replace dysfunctional
  factor in blood
• Treatment of Choice DDAVP
• Injury Prevention

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ITP (Immune Thrombocytopenic Pupura)

• Autoimmune disorder (antiplatelet antibody) or
  cause is unknown (idiopathic)
• Occurs most commonly at age 2-4 years
• Reduction in and destruction of platelets
• Typically seen 2 weeks after a febrile, viral
  illness

55
Signs Symptoms

• Excessive bruising and petechiae
• Epitaxis
• Bleeding into joints
• Tourniquet test shows many petechiae after
  inflation of BP cuff

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Diagnosis

• Labs
• Platelets lt 150 (Marked thrombocytopenia)
• PT and PTT Normal

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Management

• Prednisone
• IVIG (IV immunoglobulin)
• PLT transfusion (only a temporary solution)
• Most cases are self-limiting
• Avoid when possible
• administering intramuscular injections
• aspirin, aspirin-containing products, and
  nonsteroidal antiinflammatory medications (e.g.,
  ibuprofen)
• taking temperatures rectally
• perform invasive procedures with extreme caution

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Compare and Contrast
59
Oncology

• Cancer in adults
• abnormal cell is transformed by genetic mutation
  of its DNA
• usually as a result from exposure to a tetragon
• Cancer in children
• usually arises from chromosomal abnormalities,
  genetic mutations and proliferation of embryonic
  cells

60
Oncology Treatments

• Chemotherapy
• antineoplastic agents
• attempt to destroy tumor cells by interfering
  with cellular functions and reproduction
• cytotoxic drugs that are designed to cause cell
  death.
• Normal cells that have rapid growth are also
  affected, such as hair growth.
• Toxic side effects

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Oncology Treatments

• Surgical intervention
• removing the entire cancerous tumor (most ideal
  and frequently used treatment method)
• Radiation therapy
• interrupt cellular growth by breaking the DNA
  stands, leading to cell death.

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Types of Cancer in Children

• Small percentage Carcinoma (opposed to large
  percentage in adults)
• Mostly Leukemia
• Followed by Lymphoma
• The rest is solid or soft tissue tumors

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Clinical Manifestations

• Differ based on type of cancer
• Many symptoms are similar to common childhood
  illnesses
• Symptoms may be in site other than the cancer
• delay in diagnosis
• Often diagnosis made when cancer is advanced

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Common Clinical Manifestations

• Pain
• Anemia
• Anorexia, weight loss
• Infections
• Bruising
• Neurological symptoms
• Palpable mass

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Psychosocial Concerns

• Parents in disbelief
• Health child suddenly becomes ill
• Potentially life-threatening
• Treatment decisions, can last months-years
• Travel for treatment, heavy financial
  responsibilities
• Effects of siblings

66
Effects on Child

• Infants- unaware of diagnosis
• Toddlers- aware they do not feel well
• Preschoolers-beginning understanding of illness,
  not cancer
• School-age-understand cancer, benefit from
  talking about it
• Adolescents-mature understanding, benefits from
  other adolescents with cancer

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General Nursing Considerations

• Provide optimal nutrition- high metabolic rate of
  cancer depletes stores
• Ensure adequate hydration-ice pops, jello
• Manage pain
• Promote growth and development
• Prevent Infection (next slide)

68
Risk for infection r/t Immunosuppressed state.

• Monitor vital signs q4h
• Instruct parents how to measure temp at home
• Proper handwashing
• Inspect childs skin for breakdown
• Inspect childs mouth for ulcers
• Teach child and parents meticulous oral hygiene
• No live virus administration

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Leukemia
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Leukemia

• Broad term describing a group of malignant
  diseases
• Normal Bone Marrow is replaced by abnormal
  immature cells
• Etiology variety of agents thought to increase
  risk (virus, toxins, drugs) combined with
  genetics
• Two forms of leukemia
• ALL Acute Lymphocytic Leukemia
• AML Acute Myelogenous Leukemia

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Acute Lymphocytic Leukemia

• Most frequently occurring type of cancer in
  children lt 15yo (peak 2-6)
• Distorted and uncontrolled proliferation of
  immature WBCs (lymphoblasts)
• Causes decreased RBCs, platelets, and mature
  WBCs production and invasion of body organs by
  rapidly increasing lymphoblasts

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Signs Symptoms

• Fever
• Bone or joint pain
• Bruising
• Decreased RBCs
• Decreased PLTs
• Abnormal high WBC counts
• Lymphadenopathy
• Hepatosplenomegaly
• CNS invasion

73
Diagnosis

• Based on
• Signs symptoms
• CBC changes
• Bone marrow aspiration (gt 25 of lymphoblast
  cells present)

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Management

• Chemotherapy in 3 stages
• For 2-3 years
• Induction
• Sanctuary
• Maintenance

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Induction

• 1st month aim is to induce remission (blast
  cells to lt 5, normal Physical Findings)
• Approximately 95 of children achieve remission
  within 1 month

76
Sanctuary or Consolidation

• Begins after remission, 4 weeks
• Goal
• to maintain remission
• prevent disease from invading sanctuary sites

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Maintenance

• goal to maintain remission
• eliminate residual leukemic cells
• combination of drugs, outpatient basis
• girls treated for 2 years, boys for 3
• Cure free of disease for 4-5 years

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High Doses of Chemotherapy Can Lead to

• Tumor Lysis Syndrome
• Metabolic emergency
• results from the lysis (dissolving or
  decomposing) of tumor cells and rapid release of
  their contents into the blood

79
Tumor lysis syndrome

• Rapid cell destruction releases high levels of
• uric acid
• potassium
• phosphates
• Uric acid overloads the kidneys
• Leads to cardiac arrhythmias and renal failure

80
Nursing Considerations

• Children receiving chemotherapy
• Monitor for
• Hyperuricemia
• Hyperkalemia
• Hyperphosphatemia
• Hypocalcemia

81
Nursing Considerations

• Administer vigorous hydration (24 times rate for
  maintenance fluid)
• Administer allopurinol or urate oxidase
  (rasburicase) to reduce conversion of metabolic
  by-products to uric acid

82
Soft Tissue Tumors

• Hodgkin's
• Non Hodgkin's
• Retinoblastoma

83
Lymphomas

• A malignancy that arises from the lymphoid system
  
• Two types
• Hodgkins
• Non Hodgkins

84
Hodgkins Disease

• Neoplasm of cervical lymphatic tissue
• Starts in a single or group of lymph nodes then
  spreads predictably to nonnodal sites such as
  spleen, liver, bone, marrow, lungs, mediastinum
• Affects adolescents to late 20s
• Males gt females
• Etiology unknown- infectious agent likely

85
Signs Symptoms

• Painless enlarged cervical node
• Unexplained weight loss, unexplained fevers,
  night sweats

86
Diagnosis and Treatment

• Diagnosis
• Biopsy of enlarged lymph node
• Staged 1-4
• Treatment
• Chemotherapy
• Radiation-low doses, higher is physiologically
  mature
• Good Prognosis-single origin

87
Non-Hodgkins Lymphoma

• No single origin
• Males gt females
• Cause unknown
• Aggressive proliferation of B or T lymphocytes in
  lymph nodes
• Rapid in onset (ages 5-15)
• Usually found with wide-spread involvement via
  bloodstream (multiple enlarged nodes)
• Responds quickly to therapy

88
Signs Symptoms

• Acute abdominal and chest pain, constipation,
  cramping
• Anorexia, weight loss
• Painless enlarged lymph nodes found in cervical
  or axillary region
• Ascites and obstruction with vomiting a late sign
• Advanced disease CNS symptoms, HA n/v,
  mediastinal mass, petichaie, bruising, bone pain

89

• Diagnosis
• Biopsy from bone marrow or lymph node
• Staging 1-4
• Treatment
• Aggressive multi-agent chemo for 6 mos to 2 years
• Risk for tumor lysis syndrome
• Intrathecal chemo and crainal radiation

90
Compare and Contrast
91
Retinoblastoma

• Malignant tumor of retina
• Inherited autosomal dominant
• Immature retinal cells become malignant
• 6 weeks of age to preschool age
• Unilateral or bilateral

92
Signs Symptoms

• Absent red reflex
• Whitish glow to pupil
• Strabismus develops
• Eye pain
• Metastases to optic nerve, subarachnoid space,
  brain, 2nd eye

93
Retinoblastoma

• Treatment
• If small cryosurgery, partial vision
• If mets chemo radiation
• If large enucleation, eye prosthesis 3 weeks
  post-op
• Survival rate 90

94
Solid Tumors

• Neuroblastoma
• Nephroblastoma
• Osteoscaroma
• Ewings Sarcoma

95
Neuroblastoma

• Solid tumor of infants and pre-school children
  (peak 22mos)
• Cancer cells arise from sympathetic nervous
  system called crest cells
• Embryologic cells of adrenal glands
• Etiology unknown

96
Signs Symptoms

• Depend on
• extent of disease
• location of tumor
• 65 present with protuberant, firm, irregular
  abdominal mass that crosses midline

97
Neuroblastoma

• Other manifestations
• impaired ROM mobility
• pain limping
• large abdominal mass
• respiratory symptoms if chest tumor

98
Neuroblastoma

• Diagnosis
• Chest x-ray
• CT scan of abdomen, pelvis, spine
• Bone marrow aspiration
• Management
• depends on the presence and extent of metastasis

99
Wilms Tumor (Nephroblastoma)

• Malignant tumor of the kidneys
• Peak age 3-4 years
• Girls gt boys
• Cause is unknown
• Other GU problems
• Occurs in asymptomatic child
• May have genetic predisposition
• Is associated with congenital anomalies

100
Nephroblastoma

• Parents usually notice a large, mobile abdominal
  mass while bathing or the diaper doesnt fit
  anymore
• Grows extremely quickly, in a matter of days
• DO NOT PALPATE ABDOMEN
• can rupture the tumor and cause spreading of
  cancerous cells

101
Other Signs Symptoms

• microscopic to gross hematuria
• hypertension
• abdominal pain
• fatigue, anemia, fever

102
Diagnosis

• Suspected from a good history
• CT scan
• Definitive dx made at time of surgery
• Staged 1-5

103
Staging 1 through 5

• tumor confined to the kidney and completely
  removed surgically
• tumor extending beyond the kidney but completely
  removed surgically
• regional spread of disease beyond the kidney with
  residual abdominal disease postoperatively
• metastases to lung (primary site), liver, bone,
  distant lymph nodes
• bilateral disease

104
Treatment

• State 1 and 2
• Nephrectomy
• Chemotherapy
• Stage 3-5
• Nephrectomy
• Radiation
• Chemotherapy
• Survival rates are good (up to 90)

105
Bone Cancers
106
Osteogenic Sarcoma (Osteosarcoma)

• Most common bone malignancy in children (teenage
  years)
• Occurs in distal long bones
• Attributed to extremity injury or growth spurt
• Originates from bone producing cells
• 40-50 occur at distal femur and knee

107
Signs symptoms

• Progressive, insidious or intermittent pain at
  site of tumor
• Palpable mass swelling
• Limping, progressive limited range of motion
• Pathological fractures

108

• Diagnosis
• X-ray, CT, MRI
• Tumor biopsy
• Look for chest metastases

109
Management

• Remove tumor, prevent spread of disease
• Combination of surgery chemo
• Amputation my be necessary
• Limb salvage operation
• Cure rate 60-65 without overt metastases

110
Nursing care

• Comfort
• Infection
• Potential hemorrhage
• Phantom limb pain
• Prosthesis
• Changes in body image and functioning

111
Ewings Sarcoma

• Highly malignant tumor in bone marrow of long
  bones
• Can present in any bone
• Spreads longitudinally through bone
• Affects young adolescents and older children
• Metastases is usually present at time of dx
  (lungs, bone, CNS, lymph nodes)

112
Signs Symptoms

• Intermittent pain attributed to injury
• Swelling at tumor site
• Pain becomes constant
• Progresses into
• Weight loss
• Fever
• Increased sed rate

113

• Diagnosis
• Bone scan
• Bone marrow aspiration biopsy
• CT of lungs
• Definitive dx biopsy of tumor site

114

• Treatment
• Surgery
• Multi agent chemo
• Radiation

115
Compare and Contrast
116
Chronically Ill ChildNursing Diagnosis

• Fear
• Death Anxiety
• Anticipatory Grieving
• Hopelessness

117
Goals for Care of the Chronically Ill Child

• Goals for the child
• Achieve and maintain normalization
• Obtain the highest level of health and function
  possible
• Goals for the family
• Remain intact
• Achieve and maintain normalization
• Maximize function throughout the illness

118
Nursing Care for Children with Chronic
Conditions and Their Families

• Attend to the needs of the family system
• Revise goals frequently to meet the childs
  changing developmental needs
• Listen carefully to the child's perception of the
  condition

119
Nursing Care for the Dying Child and the Childs
Family

• Be available to assist both child and family
• Avoid imposing personal beliefs and expectations
• Provide time and attention to the dying child
• Recognize the need to talk about illness and
  death
• Provide adequate pain control, oral care,
  privacy, and information about the signs of
  imminent death
• After death, allow family members as much time as
  they desire with the child

120
Practice Questions!
121

• A child is being admitted to the unit with
  thalassemia major (Cooleys anemia). In preparing
  client assignments, the charge nurse wants to
  assign a nurse to this child who can
• Teach dietary sources of iron
• Administer blood infusions
• Work with a dying child
• Monitor the child for bleeding tendencies

122

• A 14-year-old boy with sickle cell anemia is
  admitted with severe pain in his abdomen and
  legs. He asks why the doctor ordered oxygen when
  he is not having any breathing problems. The
  nurse states the therapeutic action of O2 is
• Prevent further sickling
• Prevent respiratory complications
• Increase O2 capacity of RBCs
• Decrease the potential for infection

123

• A 10-year old in the ER has a CBC results that
  include a Hgb of 8, and Hct of 24. The nurse
  determines that based on the lab results which
  nursing action has a high priority?
• Promotion of skin integrity
• Promotion of hydration
• Promotion of nutrition
• Conserving energy

124

• A 4-year-old is diagnosed with ALL. Following
  teaching about the staging and therapy, the nurse
  evaluates the familys understanding of the
  problem. The statement by the family that
  indicates appropriate knowledge is Staging will
• Determine the extent of the tumor process and
  need for palliation
• Help determine if treatment is needed
• Determine if surgery is needed
• Determine the extent of malignant process and
  stage the leukemia

125

• A 17-year old is being admitted for an amputation
  related to a bone tumor. The nurse is developing
  a nursing care plan and determines the most
  appropriate age related diagnosis is
• Risk for disuse syndrome
• Disturbed body image
• Self-care deficit
• Activity related intolerance

126
The nurse is reviewing the lab work on a child
admitted for fatigue

• WBC 7,200
• RBC3.01
• Hgb 9.1
• Hct 29.3
• Platelets 371,000

• Iron 64
• Ferritin 70
• Transferrin 250
• Bilirubin 18.2
• PTT 45 seconds

127

• After analyzing the results, the nurse suspects
  the child may have
• 1. Fe Deficiency Anemia
• 2. Cooleys Anemia
• 3. Sickle Cell Anemia
• 4. Aplastic Anemia

128

• The nurse is admitting a child for a swollen
  elbow. The history indicated multiple bruising.
  Which of the following laboratory results
  heightens the nurses suspicion for Hemophilia?
• 1. Hbg 12,000
• 2. WBC 9,000
• 3. Platelets 356,000
• 4. PTT 73 seconds